Lymphogranuloma Venereum (LGV)

LGV is caused by the L serotype ofChlamydia trachomatis. It is uncommon in the United States.

Symptoms. The initial lesion is a painless ulcer.

Examination. A painless vesiculopustular eruption, usually on the vulva, spontaneously heals.This is replaced within a few weeks by perirectal adenopathy that can lead to abscesses and fistula formation. The classic clinical lesion is a double genitocrural fold, the “groove sign.”

Diagnosis. A positive culture of pus aspirated from a lymph node confirms the diagnosis.

Management. CDC-recommended treatment includes oral doxycycline or erythromycin for3 weeks.

Granuloma Inguinale (Donovanosis)

This disease is caused by Calymmatobacterium granulomatis, a Gram-negative intracellular bacterium. It is uncommon in the United States.

Symptoms. The initial lesion is a painless ulcer.

Examination. A vulvar nodule breaks down, forming a painless, beefy red, highly vascular ulcerwith fresh granulation tissue without regional lymphadenopathy. Lymphatic obstruction can result in marked vulvar enlargement. Chronic scarring can lead to lymphatic obstruction.

Diagnosis. Culture of the organism is difficult but microscopic examination of an ulcer smearwill reveal Donovan bodies.

Management. CDC-recommended treatment includes oral doxycycline or azithromycin for3 weeks.

AZITHROMYCIN

Table II-7-1. Comparison of STDs

With Ulcers	No Ulcers	Painful Ulcers

Chancroid	Chlamydia	Chancroid
Granuloma inguinale	HPV	Genital herpes
Genital herpes	Gonorrhea
LGV	Hepatitis B
Syphilis	HIV

Table II-7-2. Comparison of STDs with Ulcers

Chancroid (painful)	Ragged, soft edge inflamed

LGV	Groove sign

Granuloma inguinale	Beefy red; Donovan bodies

Syphilis	Rolled, hard edge

Herpes (painful)	Smooth edge inflamed

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Chapter 7 l Sexually Transmitted Diseases

STDs WITHOUT ULCERS

Condyloma Acuminatum

Background. This disease is caused by the human papilloma virus (HPV). It is the most common overall STD in women, as well as the most common viral STD. Transmission canoccur with subclinical lesions. HPV subtypes 16 and 18 are associated with cervical and vulvar carcinoma whereas condyloma is associated with HPV types 6 and 11. Predisposing factors include immunosuppression, diabetes, and pregnancy.

Symptoms. HPV is subclinical in most infected women. Symptoms of pain, odor, or bleedingoccur only when lesions become large or infected.

Examination. Clinical lesions are found in only 30% of infected women. The characteristicappearance of a condyloma is a pedunculated, soft papule that progresses into a cauliflower-like mass. The most common site of lesions is the cervix.

Diagnosis. The lesions have an appearance so characteristic that biopsy is seldom necessary.

Management: is topical or local. Systemic therapy is not available.

• Patient-applied topical treatment: podofilox [Condylox] solution or gel (antimitoticdrug); imiquimod [Aldara] cream (topically active immune-enhancer); or sinecat-echins ointment (green-tea extract)

• Provider-administered local treatment: cryotherapy (liquid nitrogen or cryoprobe);podophyllin resin (not used in pregnancy); trichoroacetic acid [TCA] or biochloroace-

tic acid [SCA] (caustic agents); or surgical removal

Trichomonas Vaginitis

Refer to Gynecology, Chapter 3, Disorders of the Vagina and Vulva.

Chlamydia

Background. This disease is caused byChlamydia trachomatis, an obligatory intracellular bacte-rium. It is the most common bacterial STD in women, occurring up to 5 times more frequently than gonorrhea. The long-term sequelae arise from pelvic adhesions, causing chronic pain and infertility. When the active infection ascends to the upper genital tract and becomes symptom-atic, it is known as acute pelvic inflammatory disease (acute PID). Transmission from an infected gravida to her newborn may take place at delivery, causing conjunctivitis and otitis media.

Symptoms. Most chlamydial cervical infections, and even salpingo-oophoritis, are asymptomatic.

Examination. The classic cervical finding is mucopurulent cervical discharge. Urethral andcervical motion tenderness may or may not be noted.

Diagnosis. Nucleic acid amplification tests (NAAT) of either cervical discharge or urine is used.

Management. The CDC-recommended treatment includes a single oral dose of azithromycin ororal doxycycline for 7 days. Patients should avoid coitus for 7 days after therapy. A test-of-cure (repeat testing 3−4 weeks after completing therapy) is recommended for pregnant women.

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USMLE Step 2 l Gynecology

Gonorrhea

Background. This disease is caused byNeisseria gonorrhoeae, a Gram-negative diplococcus.The long-term sequelae arise from pelvic adhesions, causing chronic pain and infertility. When the active infection becomes symptomatic, it is known as acute pelvic inflammatory disease (acute PID). Systemic infection can occur.

Symptoms. Lower genital tract infection may lead only to vulvovaginal discharge, itching,and burning with dysuria or rectal discomfort. Upper genital tract infection leads to bilateral abdominal-pelvic pain. Disseminated gonorrhea is characterized by dermatitis, polyarthralgia, and tenosynovitis.

Examination. Vulvovaginitis is seen on inspection. Mucopurulent cervical discharge is seenon speculum exam. Cervical motion tenderness is common with bimanual pelvic exam. A Bartholin abscess may be found if the gland duct becomes obstructed due to an acute infection. Petechial skin lesions, septic arthritis, and rarely, endocarditis or meningitis, may demonstrate with disseminated gonorrhea.

Diagnosis. Same as for chlamydia, above.

Management. Dual therapy for gonococcus and chlamydia is recommended by the CDCbecause of the frequency of coinfection. The CDC-treatment recommendations include a single dose of IM ceftriaxone plus a single oral dose of azithromycin. A Bartholin abscess needs to undergo incision and drainage with a Word catheter.

Bartholin Abscess/Cyst