ULCERATIVE SEXUALLY TRANSMITTED INFECTION

TONY S. DJAJAKUSUMAH
DEPARTMENT OF DERMATOVENEREOLOGY PADJADJARAN SCHOOL OF MEDICINE

DEFINITION IS STI THAT SHOWS ULCERATIVE

LESIONS DURING THE COURSE OF THE ILLNESS

THE IMPORTANCE OF ULCERATIVE STI

1. 2.

INCREASE THE RISK OF HIV TRANSMISSION INCREASE THE RISK OF HIV ACQUISITION

ULCERATIVE STI
1. 2. 3.

SYPHILIS CHANCROID GENITAL HERPES

SYPHILIS (1)
1. 2. 3. 4. 5. 6. 7. 8. 9.

A chronic systemic infection Manifestation virtually in all organ system if untreated Transmitted during sexual intercourse or other intimate contact Transmitted to the fetus in utero or contact to maternal lesion during birth Caused by T.pallidum Sp pallidum Never succesfully cultured in artificial media Unstainable Syphilis is a great imitator Characterized by period of active and latent phase Positive serologic test can be positive in infetion caused by other Sp. ie. pertenie, endemicum, carateum

SYPHILIS (2)
Infectious during primary & secondary Syphilis (if skin or mucosal lesions present) Early Syphilis when spirochaetemia + Seldom in early latency Latent Syphilis : Clinical sign T. pallidum can only demonstrated in tissue Diagnosisonly based on serology Poor medical treatment Congenital Syphilis 

CLINICAL MANIFESTATION
1.

EARLY SYPHILIS
1.1. Primary syphilis 1.2. Secondary syphilis 1.3. Early latent syphilis

2.

LATE SYPHILIS
2.1. Late latent syphilis 2.2. Tertiary syphilis

PRIMARY SYPHILIS (1)

Develop 3 weeks (10-90 days) after infection Chancre (syphilitic ulcer) develops at the site of inoculation (skin or mocous membrane) genital
Coronal sulcus Labia Glans penis Fourchette Preputium Rare in Cervix & Meatus vagina Corpus penis Finger, lips, tongue, tonsil, nipple, anus and anal canal

extra genital

STS maybe negative in early PS positive 1-4 weeks since the present of ulcer Chancre absent in transmission due to deep needle puncture/ Blood transfusion (Syphilis damblee)

PRIMARY SYPHILIS (2)

Characteristic features of the ulcer
1. Solitary (single) 2. Indolent (painless) 3. Indurated (button in tissue), clean base, rolled edge, dull red 4. Diameter > 0.5 cm 5. Non tender nonfluctuant ipsilateral adenopathy 6. Untreated persists for 2-6 weeks heals 7. Motile T.pallidum demonstrable in untreated ulcer Treated oral/topial AB, healing lesions not demonstrable 8. No constitutional symptom 9. Secondary infection atypical ulcer pyogenic secondary infecton 10. Constitutional symptom -

SECONDARY SYPHILIS (1)

6 weeks - 6 months in untreated case Ulcer maybe still present Manifestation of the spread of T.pallidum Generalized non specific symptoms Generalized lymphadenopathy > 50% Hepatomegaly, splenomegaly Laboratory finding : Leukocytosis, anemia, ESR
SGPT/SGOT Positive STS syphilitic hepatitis

most tissue

(fever, malaise, headache, sore throat, athralgia and anorexia)

SECONDARY SYPHILIS (2)

CUTANEUS MANIFESTATION (SYPHILLID)
EXTREMELY VARIABLE IN APPEARANCE 75% OF CASES EARLY SYPHILID IS GENERELIZED & SYMETRICAL FREQUENT LESIONS IN PALMS AND SOLES LATE SYPHILID IS LOCALIZED ASYMETRICAL

SECONDARY SYPHILIS (3)

MACULAR LESION
Symmetric generalized, Rash begins on the trunk Pruritus is absent Erythematous, brownish or hyperpigmented macules Macule may be enlarge and annular Absent scaling Macule thickened papular coexist with papular syphilid

SECONDARY SYPHILIS (4)

PAPULAR SYPHILIDS
More common Untreated dry thin collarette Varieties of papular syphilids
Papulosquamosa Psoriasiform Annular Lenticular Syphilis cornee (resemble clavi) Framboesiform (verrucous & eroded)

SECONDARY SYPHILIS (5)

Hypertropic lesion in intertriginous area condyloma lata
infectious Maybe extra genital Covered grayish exudate with numerous T.pallida

Mucous membrane patches

Buccal, labial mucosa Round or oval Grayish or denuded patches

Patchy thinning or diffuse alopecia

All hairy area may be involved Regrows in treated and untreated case

Rash occurs a few weeks after infection)

may relaps if untreated (1-2 years

DIFFERENTIAL DIAGNOSIS
PRIMARY SYPHILIS
1. 2. 3.

