Sexually Transmitted Diseases (Venereal Diseases) Virendra N Sehgal
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Sexually Transmitted Diseases

History Taking1

History taking and the physical examination of a venereal disease patient is similar to that in general medicine. This examination should be preceded by reassurance and evincing confidence in him. This is imperative, for venereal diseases are invariably associated with some psychological aberrations. An endeavour should always be, to form an absolute picturesque genesis of the relevant disease. In order to accomplish this objective, an emphasis should be laid on the following points while forming the history.
Marital status—Single/married/divorcee/or a widow/widower. Occupation, whether living at home or away from home and patient's temporary and permanent address. Recent history of sexual exposure should be taken in great detail. The exact dates of exposure and its particulars such as, place of exposure; whether it was heterosexual or homosexual; contraceptives used, if any; details of intercourse; genital/orogenital/oral: history of trauma to genitalia and amount of money paid, should be recorded. It is necessary to ask about the health of sexual partner incorporating whether she was having vaginal discharge and/or genital sores at the exposure time, and details of each should be noted.
Venereal disease patient usually presents with a complaint of either discharge per urethra and/or genital sore. In patients presenting with discharge per urethra and burning micturition, the following details should be noted: amount—copious/scanty; colour—milky white/yellowish/bloodstained; consistency—thin watery/thick, and its relation to micturition. History of morning gleet, dull pain in the abdomen/perineum, sense of fullness of rectum and pain during defecation should also be elicited.
In patients presenting with genital sore(s), further details namely number of lesions; whether they are painful or painless; any preceding erythema and/or burning sensation; discharge from the sore and swelling confined to glans, prepuce or both, should be recorded. In patients presenting with genital growth, it is necessary to ask whether it bleeds on touch, and its rate of progress. Further, history of constitutional features and/or skin lesions may be contributory. The incubation period in particular may be recorded, as it may be very useful for arriving at a diagnosis. The 2incubation period in tropics, is as follows: gonorrhea and chancroid (2–5 days); syphilis (9–90 days); herpes genitalis (4–5 days); venereal warts (6–32 weeks); lymphogranuloma venereum (3 days-3 weeks); donovanosis (8–80 days) and non-specific urethritis (8–14 days).
Past history of venereal disease(s) and response to treatment should also be enquired. Personal history includes details about education, occupation, monthly income and addiction (alcohol/narcotics). In married patients, the date of last marital exposure, relation with the spouse and frequency of sexual intercourse, should be enquired. When relevant, enquire about health of the parents, siblings and causes of death, if any, in the family.
In female cases menstrual history is recorded. The obstetric history is noted in detail. The number of living children and their health, the causes of death, if any, and dates of any miscarriages, abortions or stillbirths, is important.
 
 
Clinical Examination
The patients should always be examined in daylight if possible. The genitalia are examined for any discharge, inflammation, edema, erosions, ulcers, warts or rashes. In case the prepuce is phimotic, the subpreputial discharge should be cleaned with a moist saline gauze and the prepuce is retracted as far back as possible. Examination of the genitalia should include the glans, coronal sulcus, external urethral meatus, shaft, scrotum, and pubic region. Other sites namely the inguinal, perianal regions, thighs, buttocks and breasts are also inspected. All mucous membranes are examined in detail.
The details of urethral discharge are recorded as amount; colour; consistency; whether blood-stained or not; any associated redness and swelling of external urethral meatus. The following details of ulcers are then noted; number—single/multiple; size; shape—irregular/circular; borders—clear cut/everted/undermined/inflammatory; depth—superficial/deep; floor—clean/covered with necrotic material/having healthy granulation tissue; tenderness; induration and tendency to bleed on touch. The inguinal, external iliac, epitrochlear, axillary and cervical group of lymph nodes are also examined and their details noted as unilateral/bilateral; single/multiple; discrete/matted; consistency; tenderness; mobility; erythema of overlying skin and fixity to surrounding tissues.
The female patients should be examined in lithotomy position, in the presence of a female attendant, after taking consent of the patient. The abdomen is palpated for signs of tenderness and presence of scars. The pubic hair are examined for the presence of lice. The perineum, vulva, labia majora, labia minora and fourchette are examined for any discharge, signs of inflammation, edema, erosion, ulcers, warts or rashes. The labia are separated, the urethra examined and the Bartholin's glands palpated. After that a Cuscos bivalve speculum is passed inside the vagina and vaginal portion of the cervix is inspected. This examination should not be performed in a virgin. In children and virgins, the cervix is visualised with the ophthalmoscope for impacted foreign body or any other abnormality. The cervix is examined for any discharge and its character noted. After cleaning the discharge, the cervix is examined for any erosion/ulceration. As the speculum is being gradually withdrawn, the vaginal walls are inspected for any inflammation, cheesy plaques of candidosis and vaginal discharge. The details of discharge and ulcers are noted as in male patients. The smell of vaginal discharge, in particular, should be noted for this discharge in consequence to Trichomonas vaginalis is foul smelling and may be the presenting complaint. In addition pH of the discharge is worth recording. The fornices, the 3uterus and its appendages are then palpated. The movement of the cervix elicits marked tenderness in presence of pelvic inflammatory disease (PID). This sign is called Chandelier's sign. The urethra is massaged with the finger forward along the anterior vaginal wall. Any discharge from the urethra or paraurethral glands of Skene is noted. Examination for the extragenital lesions, mucosa and lymph nodes is done as in males. A rectal smear and a throat swab should be taken whenever indicated.
The systemic examination must include details of the skin and mucosal surface, lymph nodes, joints, central nervous system, cardiovascular and respiratory system. An ophthalmic examination should also be done.
 
