Sexually Transmitted Diseases



Sexually Transmitted Diseases


Mary Ruth Buchness

Herbert P. Goodheart





Overview



  • Until the 1990s, sexually transmitted diseases (STDs) were commonly known as venereal diseases. Veneris is the Latin form of the name Venus, the Roman goddess of love.


  • Syphilis is common worldwide, and since the late 1990s infectious early syphilis has re-emerged as an important disease in western Europe and the United States and is an important facilitator of human immunodeficiency virus (HIV) transmission.


  • An estimated 1% of the population of the United States has clinically evident lesions of the human papilloma virus (HPV), and 15% have latent HPV infection. HPV is thought to be one of the main causes of cervical cancer, and it has also been linked with other types of cancers of the female and male reproductive system.


  • Herpes simplex virus (HSV) infection is another STD that presently has no cure. The incidence of HSV-2 infection is also one of the most rapidly increasing among STDs in the United States.


  • Chancroid is rare in the United States and Western Europe. In the United States, it is associated with the use of crack cocaine.


  • Lymphogranuloma venereum and granuloma inguinale are also reported rarely in the United States and Western Europe and are more frequently seen in tropical and subtropical regions.



Anogenital Warts


Basics



  • Anogenital warts, for the most part, are sexually transmitted viral warts caused by infection with specific types of HPV. Despite the generally benign nature of the proliferations, certain types of HPV can place patients at a high risk for anogenital cancers.


  • Treatment of genital warts can be difficult and lengthy. Patients should be counseled about their risk of infectivity to others. They also should be advised of their increased risk of having other STDs.


  • The incubation period is variable, ranging from 3 weeks to 8 months, with a reported average, in one study, of 2.8 months.


  • HPV has been identified in the skin of infected persons at a distance of up to 1 cm from the actual lesion; this feature may explain the high recurrence rate. HPV types 16, 18, 31 to 35, 39, 42, 48, and 51 to 54 have been identified in cervical and anogenital cancers.


  • The median duration of infection is 8 months. In a study of college women, only 9% had persistence of infection after 2 years, even among those infected with oncogenic subtypes.


  • Lesions tend to be more extensive and recalcitrant to treatment in immunocompromised persons; they also tend to grow larger and more numerous during pregnancy.


  • Women with HPV infection who are pregnant or who are considering pregnancy pose specific challenges. In addition to the potential for rapid proliferation of external genital warts during pregnancy, the presence of HPV infection raises concerns regarding the risk of laryngeal papillomatosis or genital HPV infections in the newborn; however, cesarean section does not eliminate the risk of transmission.


  • More than half of children with anogenital warts have a manifestation of viral inoculation at birth or incidental spread of cutaneous warts. Such cases often are caused by nongenital HPV infections.


Risk Factors



  • Transmission of anogenital HPV infection occurs largely by sexual intercourse.


  • Other risk factors for infection include cigarette smoking, participating in sexual activity at an early age, having a high number of sexual partners, having another STD, immunosuppression, and having an abnormal Pap smear result.


Description of Lesions

There are five morphologic types of anogenital warts, and a patient may manifest more than one type. The appearance of warts depends on its location; for example, the condyloma acuminatum type tends to occur on moist surfaces.



  • Condyloma acuminatum may resemble small cauliflowers (Fig. 19.1).


  • Warts may appear as smooth, dome-shaped, papular lesions (Fig. 19.2).






    19.1 Condyloma acuminatum. Lesions resemble small cauliflowers.






    19.2 Condyloma acuminatum. Smooth, dome-shaped papular lesions are present.



  • They can look like typical verrucous papules or plaques that resemble common warts (Fig. 19.3).


  • Occasionally, they present as flat papules that may be hyperpigmented.






19.3 Condyloma acuminatum. These papules have the appearance of common warts.


Distribution of Lesions


Anogenital Lesions



  • In men, lesions occur on the penis, scrotum, mons pubis, inguinal crease, and perianal area (Fig. 19.4).


  • In women, the vagina, labia (Fig. 19.5), mons pubis, perianal area, and uterine cervix are the most common locations.


  • Intra-anal warts are seen predominantly in patients who have engaged in receptive anal intercourse.


  • Warts may also be found in the peri- and intraurethral areas in men.






19.4 Condyloma acuminatum. Perianal warts are seen in this patient.






19.5 Condyloma acuminatum. Note the labial warts in this patient. Compare to Figure 19.7.


Outside the Genital Area



  • HPV has been associated with conjunctival, nasal, oral, and laryngeal warts.



Clinical Manifestations



  • Genital warts are usually asymptomatic.


  • Lesions may become pruritic, particularly perianal and inguinal lesions.


  • They may be painful or bleed if traumatized.


  • Genital warts may resolve spontaneously or, rarely, progress to invasive squamous cell carcinoma.


Diagnosis



  • The diagnosis of anogenital warts is generally straightforward when the patient presents with the typical cauliflowerlike lesions of condyloma acuminatum or with characteristic verrucous or filiform warts.


  • However, when lesions are papular (flat-topped), pigmented, moist, or erosive, the diagnosis may not be as clinically obvious.






19.6 Cervical warts. Acetowhitening of subclinical lesions on the cervical mucosa is shown here.


Acetowhite Test on Mucous Membranes



  • In women, colposcopy is performed using 35% acetic acid, which produces an acetowhitening of subclinical lesions on the vaginal and cervical mucosa (Fig. 19.6).


  • Atypia or koilocytosis found on Pap smears represents early changes resulting from HPV infection.


Acetowhite Test on Non-Mucous Membrane Areas



  • Application of a 5% concentration of acetic acid for 15 to 20 minutes makes subclinical lesions turn white.


  • Any lesion with epidermal hyperkeratosis appears white. Thus, this method often produces false-positive results and is no longer recommended for routine screening for genital warts.


Biopsy

A biopsy may be needed to identify confusing anogenital lesions.



  • After local anesthesia with lidocaine, curved iris scissors are used to obtain a small specimen (snip biopsy) from the labia minora or perianal area. A punch biopsy or, more simply, a shave biopsy may be obtained from non-mucous membrane skin (see Chapter 26, “Diagnostic and Therapeutic Procedures”). If an ulcer or an indurated nodule is present—particularly if carcinoma is suspected—a punch or excisional biopsy should be performed.


  • A biopsy is used to rule out anogenital bowenoid papulosis or frank squamous cell carcinoma in atypical or recalcitrant lesions.





Jun 25, 2016 | Posted by in Dermatology | Comments Off on Sexually Transmitted Diseases
Premium Wordpress Themes by UFO Themes