Syphilis Primary Secondary Tertiary Primary syphilis Probability 50
Syphilis Primary Secondary Tertiary
Primary syphilis • Probability = 50% after sexual encounter with a patient with active syphilis • Incubation period 10 -90 days • Chancre arises at site of spirochetal entry a painless ulcerated lesion with a raised border and indurated base • Resolves on its own in 3 -6 weeks
Secondary syphilis • Disseminated spread of spirochetes all over the body • 2 -4 weeks after primary infection resolves • 90% skin and mucous lesions Rash begins on trunk and proximal extremities and spreads outward. Pruritic esp on palms and soles • Generalized lymphadenopathy 85% • Fever and malaise 70 %
Tertiary syphilis • 33% will progress to this stage if untreated • Cardiovascular ( Aortic Insufficiency Aneurysm) • CNS (tabes Dorsalis, optic atrophy, Argyle. Robertson pupil • Musculoskeletal
Diagnostic Testing • Darkfield testing • Serologic testing Nonspecific (VDRL RPR ) with titer Specific (MHATP FTSAb)
Spinal tap for syphilis • • • Neurological symptoms Ophthalmic symptoms Tertiary syphilis Treatment failure HIV or other immunosuppressed patient with latent or unknown length of infection
Treatment • Primary: Benzathine Pen. G 2. 4 mil units IM or Doxycycline 100 mg BID for 2 weeks • Secondary (<1 year) Same as Primary (> 1 year) Benz Pen. G 2. 4 mill units IM qweek for 3 weeks or Doxycycline 100 mg bid for 4 weeks • Tertiary Cardiovascular same as late secondary CNS Pen. G 3 -4 mill units IV q 4 hr
Treatment • All patients with a primary contact • All patients with a positive darkfield • All patients with serologic evidence of syphilis • Previously treated patients with a 4 fold rise in titer
Sexually transmitted diseases • 3 mill adolescents acquire STD yearly • Changing emphasis old GC and syphilis new chlamydia, HSV, HPV and HIV • Newer infections are more difficult to treat or cause chronic disease HIV AIDS HPV Genital Cancer HSV recurrent infections
Sexually transmitted diseases • More serious consequences in women genital cancer with HPV Decreased reproductive capacity from tube damage during infection complications of pregnancy spontaneous abortion, still births, preterm births, chorioamnionitis, low birth weight transmission to the fetus (HIV, syphilis, HSV, CMV HBV)
Gonorrhea • Symptoms discharge, abnormal bleeding, pelvic pain • 40 -60 % have symptoms (asymptomatic more common in women) • Incubation period less than 10 days
Disseminated GC • Early: Arthritis (migratory) tenosynovitis and dermatitis • Late: arthritis, perihepatitis, osteomyelitis, pericarditis, endocarditis, meningitis
Diagnosis of GC Male gram stain or culture. Gram stain positive in 90 -95 % if symptoms Female Gram Stain or culture Gram stain only positive in 50 -70 %
Treatment of GC • Rocephin 250 mg single dose • Doxycycline 100 mg bid • Zithromax 1 gram po
Chancroid • Acute ulcerative disease often associated with inguinal adenopathy (bubo) • Causative agent H Ducreyi (gram neg rod) • Lesions generally limited to genital sites • Incubation period 3 -10 days
Chancroid • Small papule at site of entry surrounded by a zone of erythema. Within 2 -3 days the lesions become pustular or vesiculopustular and ulcerate • Classic ulcer is superficial and shallow with a ragged edge. The base of the ulcer is covered with a necrotic exudate This ulcer is painful unlike syphilis
Chancroid • In 50 % of cases a bubo develops 7 -10 days after the initial lesion. Tender inflammatory If untreated it will rupture forming a large ulcer
Chancroid Treatment • Zithromax 1 gram po • Rocephin 250 mg IM • Cipro 500 mg po bid for 3 days
LGV • LGV is an infection caused by Chlamydia Trachomatis L 1 L 2 L 3 • Primary infection of the lymphatic tissue • Infection spreads from lymph node into adjacent tissue. Lymph nodes enlarge, necrose and form abscesses • Long term complication is destruction of lymphatic tissues with resulting edema
Diagnosis and Treatment of LGV • Diagnosis: PCR of chlamydial antigen from aspirated or draining pus • Treatment: Doxycycline 100 mg bid for 21 days
HPV • • Papova viral family (double stranded DNA) Requires squamous epithelium to grow Causes genital and skin warts Important because the virus is implicated in anogenital cancer (90% of cancer of the anogenital tract have HPV DNA present) • Treatment is aimed at eradication of the wart but does not eliminate the virus
Examination of the Male GU Tract • Most common finding is mass a) all masses arising from testicle are cancer b) masses arising from spermatic cord structures are non cancerous
Torsion • Torsion – twisting of testis on spermatic cord resulting in a strangulation of blood supply • Most common age 12 -20 • Acute onset unilateral pain and swelling of testis. May be difficult to differentiate from epididymitis. Sono with color flow doppler to differentiate
Hydrocele • Fluid collection between tunica vaginalis and testis. Patients present with progressive swelling and discomfort on the involved side of the scrotom. Diagnosis made with sono
Varicocele • Enlarged tortuous spermatic vein above the testicle usually on left. Typically this decreases in size when supine
Herpes • HSV 1 or HSV 2 • Primary infections painful pustular or ulcerative lesions occurring 8 – 16 days after contact. Systemic symptoms are common and include fever headache and myalgias • Treatment Zovirax Famvir
Epididymitis • Onset of pain is usually more gradual than torsion • Typically sex related • Sono to help differentiate from torsion • Treatment doxycycline for 10 days, bactrim or levaquin
Scrotal Infections • Cellulitis • Abscess Skin only or involves or even originates from infection from one of the primary intrascrotal organs. Consider admission if diabetic or significant systemic symptoms • Fourniers gangrene- polymicrobial inf of subcutaneous tissues that originates from 1 of 3 sites. Skin, Urethra, and Rectum
Abnormal Genital Bleeding • • • Rule out pregnancy Localize bleeding to uterine cavity Stabilize with fluid – Blood as needed Conjugated estrogen 20 mg iv or BCP Follow up with gynecology Referral for all postmenopausal patients
Criteria for Diagnosis of PID All 3 must be present Abdominal tenderness Cervical Motion Tenderness Adnexal Tenderness One of these must be present positive gram stain temp>38 WBC > 10 Inflammatory mass on exam or sono
Treatment of PID • Consider admission if future fertility is an issue or systemic symptoms • Outpatient – Rocephin 250 IM plus doxycycline 100 mg bid for 10 days • Inpatient – Cefoxitin 2 gm IV every 6 hr or Cefotetan 2 gm IV every 12 hr followed by doxycycline 10 mg bid for 10 days
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