OFFICE PROCEDURES
Two glass test The two glass test is done to assess the status of urethra. It gives a fair index of spread of gonococcal infection. The patient is asked to pass urine in two separate glasses, half in each glass. In case of urine being hazy in the first glass, it suggests anterior urethritis, while in the second, it indicates that infection has spread to the posterior urethra.
Prostatic massage It is a vital component of clinical examination and is usually performed 28 days after adequate and specific treatment for urethritis. It should be undertaken in cases where past history of discharge per urethra; burning, frequency or difficulty in micturition, heaviness in lower abdomen and sense of fullness of rectum is experienced. It is also indicated in cases of posterior urethritis, where the second glass (in two glass test), is hazy. Further, it is imperative to prepare a urethral smear and then the patient is asked to void the urine before the prostatic massage is undertaken.
The object of the prostatic massage is to express the prostatic fluid from the gland into the posterior urethra, from where it will pass into anterior urethra and can be collected at the urinary meatus. After evacuating the bowels, the patient is placed in the knee-elbow position. The perianal region is inspected for piles, ulcers or growth. The patient should be told about what is to be done. He is also instructed to open his mouth and breathe smoothy. A gloved index finger lubricated with vaseline is kept at the anal opening and gentle pressure is exerted until the finger gradually slips into the rectum. The finger is then passed over the prostate till the superior border is felt. Its size, shape, consistency, state of overlying mucosa, surface (whether regular or not) and presence of tenderness, is noted. The groove between prostate and the seminal vesicles, is also felt. The condition of median groove is noted. Massage is undertaken only if there is no evidence of acute infection. The finger is gently passed above the lateral edge of the right lobe and firmly brought down in a direction parallel to the midline. Two other strokes are made with the finger medially. The same procedure is used on the left lobe. As a result the prostatic secretion is expressed into the urethra. Finally the finger is brought down in the midline twice, so as to express the fluid through the sphincter into the penile urethra. During this period the patient feels a desire to urine and the secretions from urethral meatus are collected on clean glass slides for laboratory examination. Alternatively prostatic massage may be performed by stroking it from either side in a transverse direction.
Gram's stain The smear from the material is prepared with the platinum loop, it is dried and fixed by passing over the flame. It is stained with 0.5 per cent methyl violet (crystal violet) solution for 20–30 seconds. The excess stain is poured off and Lugol's iodine solution is added 4to wash away methyl violet. Iodine is allowed to act for 30–60 seconds. Lugol's iodine is washed repeatedly with absolute alcohol until the colour ceases to come out of the preparation. Later the smear is washed with water and counter stained with 0.5 per cent safranine or neutral red for 30–60 seconds. Again it is washed with water and dried in between blotting papers. The stained smear is now ready for microscopic examination.
Wet preparation Wet preparations are useful to demonstrate Candida albicans and Trichomonas vaginalis. The method adopted for the collection of material, however, differs.
Candida albicans For its demonstration the scraping or discharge is collected on a clean glass slide, to which a drop of KOH (10–20 per cent) is added. After a short interval, the slide is examined under the light microscope for the spores or pseudomycelia.
Trichomonas vaginalis Here again the discharge is collected on a glass slide. It may either be instantly examined or a drop of normal saline is added, before undertaking the examination. The morphology or motility can well be seen under light or dark-ground microscope.
Dark ground examination The material for the dark ground examination for Treponema pallidum is collected, by applying an edge of the cover slip to the lesions such as primary chancre, condylomata lata, mucous membrane patches, after bathing them with normal saline. While the material from the lymph glands is collected by injecting a little quantity of normal saline into the glands, and aspirating it. This material too is taken on a cover slip which is later placed on a thin slide and examined under the dark-ground microscope.
 
 
Serological Tests for Syphilis
At least one non-specific-VDRL, TPHA and one specific TPI/ FTA-ABS test should preferably be performed in each case.
 
Tissues Smear for Donovan Bodies
After thorough clearning of the lesion, a small piece of granulomatous tissues is removed from the edge of a lesion with a forceps. The blood from the tissue is absorbed in a filter paper and an imprint of the tissue is made on a glass slide. The smear is dried, fixed, and stained with Giemsa's stain. The characteristic Donovan bodies are located in the mononuclear cells and are usually recognised by their “Safety pin” appearance, produced by the bipolar distribution of the chromatin material. In early cases the Donovan bodies may show no capsule. Occasionally, Donovan bodies may be seen lying extracellularly, consequent to rupture of a heavily parasitised mononuclear cell.