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Fifth stage 

Gynecology 

Lec-5

 

 .د

  ولدان

16/3/2016

 

 

STD & Genital tract ulcers

 

 

Chlamydia trachomatis 

 

Is the commonest bacterial sexually transmitted infection which is commonly a 
symptomatic. 

 

It is small bacterium an obligate intracellular pathogen 

 

Serovars D-K cause genital infections 

 

Clinical feature 

 

80% asymptomatic 

 

Postcoital and intermenstrual bleeding 

 

Lower abdominal pain 

 

Purulent vaginal discharge 

 

Mucopurulent cervicitis & or contact bleeding 

 

Risk factors 

 

Age < 25 years 

 

Multiple sexual partners 

 

More with those using cocp 

 

Termination of pregnancy 

 

Complication 

 

PID and subsequent Fitz-Hugh-Curtis syndrome 

 

Tubal damage, ectopic pregnancy, infertility, and chronic pelvic pain 

 

Transmission to the neonate causing conjunctivitis and pneumonia 

 

Arthritis and Reiter's 

 

Diagnosis 

 

Endocervical, urethral, and vaginal swab for culture but are not sensitive 

 

ELIZA test on endocervical smear 

 

Direct fluorescent antibody test 


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Management 

 

Doxycycline 100 mg twice a day for 7 days 

 

Azithromycin 1 g as single dose 

 

 Ofloxacine 400 mg daily for 7 days 

 

 In pregnancy: 

o  Azithromycin 1 g as single dose 
o  Erythromycin 500 mg twice a day for 14 days  

 

 Partner should be fully screened and treated 

 

Gonorrhoea 

 

It is a STD 

 

 Caused by gram negative diplococcus N.gonorrhoeae . 

 

Sites of infection are mucous membrane of urethra, endocervix, rectum, pharynx, and 
conjunctiva 

 

Vertical transmission from the mother to the fetus may occur during labour 

 

Clinical Features 

 

50% asymptomatic 

 

 50% increased or altered vaginal discharge 

 

 25% lower abdominal pain 

 

 12% dysuria 

 

 Rare intermenstrual bleeding or menorrhagia due to endometritis 

 

Clinical sign 

 

< 50% mucopurulent endocervical discharge and bleeding 

 

 < 5% pelvic or lower abdominal tenderness, 

 

 In the infant cause sever conjunctivitis (ophthalmia neonatorum) 

 

Complications 

 

Spread of m.o. cause PID < 10%  

 

 Haematogenous spread causing skin infection, arthralgia, and arthritis 

 

Diagnosis 

 

Endocervical and urethral swab for culture is the most reliable diagnostic-test 

 

 


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Recommeded treatment 

 

Ampecillin 1 g + probenecid 2 g as single dose 

 

 Ciprofloxacin 500 mg as single dose 

 

Spectinomycin 2 g I.M. as single dose 

 

Azithromycin 1 g as single dose 

 

Ceftriaxone 250 mg as single dose 

 

Cefixime 400 mg as single dose 

 

More than 50% has concomitant chlamydial infection, therefore, treatment for the 
patient and partner should be done 

 

The partner should be screened for the infection and treated 

 

Genital ulcer disease 

Classification of genital ulcers 

Infective causes: 

 

 Herpes simplex 

 

 Primary syphilis 

 

 Lymphogranuloma veneri 

 

Chancroid 

 

 HIV 

Non infective causes 

 

Aphthous ulcer 

 

Trauma 

 

Skin disease 

 

 Bahcet syndrome 

 

Sarcoidosis 

 

Genital herpes 

 

STD 

 

 Herpes simplex virus type 1 (HSV-l) [ the usual cause of oro-labial herpes, or HSV-2 

Primary herpis 

 

 3 weeks after acquisition 

 

 Involve vulva, vagina and cervix 

 

 Painful vesicle coalesce into multiple ulcers 

 

 Periurethral involvement cause pain and retention of urine 


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Diagnosis confirmed by culture, or electrical microscope of swab from the lesion 

 

 Treatment: 

  analgesia, lignocaine gel 

  aciclovir 200 mg 5 times a day for 5 days 

 

Recurrent herpis 

 

Following primary infection, virus colonizes the neurons in the dorsal root ganglia, 
causing a latent infection.  

 

 The spectrum of severity is: 

 

asymptomatic shedding of the virus. 

 

Ulcers resembling small abrasions on the vulva. 

 

Localized clusters of vesicles & ulcers 1-2 cm in  diameters 

 

Wide spread or chronic ulceration, like primary one seen in pregnant women. 

 

Large atypical chronic ulcers in immunosuppresed patient. 