Chancroid Granuloma inguinale Genital herpes Pityriasis rosea Tinea versicolor Psoriasis Scabies Drug eruption Viral exanthema

SECONDARY SYPHILIS
1. 2. 3. 4. 5. 6.

LATENT SYPHILIS
Period of quiescence After completion of secondary syphilis No clinical manifestation Infrequently no history of syphilis Diagnosis is only based on STS Classification : Early phase
First year after secondary syphilis Relaps apt to occur in untreated case Transmission occasionally occur

Late phase
> in the latent period Decreasing risk of transmission

DIAGNOSIS
1. 2. 3.

Anamnesis Physical examination Laboratory examination

LABORATORY EXAMINATION
DIRECT DIAGNOSIS Specimen : Reitz serum from the ulcer Dark field examination DFA-TP PCR INDIRECT DIAGNOSIS Serologic Test for Syphilis 1 VDRL : highly sensitive screening test (Positive if titer > 1/8 or u) 2 TPHA : highly specific confirmation test

TREATMENT
A. EARLY SYPHILIS (primary, secondary, latent < 1 years duration) 1. Benzathine penicillin G 2.4 million U 2. For allergic patient : - Tetracycline 500 mg po qid for 15 days - Doxycycline 100 mg po bid for 15 days - erythromicyne 500 mg po qid for 15 days B. SYPHILIS MORE THAN ONE YEARS DURATION (latent syphilis or indeterminate or > 1 year.s duration, cardiovascular, late benign syphilis but not neurosyphilis) 1. Benzathine penicillin G 2.4 million U weekly for 3 succesive weeks 2. For allergic patients same as A2 for 30 days Doxycycline and tetracycline are CI for pregnant woman

GENITAL HERPES
TONY S. DJAJAKUSUMAH
DEPARTMENT OF DERMATOVENEREOLOGY PADJADJARAN SCHOOL OF MEDICINE

INTRODUCTION
Genital herpes is a common STI Characterized by group vesicles on erythematous base Caused by Herpes Simplex Virus (HSV) Type 1&2 Type 2 90% of cases Transmission due to viral shedding Neutralizing antibody not prevent recurrence Antibody attenuate the severity recurrence milder Impaired CMI severe, prolonged, frequently recurring

CLINICAL MANIFESTATION
1. 2. 3. 4.

FIRST EPISODE PRIMARY FIRST EPISODE NON PRIMARY RECURRENT ASYMPTOMATIC

FIRST EPISODE PRIMARY GH (1)

TRUE PRIMARY INFECTION NO HISTORY OF PREVIOUS GH LESIONS SERONEGATIVE FOR HSV AB MOST SEVERE

FIRST EPISODE PRIMARY GH (2)

CLINICAL MANIFESTATION
Incubation period 1 week (2-12 days) Painful grouped discrete vesicles in erythematous base pustules erodes ulcer grayish plaques crust Llkjkj New lesion appear until the 10th day Reepithelization wqafter 15-20 days Viral shedding 10-12 days

FIRST EPISODE PRIMARY GH (3)

CLINICAL MANIFESTATION
Localization
: Glans, coronal sulcus, urethra Penile shaft, perineal region Less frequent : scrotum, mons area, thigh, buttocks Less frequent : Perineal, perineal region, thigh, buttocks : Introitus, meatus, labia, cervix (70%)

Complication
Neurologic complication (13-35%) Aseptic meningitis Transverse meningitis Sacral radiculitis urinary retension

FIRST EPISODE NON PRIMARY GH

FIRST EPISODE RECOGNIZED POSITIVE HSV AB LESS SEVERE THEN PRIMARY MORE SEVERE THEN RECCURENT GH

RECCURENT GENITAL HERPES

REPEATED EPISODES TRIGGER FACTOR : STRESS. FATIGUE, MENSES MILDER SYMPTOMS AND SIGNS ASYMPTOMATIC VIRAL SHEDDING SEVERE DISCOMFORT PRODROMAL SYMPTOM : ITCHING, BURNING, TINGLING, DYSURIA ABORTED PRODROMEPAINFUL GROUP VESICULES ON ERYTHEMATOUS BASE REEPITHELIZATION + 10 DAYS VIRAL SHEDDING + 4 DAYS RATE OF RECCURENCE 5-8/YEAR RATE OF RECCURENCE HSV-2 > HSV-1

DIFFERENTIAL DIAGNOSIS
1. 2. 3. 4.

