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OBJECTIVE 1:DIFFERENTIAL DIAGNOSIS OF PAINFUL LESIONS ON GENITAL

Definition: Any sore that appears on the penis, scrotum or urethra

INFECTIOUS
Herpes simplex
Syphilis
Condyloma
accumonata
Candida

INFLAMMATORY
Fixed drug
eruption
Balanitides
Proriasis
Contact dermatitis
Lichen planus

NEOPLASTIC
Squamous cell
carcinoma
Bowens disease

TRAUMATIC
Accident/ burns
Suction/vacuum
erection divice
Zipper entrapment
Sexual induced
Amateur
circumcision

OBJECTIVE 2 : GENITAL ULCER [PAINFUL, INFECTIOUS, NO]

ETIOLOGY
Herpes simplex

Chancroid

ETIOLOGY
Primary syphilis
(Chancre)

Lymphogranuloma
venereum

PAINFUL GENITAL ULCERS


CLINICAL PICTURES
DIAGNOSIS
Multiple, vesicular lesions that Definitive : Herpes simplex virus
on PCR, scrapping/vesical fluid
rupture painful shallow
aspirate
ulcer
Associated with constitutional
symp, lymphadenopathy on
1st time infection
Definitive : Hemophilus Ducreyi
Multiple, non-indurated,
on culture [school of fish pattern]
painful with serpiginous
border, friable base +
necrotic, purulent exudate
Tender, unilateral inguinal
lymphadenopathy
PAINLESS GENITAL ULCER
CLINICAL PICTURES
1.
Single, painless, well
demarcated ulcer, indurated
border
2.
Mild tender inguinal
lymphadenopathy
1.
Small, shallow, painless
papule/ulcer
2.
no induration
Unilateral, tender inguinal/
femoral lymphadenopathy
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DIAGNOSIS
Treponema pallidum on
darkfield microscopy/direct
fluorescent or LN aspirate
+ve serologic non treponemal
testing
Definitive : Chlamydia
trachomatis on culture
LN aspirate +ve
immunofluorescence = Bodies
inclusion/+ve C.trachomatis

Granuloma inguinale

Persistent, painless, beefy red


papules/ulcer
No lymphadenopathy

Definitive :
1. Intracytolasmic Donovan
bodie on Wright stain
2. +ve Giemsa stain

OBJECTIVE 3: INGUINAL LN ENLARGEMENT IN STD


Site : Situated in the crease between the leg and pelvis (laterally)
Drainage: Penis, scrotum, perineum, gluteal region, lower abdominal wall, lower
anal canal
Causes : Herpes simplex, chancroid, herpes simplex, lymphogranuloma venereum,
gonococcal infection

OBJECTIVE 4 : DIFFERENTIAL DIAGNOSIS OF URETHRAL DISCHARGE


Definition: Secretion passed through the urethral meatus at times other than
voiding. It could be clear, purulent or bloody.
Differential diagnosis
PHYSIOLOGIC
AL

1. Prostatorrhea : An escape of prostatovesico fluid from external urinary


vesicle.
Character: Clear, sticky, whitish discharge [no pus]
Timing: During micturition or defecation
Causes : In unmarried males and those without regular sexual activity,
prostate may be congested and full of secretion.
2. Urethrorrhoea : An escape of normal urethral secretion from Cowper
and Littre gland
Character: Clear viscid mucus [no pus]
Timing : During sexual excitement and before absolute normal
ejaculation
Causes : To lubricate the urethra and neutralize the acidic urine
GONORRHEA
NON-GONOCOCCAL

PATHOLOGIC
AL
Def: Acute infectious STD affects the epithelium
of lower urogenital system
Etio: Neisseria gonorrhea
MOT: Sexual contact [Homo,hetero,orogenital]
Asexual [Contaminated towel,hand]
IP : 2-5 days
CP: 1. Gonococcal ant Urethral discharge,

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1. Infectious
Sexually transm. urethritis -Chlamydia,
mycoplasma genitalium
Non sexual urethritis Bacterial + UTI,
schistommomiasis
2. Infected organ: Cystitis, Balanitis,
Prostatitis

edema of urethral orifice


2 . Extends to post urethral Dysuria,
frequency, hematuria, urgency, const sym

3. Neoplastic : Urethra polyp, carcinoma


4. Anatomical dis : Foreign body in urethra,
urethral stricture
5. Irritants from local antiseptic

OBJECTIVE 6 : INCUBATION PERIOD OF STD


ETIOLOGY
Gonorrhea Urethritis
Syphilis
Chancroid
Granuloma Inguinale
Lymphogranuloma Venerium
Genital Herpes
Aids

