HUMAN PAPILLOMA VIRUS INFECTION (VENEREAL WARTS) – MANAGEMENT
Personal hygiene is important. Affected parts should be kept clean, cool and dry. In females, any associated vaginal discharge should be investigated and treated.
Warts on the skin may be treated by the direct application of podophyllin
(10 to 25% solution in spirit or other solvent). When first used, the podophyllin should be washed away after 2 to 4 hours; if tolerated by the patient, the duration of subsequent applications can be increased. The area surrounding the wart can be protected by applying petroleum jelly before podophyllin is applied. Podophyllin is neurotoxic and large areas should not be treated at one time. Podophyllin should be avoided during pregnancy and must not be applied to the cervix. Treatment can be repeated every 2 or 3 days if necessary. Cauterisation or cryosurgery can be used for small lesions, if necessary under general anaesthetic. Trichloroacetic acid can be used for small keratinised lesions. Larger warts may be excised surgically. Carbon dioxide laser surgery possibly offers the best treatment option for patients with extensive condylomas or condylomas which are resistant to simpler treatments.
Sexual partners of patients with HPV infection should be examined.
Patients and their partners should be counselled about the prevention of transmission of the virus, including the use of condoms.
Because of the association of carcinoma with cervical HPV infection,
annual cervical cytological examination is recommended. Colposcopy is advisable for women with abnormal cervical smears. Because of the possibility of concomitant syphilis, syphilis serology should be repeated after 3 to 6 months.
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GENITAL HERPES – CLINICAL MANIFESTATIONS
The incubation period is usually from 3 to 6 days but may be longer.
In males, primary lesions usually occur on the penile shaft, prepuce or glans or the anal region.
In females, primary lesions occur commonly on the labia, clitoris, introitus and vagina. The cervix is involved in at least 50% of cases. In about 25%, the cervix is the only site of lesions and these cases may be asymptomatic.
Lesions may occur in the mouth or throat following oral sex.
Lesions may occur on the fingers, buttocks, torso and the eyes as a result of autoinoculation. Transmission may also occur on fomites.
Lesions are usually preceded by a 12-24 hour prodromal period characterised by local hypersensitivity or discomfort.
Multiple vesicles appear. They are surrounded by an areola of erythema. After 24 to 72 hours, the vesicles rupture to form painful superficial ulcers. Lesions of varying age and size coexist. Symptoms persist for 1 to 3 weeks. In 75% of cases, regional lymph nodes are enlarged and tender for up to 6 weeks.
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SYPHILIS – DEFINITION
Syphilis is caused by Treponema pallidum, one of a group of closely related spirochaetes including Tpertenue,Tcarateum and Tpallidum var Bosnia which cause yaws, pinta and endemic syphilis respectively.
In Australia, syphilis usually presents either as a primary lesion or through the chance finding of positive syphilis serology. Practitioners should be alert to the various manifestations of secondary syphilis. Congenital syphilis is rare where there is general serological screening of antenatal patients. Tertiary, cardiovascular and central nervous syphilis are rarely seen. Notifications of syphilis have increased in the past decade. This is largely attributed to a high incidence in urban homosexual men.
The usual mode of transmission is sexual intercourse. Transplacental transmission to the foetus can occur. Tpallidum may be spread by blood contamination, for example by needlestick injuries or the sharing of needles by intravenous drug users or by direct contact with open lesions.
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REACTIVE ARTHRITIS AND REITER’S DISEASE
Aseptic arthritis associated with genital tract infection is the commonest cause of acute arthritis in young adults.
Reiter’s disease is a syndrome characterised by reactive arthropathy, eye involvement and urethritis. It usually follows infection with ะก trachomatis. It is IS times more common in men than in women and is manifested by urethritis with one or more extragenital immune complications such as arthritis of the knees, ankle, spine (notably a sacroiliitis), metatarsophalangeals, wrists, elbows or tarsals, plantar fasciitis, conjunctivitis or uveitis or skin involvement (circinate balanitis or keratoderma blenorrhagica). Symptoms may occur together or sequentially. The acute disease is usually self-limited and remits after a few months. Recurrence is common. About 10% of patients develop chronic disease. Cardiac conduction disturbance or aortic incompetence may develop after some years.
Reiter’s disease may be a rare complication of gonococcal urethritis. It may also complicate gastrointestinal infections particularly shigellosis, but also infections due to salmonella and yersinia.
Reiter’s disease is one of a group of reactive arthropathies including ankylosing spondylitis and psoriatic arthritis which are commonly associated with the HLA-B27 histocompatability antigen.
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EPIDEMIOLOGICAL TREATMENT; TREATMENT SHOULD BE SPECIFIC; COUNSELLING
The term ‘epidemiological treatment’ is applied to the treatment of the sexual partner of a person known to be infected with a pathogen associated with a high risk of infection and serious sequelae whether or not there is laboratory evidence of infection.
Although treatment is given to contacts without proof of infection in some situations, shotgun therapy and repeated antibiotic prescriptions should not displace proper clinical evaluation of genital infections. Appropriate laboratory investigation should be undertaken unless precluded by circumstances.
The patient should be counselled (see p. 10) about the natural history of the disease, sequelae and method of spread, the effectiveness and side effects of therapy and the need for follow-up. The need to investigate the sexual contacts of the patient must be stressed. Advice about reducing the risk of infection should be given.
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