CHANCROID SYPHILIS WITH SECONDARY INFECTION TRAUMATIC GENITAL ULCER CONTACT DERMATITIS

LABORATORY EXAMINATION
DIRECT EXAMINATION OF CLINICAL SPECIMEN
1. 2. 3. 4. 5.

HISTOPATHOLOGY CYTOPATHOLOGY ELECTRON MICROSCOPE IMMUNOFLUORESCENCE METHODS PCR

SEROLOGY

TREATMENT
PRESENTATION
First episode
Severe, requiring hospitalization When lesion already crusted All others Acyclovir 5 mg/Kg IV over 60 min tid for 5 days No antiviral treatment Acyclovir 200 mg po 5 times daily for 10 days No antiviral treatment Acyclovir 200 mg po 5 times daily Suppressive acyclovir 400 mg twice daily Acyclovir maybe considered for severe neurologic complication and primary disease

TREATMENT

Reccurent episodes
Infrequent/or mild Infrequent moderate- severe Frequent Pregnant wpmen

Topical acyclovir is ineffective

CHANCROID

TONY S. DJAJAKUSUMAH
DEPARTMENT OF DERMATOVENEREOLOGY PADJADJARAN SCHOOL OF MEDICINE

INTRODUCTION
Synonim : soft chancre, ulcus molle Characterized by :
Multiple painful ulcer Painful inguinal lymphadenopathy Auto inoculable

Etiologic agent : H. ducreyi

Occasionally colonized in the mouth, cervix and penis

Uncommon in Indonesia

CLINICAL MANIFESTATION
Incubation period 4-10 days Course of the lesions
Tender erythematous papule/pustule at site of inoculation 1-2 days painful shallow ulcer deeper autoinoculation multiple ulcers

CLINICAL MANIFESTATION
Characteristic of the lesion
Multiple painful ulcers in > 50% Excavated into the skin Beefy granular base Irregular edge No induration Red margin

CLINICAL MANIFESTATION
Characteristic of the lesion
Location of chancre :
Often in prepuce, coronal sulcus Usually in vulvar area; cervical and anal may occur Oral SI oral ulcer Rarely in other part of the body autoinoculation Uni/bilateral painful lymphadenopathy in 50% of cases Suppurated fluctuant perforated fistula 2nd ulcers

DIFFERENCES IN CLINICAL MANIFESTATION BETWEEN MEN AND WOMAN

MEN
Invariably symptomatic Anal lesion due to anal SI

WOMEN
Occasionally asymptomatic
Lesion in cervix & vagina

Inguinal adenopathy
Up to 50% Large nodes suppurate

Also caused by drainage auto inoculation Frequent transient ulcer in inner thighs Relative infrequent
Differences in lymphatic drainage Suppuration not common

DIFFERENTIAL DIAGNOSIS

1. SYPHILIS 2. GENITAL HERPES

IN + 10% OF CASES COEXIST WITH ONE OF THE DISEASE

LABORATORY EXAMINATION
HISTOPATHOLOGY MICROSCOPY
Gram stain : Gram negative streptobacil 0.5-0.6 x 1.6-2.0 um
Railroad track Sensitivity 40-60% : > sensitive than culture

PCR Immunofluerecence assay Culture : Best media Columbia agar + 5% fetal bovine serum +
1% Hb + 1% iso vitaplex + 0.2% activated charcoal Colony can be pushed by wire loop School of swimming fish configuration Positive culture diagnostic

DIAGNOSTIC METHOD
PRESUMPTIVE Characteristic lesions Gram stain Immunofluorescence assay
(monoclonal antibody)

DIAGNOSTIC Culture PCR

TREATMENT
1. 2.

3. 4. 5.

