Atlas of pathophysiology, 2 Edition

Part II - Disorders

Genital Diseases

Sexually Transmitted Infections

Chlamydial urethritis in men and chlamydial urethritis and cervicitis in women are a group of infections caused by the same organism. They're transmitted by orogenital contact or vaginal or rectal intercourse with an infected person. Chlamydial infections are the most common sexually transmitted diseases in the United States.

Causes

Chlamydia trachomatis

Signs and symptoms

·   Commonly asymptomatic

·   Dysuria, urinary frequency, pyuria, pelvic or abdominal pain

·   Chills, fever

·   Genital discharge, genital pain

·   Vaginal bleeding after intercourse; painful scrotal swelling

Diagnostic tests

·   Swab culture of the infection site shows C. trachomatis.

·   Serologic studies reveal previous exposure.

·   Enzyme-linked immunosorbent assay shows C. trachomatis antibody.

Treatment

Appropriate antibiotic therapy with tetracyclines, azithromycin, or erythromycin

Gonorrhea

Gonorrhea of the genitourinary tract (most commonly the urethra or cervix), or, occasionally, the rectum, pharynx, or eyes, almost always follows sexual contact with an infected person. An infected mother can transmit it during delivery.

Causes

Neisseria gonorrhoeae

Signs and symptoms

In males

·   May be asymptomatic

·   Three to 6 days after contact, urethritis, dysuria, purulent discharge, redness, and swelling at the site

In females

·   Generally asymptomatic

·   Occasionally, inflammation, burning, itching, or greenish-yellow discharge

In either sex

·   Urinary frequency, incontinence, pelvic and lower abdominal pain or distention

·   Nausea, vomiting, fever, tachycardia, polyarthritis (advanced disease)

Gonococcal ophthalmia neonatorum

·   Lid edema, redness, abundant purulent discharge appearing 2 or 3 days postpartum

Diagnostic test results

·   Positive culture of N. gonorrhoeae from site confirms infection.

·   Conjunctival scrapings confirm gonococcal conjunctivitis.

·   Gonococcal arthritis is confirmed by Gram stain of smears from joint fluid and skin lesions.

Treatment

·   Ceftriaxone plus doxycycline

·   Alternative agents given with doxycycline: cefixime, ofloxacin, spectinomycin, ciprofloxacin, erythromycin

Genital herpes

Genital herpes is an acute inflammatory disease of the genitalia. It's typically transmitted through sexual intercourse, orogenital sexual activity, kissing, and hand-to-body contact. Pregnant women may transmit the infection to neonates during vaginal delivery if an active infection is present.

Causes

·   Herpes simplex virus (HSV) type 2—most common

·   HSV type 1—increasing incidence

Signs and symptoms

In both men and women after a 3- to 7-day incubation period

·   Appearance of genital vesicles

·   Fever, malaise, dysuria, possible lesions on mouth or anus

In women

·   Cervix (primary site), labia, perianal skin, vulva, or vagina

·   Leukorrhea

In men

·   Vesicles on glans penis, foreskin, or penile shaft

Diagnostic test results

·   Staining of lesion scrapings shows characteristic giant cells or intranuclear inclusion of herpes virus infection.

·   Tissue culture shows isolation of virus.

·   Tissue analysis shows HSV antigens or deoxyribonucleic acid.

Treatment

·   Acyclovir:

§  oral administration for new infection or recurrent outbreaks

§  I.V. administration for patient hospitalized with severe genital herpes or immunocompromised patient with a potentially life-threatening herpes infection

§  daily prophylaxis is only appropriate for patients with frequent outbreaks and may not decrease transmission rate

·   Other antiviral agents, such as famciclovir, valacyclovir, penciclovir, foscarnet

Genital warts

Genital warts, also known as venereal warts or condylomata acuminata, grow rapidly in the presence of immune suppression or pregnancy and can accompany other genital infections.

Causes

Human papillomavirus

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MANIFESTATIONS OF SEXUALLY TRANSMITTED INFECTIONS

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Signs and symptoms

·   After a 1- to 6-month incubation period (usually 2 months), tiny, red or pink, painless swellings on moist surfaces:

§  subpreputial sac, in urethral meatus and, less commonly, on penile shaft

§  vulva and on vaginal and cervical walls

·   Progressive disease:

§  spread to perineum and perianal area

§  large warts up to about 4″ (10 cm) in diameter

§  pedunculated; typical cauliflower-like appearance

·   Resemble condylomata lata associated with second-stage syphilis

Diagnostic test results

·   Dark-field microscopy of wart-cell scrapings show marked epidermal cell vascularization.

