Sexually Transmitted Conditions

Urethritis

• Gonococcal urethritis is caused by Neisseria gonorrhoea. It presents with urethral burning and a thick yellow or brown discharge. There is usually a history of sexual contact during the previous 3 to 10 days
• The two most common organisms responsible for non-gonococcal urethritis are Chlamydia trachomatis or Ureaplasma urealyticum. Both organisms cause a clear or whitish discharge which commonly occurs 7 to 21 days after contact

If urethritis is suspected intra urethral swabs should be taken and sent off for culture and sensitivity. Special swabs are required to detect chlamydia. A Gram stain should also be done at the same time. If Gram negative diplococci are present within leukocytes then the diagnosis of GC in made.

Many untreated cases of urethritis will resolve spontaneously but others will lead to scarring of the urethra with stricture formation. Systemic spread of gonococcus is also possible with arthritis, meningitis and septicaemia. Refer to GU clinic.

It is important that all recent partners also be treated. The patients should be sure to use a condom until the end of treatment. Follow up should be arranged for repeat testing one week after the end of treatment.

Don't forget that gonorrhoea and chlamydia are notifiable conditions.

Genital Lesions

The Herpes simplex virus typically presents as painful vesicles on the external genitalia. It is diagnosed by its characteristic blistered appearance and positive viral cultures. Herpes simplex virus types 1 and 2 are both commonly cultured from genital lesions with type 1 being of oral origin. Treatment includes of oral Acyclovir 400 mg TID for 10 days. This does not cure the disease but does speed the healing process. Recurrent eruptions are the rule, especially in times of stress. Infected patients should avoid intimate contact while the lesions are present. Unfortunately, the virus can still be spread while the carrier is asymptomatic.

Condylomata accurninatum is caused by the human papilloma virus and is diagnosed clinically by its characteristic wart-like appearance. It has been associated with cervical and penile cancer. For this reason all lesions should be fully treated. Options include topical Podophyllin, liquid nitrogen or trichloroacetic acid. Patients should return for weekly treatment until all signs of disease are gone. If the lesions are very extensive laser vaporization may be necessary and a referral is appropriate.

Syphilis causes a clean painless ulcer. It is caused by the spirochete Treponema pallidum. The diagnosis can be made by the finding of spirochetes on dark-field exam. Serological tests include rapid plasma reagin (RPR) and VDRL. However, these test may remain negative for up to 3 weeks following the appearance of the ulcer or chancre. The fluorescent Treponema antibody absorption test (FTS-ABS) is the most specific and sensitive test. If left untreated serious systemic spread is possible, most notably to the CNS. Treatment consists of penicillin G 2.4 million units IM given as a one time dose. If the patient is allergic to penicillin, Doxycycline 100mg for 14 days is a reasonable alternative.

Syphilis is also notifiable.

Cancer of the Penis

This squamous cell carcinoma is not common (<I% of all male cancers). It may be of viral aetiology. It has been associated with the human papilloma virus and cervical cancer. It presents as an ulcerative, nodular or fungating lesion on the penis, usually starting on the glans or prepuce (foreskin). If there is any question in your mind about the nature of a penile lesion, a referral to a urologist should be made.

Deep biopsies will be done if the lesion is suspicious. Palpable inguinal lymphadenopathy is present in many patients, but in only 50% will it represent metastases. Half will be secondary to inflammation. Treatment is for the most part surgical. Unless the lesion is discovered very early, most penile cancers are treated with penile amputation.