CIPROFLOXACIN 500 MG PO BID 3 DAYS ERYTHROMYCIN STEARATE 500 MG PO TID 7 DAYS AZYTHROMYCIN 1 GRAM PO SINGLE DOSE CEFTRIXONE 250 MG IM SINNGLE DOSE AMOXYCILLIN + CLAVULANIC ACID PO TID 7 DAYS

Concurrent HIV infection failure of treatment Not due to resistency Promising regimen fleroxacin 400 mg po once daily 5 days

GENITAL ULCER
CHANCROID SYPHILIS GENITAL HERPES H. simplex Virus II 1-12 weeks Male Glans penis, preputium, corpus penis Female Cer ix, vagina, labia, fourchette,clitoris Multiple Primary G > recurrent HG

Etiology Incubation period Predilection

H. Ducreyi 1-14 (+ 3-6) days Male Frenulum, preputium, sulcus coronarius, glans & corpus penis. Female Cervix, vagina, fourchette, labia, perianal. 1-3 to 10

T. pallidum 10-90 (21) days Male Sulcus coronarius, glans & corpus penis, perianal Female Cervix, vagina, fourchette, labia

Number of lesions

1, sometimes > 1

Ulce

CHANCROID

S PHILIS

GENITAL HERPES Vesicule 1 cm Small he pe i o m Ve shallo igh ed

Ini ial lesion Size Shape

Macule, papulae pus ule p o 2 cm I egula shape and bo de . nde mined Filled i h pus, bleeds easil , cove ed i h nec o ic issue

Papule Some mms o 1 2 cm Sha pl dema ca ed, ound/oval. Rolled edge Clean, dull ed, cove ed i h se um

o de ase

Indu a ion Pain ++

_ +

GHANCROI Adenopathy 50 , usually solitary, maybe bilateral, painful erythematous. Maybe suppurated Rare

SYPHILIS ilateral, multiple, painless

GENITAL ERPES Painful, 50 primary G bilateral

Constitutional symptom Microscopy

Rare in 1

ften in primary G, rare in reccurent G Gie sa : Giant cell with ultiple nuclei Acyclo i Epi ode 1 : 5 200 g/po/7days Recc episode : 5 200 g/po/ 5 days

Gram : Gram -), forming long trail railroad tracks Cip oflokxacin 500 g/po/sd floxacin 400 g/po/sd

ark field : Corckscrew, characteristic ove ent en atin peniciline 2,4 illion/ i /sd epends on the stage

Treat ent

FURTHER READING
Ballard RC, Morse SA Chancroid, In Morse A, Moreland AA, Holmes KK,eds. sexually transmitted diseases and AIDS 2nd ed. London: Mosby wolfe 1996:47-64 Moreland AA, Shafran SD, Byran J et al. Genetil Herpes. In Morse A, Moreland AA, Holmes KK,eds. sexually transmitted diseases and AIDS 2nd ed. London: Mosby wolfe 1996:207224 Larsen SA, Thomson SE, Moreland AA. In Morse A, Moreland AA, Holmes KK,eds. sexually transmitted diseases and AIDS 2nd ed. London: Mosby wolfe 1996:21-46 King A, Nicole. Venereal diseases ELBS, London 1975

PROGRAM of REPRODUCTIVE SYSTEM

VENEREOLOGICAL EXAMINATION

What is the clinical skills program?

 The clinical skills program is designed to

develop and refine the clinical techniques of medical students:

Human interaction skills Physical examination behaviors

education of a sensitive and effective physician

Goals
 To prepare students for patient contact in

community office practice programs, clinical clerkships, residency and future personal office practice

Objective
 After completing a practice of venereological

examination the students will be able to perform the venereological examination

COMPREHENSIVE PATIENT MANAGEMENT OF SEXUALLY TRANSMITTED INFECTION (STI)


    

Correct diagnosis Effective treatment Counseling on risk reduction Partner notification & treatment Testing for other STIs Clinical follow up

WHAT IS THE ESSENTIAL COMPONENTS IN THE DIAGNOSIS of STI?

 History taking  Genital/Venereological Examination  Laboratory Examination

HOW THE STI PATIENTS FEEL ABOUT THEIR CONDITIONS?