·   Application of 5% acetic acid turns warts white if they're papillomas.

Treatment

·   None to eradicate virus; relapse is common

·   Small warts: topical 10% to 25% podophyllum in tincture of benzoin, trichloroacetic acid, or bichloroacetic acid

·   Warts larger than 1″ (2.5 cm): carbon dioxide laser treatment, cryosurgery, or electrocautery

·   Podofilox, imiquimod, interferon, combined laser and interferon therapy

Syphilis

Syphilis is a contagious, systemic venereal or congenital disease caused by a spirochete. It begins in the mucous membranes and quickly spreads to nearby lymph nodes and the bloodstream. Transmission occurs primarily through sexual contact during the primary, secondary, and early latent stages of infection. Transmission from a mother to her fetus is possible.

Causes

The spirochete Treponema pallidum

Signs and symptoms

Primary syphilis

·   Develops after 3-week incubation period

·   One or more chancres erupt at site of infection, usually genitalia or, possibly, on anus, fingers, lips, tongue, nipples, tonsils, eyelids

Secondary syphilis

·   Symptoms develop within a few days or up to 8 weeks after onset of primary chancres

·   Symmetrical mucocutaneous lesions—of uniform size; well defined; macular, papular, pustular, or nodular:

§  commonly between rolls of fat on the trunk and, proximally, on the arms, palms, soles, face, and scalp

§  in warm, moist areas, lesions enlarge and erode becoming highly contagious, pink or grayish white lesions (condylomata lata)

·   Headache, malaise, anorexia, weight loss, nausea, vomiting, sore throat and, possibly, slight fever, lymphadenopathy

·   Alopecia, usually temporary; brittle, pitted nails

Latent tertiary syphilis

·   Absence of clinical symptoms

·   Reactive serologic test for syphilis

Late syphilis

·   Final, destructive but noninfectious stage of the disease

·   Any or all of three subtypes: late benign syphilis, cardiovascular syphilis, and neurosyphilis

Diagnostic test results

·   Dark-field microscopy identifies T. pallidum from lesion exudate.

·   Non-treponemal serologic tests include the Venereal Disease Research Laboratory (VDRL) slide test, the rapid plasma reagin test, and the automated reagin test, detecting nonspecific antibodies.

·   Treponemal serologic studies include the fluorescent treponemal antibody absorption test, the T. pallidum hemagglutination assay, and the microhemagglutination assay that detect the specific antitreponemal antibody and confirm positive screening results.

·   Cerebrospinal fluid examination identifies neurosyphilis when the total protein level is above 40 mg/dl, the VDRL slide test is reactive, and the white blood cell count exceeds 5 mononuclear cells/mm.

Treatment

·   Primary, secondary, or early latent: single injection of penicillin G benzathine I.M.

·   One year duration (latent): penicillin G benzathine I.M.

·   Nonpregnant patients allergic to penicillin: oral tetracycline or doxycycline for 15 days for early syphilis, 30 days for late infections

Trichomoniasis

A protozoal infection, trichomoniasis affects about 15% of sexually active females and 10% of sexually active males. Common sites of infection in females include the vagina, urethra and, possibly, the endocervix, bladder, Bartholin's glands, or Skene's glands; in males, the lower urethra and, possibly, the prostate gland, seminal vesicles, or epididymis.

Causes

Trichomonas vaginalis, a tetraflagellated, motile protozoan

Signs and symptoms

·   None in approximately 70% of females and most males

·   In females with acute infection:

§  gray or greenish-yellow and possibly profuse and frothy, malodorous vaginal discharge

§  severe itching, redness, swelling, dyspareunia, dysuria; occasionally, postcoital spotting, menorrhagia, dysmenorrhea

Diagnostic tests

·   Microscopic examination of vaginal or seminal discharge or urine specimen is positive for T. vaginalis.

Treatment

Metronidazole

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EFFECTS OF SEXUALLY TRANSMITTED DISEASES

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