 

diagnosis by swabbing the ulcer 

 

 patient usually has recurrent episodes requesting treatment, by prescribing long term 
suppression with aciclovir 400 mg twice a day 

 

Complications 

 

Psychological distress 

 

Neurological involvement like aseptic meningitis and transverse myelitis 

 

Herpes keratitis causing corneal scarring and blindness. 

 

Syphilis 

Primary syphilis: 

 

 First manifestation of syphilis which is painless ulcer (chancre) at the site of 
inoculation 

 

The chancre is in form of shallow punched-out ulcer with well defined edges &smooth 
shiny floor with rubbery consistency &exudes serous discharge. 

 

 Usually single but can be multiple 

 

 regional lymph nodes enlargement 

 

 common site is cervix 

 

 it arise 3-6 weeks after infection 

 

resolve spontaneously without treatment after few weeks 


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 diagnosis done by demonstrating the organism by darkfield microscope from the 
ulcer serum exudates 

 

 specific serological test like fluorescent terponemal antibody (FTA) test, and 
treponema pallidum haemagglutination test (TPHA) or non specific test like venereal 
disease reference laboratory (VDRL) test can be used, although it may be negative . 

 

Secondary syphilis 

 

occur 6 months after the disappearance of chancre 

 

systemic non itchy maculopapular rash, involving the palms and soles 

 

 florid lesions resembling warts (condylomata lata) mainly in peri-anal area 

 

 mucous patch and linear ulcers (snail track) on the mucosal surfaces 

 

 generalized lymphadenopathy 

 

 alopecia, arthritis and meningitis 

 

 diagnosis by serological test which are positive with VDRL titer 1/32 or more 

 

Tertiary syphilis 

 

A firm elastic tumours may occur in skin, mucosa, bones & viscera called gummata 

 

neurosyphilis manifest within 5 years of infection in form of meningovascular syphilis 
with stroke  

 

20% has cardiovascular syphilis like thoracic aortic aneurysm or aortic regurgitation. 

 

Treatment 

 

Treatment of choice is penicillin like procaine penicillin 1.2 MU daily i.m., for 12 .days 

 

 Doxycycline 100 mg twice a day for 14 days 

 

 Erythromycin 500 mg, four times a day for 14 days 

o  There is risk of vertical transmission, causing intrauterine     death or severely 

affected neonate, therefore; neonate at     risk should be evaluated and received 
penicillin injection 

o   Less sever infection occur late in life manifest as  a congenital syphilis including 

nerve deafness, interstitial keratitis, and- abnormal teeth 

 

Lymphogranuioma venereum 

 

It is caused by specific serovars of Chlamydia trachomatis( L1- L3) 

 

 Small superficial ulcer slowly increase in size 

 

Enlarged inguinal lymph nodes which can matted together and discharging pus 
forming bubo 

 

Treatment by tetracycline and surgical interference 


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Chancroid 

 

Caused by ducreyi bacilli 

 

Small, shallow ulcers, multiple and painful with irregular edge 

 

 Localized lymphadenopathy 

 

 Treatment co-trimoxazole or tetracyclin 

 

Granuloma inguinale 

 

Caused by klebsiella granulomatis 

 

 Discrete papules on the skin or vulva which enlarge and form beefy red painful ulcers 

 

Healing end with fibrosis lead to lymphoedema and elephantiasis 

 

Treatment by tetracycline 

 

Anogenital warts 

Aetiology: 

 

Warts are benign epithelial skin tumours are caused by the human papillomavirus 
(HPV), subtypes 6 and 11 

 

The mode of transmission is sexual, but may be transmitted perinatally and also from 
digital lesions 

 

Clinical features: 

 

It may cause irritation or present with lumps  

 

 It can occur at any time in the genital area 

 

 Occult lesion may occur in the vagina .and cervix 

 

Warts may be exophytic, single or multiple, keratinized or not keratinized, broad base 
or pedunculated, and some are  pigmented 

 

 Diagnosis by clinical examination and biopsy if there is any doubt. Speculum 
examination for cervix and vagina should be done 

 

Management

 

Treatment is painful, uncomfortable, with failure and  relapse rate 

 

Soft poorly keratinized warts respond to podophylin,    and trichloroacetic acid 

 

Keratinized lesion treated with physical ablative therapies like cryotherapy, excision 
and electrocautery 

 

In pregnancy podophylin should be avoided and we should reduce neonatal exposure 
to the virus 

 




رفعت المحاضرة من قبل: Abdalmalik Abdullateef
المشاهدات: لقد قام 13 عضواً و 126 زائراً بقراءة هذه المحاضرة








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