 Emotionally disturbed
 Embarrassed
 

To show the genital Done a multiple sexual behaviour

WHAT SHOULD WE DO ?
EXAMINE THE PATIENT IN : Privacy & chaperon Comfortable Confidentially Non-judgmental Explained : the examination & test

SEXUALLY TRANSMITTED INFECTIONS (STI)

INFECTIONS BY A NUMBER OF VIRUSES, BACTERIAS, FUNGI, PROTOZOAS OR ARTHROPODS THAT ARE TRANSMITTED PRIMARILY THROUGH HETERO OR HOMOSEXUAL

STISTI-ASSOCIATED PRESENTING PROBLEMS

 Urethral discharge  Vaginal discharge  Genital ulcer  Scrotal swelling  Inguinal swelling  Lower abdominal pain  Vegetations

URETHRAL DISCHARGE

URETHRAL DISCHARGE GONOCOCCAL URETHRITIS NONNON-GONOCOCCAL

URETHRITIS
ETIOLOGY INCUBATION PERIOD CLINICAL FEATURES DYSURIA DISCHARGE QUALITY
SEVERE PURULENT MILD MUCOID LESS (scanty) URETHRAL SMEAR: > 5 PMNs/hpf N. gonorrhoeae 2-5 DAYS C. trachomatis 1-5 WEEKS

DISCHARGE QUANTITY MORE (abundant) MICROSCOPY

URETHRAL SMEAR: > 5 PMNs/hpf GRAM NEGATIVE STAIN: INTRA-CELLULAR DIPLOCOCCI

VAGINAL DISCHARGE

THE CAUSES OF VAGINAL DISCHARGE

1. PHYSIOLOGICAL puberty, menstrual cycles, sexual arousal, pregnancy 2. PATHOLOGICAL  noninfective : chemical, foreign body, gynecological  infective : STI & non STI patogen cervical infections, vaginal infections

THE SYMPTOMS & SIGNS OF ABNORMAL VAGINAL DISCHARGE

 EXCESSIVE
  

MALODOROUS YELLOW OR PURULENT INFLAMMATION

VAGINAL DISCHARGE : cervical infection

DIAGNOSIS ETIOLOGY GONOCOCCAL CERVICITIS N. gonorrhoeae NONNON-GONOCOCCAL CERVICITIS C. trachomatis 1-5 weeks 70% asymptomatic, vaginal discharge Erythema, bleeds easily, ectopic cervix, purulent discharge (37%) GENITAL HERPES Herpes simplex virus 2-10 days Symptomatic (>> primary infection) or asymptomatic Erythema, erosions, necrosis, purulent discharge

INCUBATION 2-5 days PERIOD SYMPTOMS 50% asymptomatic, vaginal discharge, vaginal bleeding Erythema, bleeds easily, purulent discharge, may appear normal

CERVIX

VAGINAL DISCHARGE : vaginal infection

DIAGNOSIS ETIOLOGY

NORMAL
Lactobacilli

YEAST VULVOVAGINITIS
Candida spp.

TRICHOMONAL VAGINITIS
T. vaginalis

BACTERIAL VAGINOSIS
G. vaginalis, M. hominis, Mobiluncus sp,etc vulvovaginal malodor, slightly > discharge

TYPICAL SYMPTOMS

none

vulvar pruritus and/or irritations, sometimes discharge >> scant to moderate white or yellow clumped, adherent plaques

purulent discharge, often profuse, sometimes vulvar pruritus profuse yellow, tan homogeneous

DISCHARGEDISCHARGE- amount variable (usually scant) clear or white - color - consistency nonhomogeneous, floccular

scant to moderate usually white homogeneous, low viscosity,smoothly covers vaginal mucous membrane

VAGINAL DISCHARGE : vaginal infection

DIAGNOSIS
Inflammation of vulvar / vaginal epithelium

NORMAL
None

YEAST VULVOVAGINITIS
Erythema of vaginal epithelium, introitus; vulvar dermatitis common Usually < 4.5

TRICHOMONAL VAGINITIS
Erythema of vaginal vulvar epithelium; << petechiae of ectocervix (strawberry cervix) Usually > 5.0

BACTERIAL VAGINOSIS
None

pH of vaginal fluid

Usually < 4.5

Usually > 4.7

Amine None (fishy odor) with 10% KOH Microscopy Normal epithelial cells, Lactobacilli >> (large Gram positive rods)

None

Present

Present

Epithelial cells, yeasts or pseudomycelia (up to 80%), usually few PMNs

PMNs >>, motile Clue cells; profuse Trichomonads (80- mixed flora with few 90% symptomatic or no Lactobacilli cases) << in asymptomatic