INCUBATION PERIOD
2-5 days
9-90 days
7 days [3 days to 3 weeks]
9 -90 days
1-6 weeks
2-7 days
3-10 years

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OBJECTIVE 5 : INVESTIGATION OF STD


Causative organism
Treponema pallidum
Specimen collected
Serous discharge from 1ry
ulcer
LN aspiration
Blood/CSF [for serological
test]
Causative organism
Hemophilus ducreyi
Specimen collected
From base/margin of ulcer
Aspirate from unruptured
bubo
Causative organism
Klebsiella granulomatis

SYPHILIS
1. Dark field microscopy
Bright, corkscrew-shaped
2. PCR
3. Tissue biopsy
4. Serological test
Reagin test [non-specific antibodies test]: Wasserman
reaction, Rapid Plasma Reagin Test
Trepomal test [specific] : Flourescent Treponemal
Antibody [FTA]
5. Others: CSF [>5% lymphocyte,> 40% protein]
CHANCROID
1. Direct smear stained with Grams stain
School of fish pattern
2. Direct immunofluorescent : Check antigen
3. Culture on specific media [aka beef infusion agar,
rabbits blood]
colonies of organisms
4. ELISA/PCR
GRANULOMA INGUINALE
1. Tissue Smear with Wrights/Giemsa/Grams stain
Closed safety-pin apprearance
2. PCR

Specimen collected
Tissue biopsy from the margin
of the lesion
LYMPHOGRANULOMA VENERUM
Causative organism
Chlamydia trachomatis
Specimen collected
Urethral exudate

Causative organism
Herpes simplex type 1, 2
Specimen collected
Scrapping of the lesion floor

1. Direct demonstration of C.Trachomatis by smear


or tisuue by monoclonal antibodies
2. PCR
3. Culture [by inoculation of pathogenic materials]
4. Serological test
Microimmunofluorescence [specific & sensitive]
GENITAL HERPES
1. Tzanck smear
Presence of multinucleated giant cell
2. Direct immunofluorescent antibody assay
3. Electron microscopy
HSV particles load in the specimen >106 particle/ml
4. Cell culture
Viral growth evidence by it cytopathic effect on
culture
5. ELISA/PCR
AIDS

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Causative organism
HIV 1 & 2
Specimen collected

1. Immune status [WBC:T-cell ratio <1]


2. Smear, culture, biopsy
3. Test for HIV virus
HIV culture[most accurate]
HIV antibodies by ELISA
HIV antigen by ELISA/PCR

Overall investigations
1. Dark microscopic exam 2. Serological test 3. Viral study 4. Biopsy

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OBJECTIVE 7: STD THAT CAN CROSS THE PLACENTA AND AFFECT THE FETUS
1. Bacterial STIs
Infection

Risks (M=Mom; B=Baby)

Method of Transfer

Gonorrhea

M Can result in ectopic pregnancies and


leads to PID, which can cause infertility
B Premature birth, stillbirth, eye infections

Can transfer in the birth


canal during delivery

Chlamydia

M Can result in ectopic pregnancies and


leads to PID, which can cause infertility
B Pneumonia, eye infections, blindness

Can transfer in the birth


canal during delivery

Trichomoniasis

M Can cause fallopian tube damage


B Premature birth, low birth weight

Can transfer in the birth


canal during delivery

Bacterial
Vaginosis

B Premature birth, low birth weight

Can transfer in the birth


canal during delivery

Syphilis

M Miscarriage
B Stillbirth, congenital syphilis which can
result in mental & physical problems

Can cross the placenta


during pregnancy and can
transfer in the birth canal
during delivery

2. Viral STIs
Infection

Risks (M=Mom; B=Baby)

Method of Transfer

Human
Papilloma
Virus (HPV)

M Can lead to genital cancer


B Warts can develop in the babys throat
which will require surgery

Can transfer in the birth


canal during delivery, but
very rare

Herpes

M Severe outbreak in the first trimester can


result in miscarriage
B Fetus is at higher risk. Herpes can be
contracted during pregnancy, and lead to
neonatal herpes.

Can transfer in the birth


canal during delivery and
rarely can cross the
placenta during pregnancy

Human
Immunodeficiency
Virus (HIV)

M & B HIV can develop into AIDS, which is


fatal

Can cross the placenta


during pregnancy and birth
canal during delivery. Also
through breastfeeding

OBJECTIVE 8 : VAGINAL DISCHARGE


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OBJECTIVE 9: RISK FACTOR STD

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