GENITAL ULCER

DIAGNOSIS

CHANCROID

SYPHILIS

GENITAL HERPES

ETIOLOGY INCUBATION PERIOD

H. ducreyi 1-14 days (+ 3-6 days)

T. pallidum 10-90 days (21 days) Men : sulcus coronarius, glans penis & penile shaft, perianal area Women : cervix, vagina, fourchette, labia 1, sometimes > 1

Herpes simplex virus (type 2 >>) 2-10 days Men : glans penis, prepuce, penile shaft Women : cervix, vagina, labia, fourchette, clitoris

PREDILECTION Men : SITES fraenulum, prepuce, coronal sulcus, glans penis & penile shaft Women : cervix, vagina, fourchette, labia, perianal area NUMBER OF LESIONS 1-3 (up to 10)

Multiple, Primary infection >> recurrent infection

GENITAL ULCER
DIAGNOSIS ULCERS : - Initial lesions CHANCROID SYPHILIS GENITAL HERPES Macules, papules, pustules Variable, < 2 cm Ragged undermined, irregular Excavated Dirty, gray/yellow necrotic, bleeds easily, (-) Usually very tender Papules Vesicles

- Diameter

0,5 -1,5 cm Well-defined border, elevated, round or oval. Superficial or deep Clean, red, with clear serum Firm (-)/uncommon

1-2 mm erythematous

- Edge

- Depth - Base - Induration - Pain

Superficial Bright red (-) Frequently tender

DIAGNOSIS Inguinal adenopathy

CHANCROID Unilateral/bilateral, fluctuant, painful, overlying erythema (-) suppuration (+) Seldom Gram : Gram (-), parallel-arrays (rail-track or school of fish)

SYPHILIS Bilateral, multiple, firm, nonfluctuant, Painless, overlying erythema (-) Seldom (primary syphilis) Dark field micr : Treponemal movement

GENITAL HERPES Bilateral, firm, moderatelly tender, nonfluctuant, overlying erythema (-)

Constitutional symptoms Microscopy

Often (primary inf.) Seldom (recurrent inf.) Giemsa : Multinucleated giant cells

VENEREOLOGIC AL EXAMINATION IN FEMALE

Greet client Explain the patient Wash your hand Voiding prior examination

Venereological examination : The patient should be examined in privacy, preferably by chaperon with the same gender

CASE Mrs. Vadis 22 years old, single, working in massage parlor with many sexual partners, visiting STI Clinic with the chief complain of increased vaginal discharge for 1 week. The last sexual intercourse was 2 weeks ago without condom.

EXPLAIN THE PURPOSE OF EXAMINATION

Mrs. Vadis, after I asked you all about your signs and symptoms, now allow me to examine your genital. The purpose of this procedure is to find the causes of your problem. During examination, I will take the specimen collection from the cervix and vagina, its often painful, but dont worry, I will try to perform it gently.

Dr : have you urinate Mrs. vadis? Mrs. Vadis : Not yet doc! Dr : oke, for succesfull examination please urinate.

Lithotomy Position

Put the Glove

Inguinal Region Inspect

Inguinal Region

Palpate

Lymphadenopathy ? : si e, consistency & tenderness

Skin & Pubic Hair

Lesion, lice, nits ?

Papule Molluscum Contagiosum

Nits

Pediculosis pubis

INSPECT LABIA MAJORA & MINORA

Erythema, oedema, fissuring & lesions : erosion, ulcer or papules ?

Erythema & Edema Candidosis Vulvovaginitis

Erosion

Genital Herpes

Ulcers

Syphilis

Ulcers

Chancroid

Papule Condylomata (syphilis 2)

Papules

Warts

Labia minora

separated

Any discharge ?

amount, colour, consistency

INSPECT URETHRA & PERIURETHRAL

Erythema, oedema, any lesions or discharge ? Discharge : amount, colour, consistency

presure by forefinger from above downword

Palpate the Bartholins gland

Infected

tender & pus ( ) at inflamed duct orifice

Insert a speculum vagina, at an angle hollow the sacrum opened to reveal the cervix

INSPECT VAGINAL WALL

Erythema, erosions, ulcers, papules or discharge ?

White clumped discharge Candidosis

Yellow, homogen, frothy discharge Trichomoniasis

INSPECT CERVIX

Erythema, oedema, any lesions or discharge ? amount, colour, consistency

External os cervix is wiped clean with cotton wool inspect

Any lesions ? Erosions, ulcers or papules ?

Cervicitis gonorrhoea