Genital warts

Organism: Human papilloma virus (HPV)

There are many sub-types of HPV Numbers 16 and 11 are commonly associated with genital warts. Numbers 16, 18, 31, 33 and 34 are less common, but may be associated with malignant changes on the cervix in some women. There are likely to be other factors involved in malignant changes.

Indications: Bumps in the skin, or easily visible warty lesions, itching and/or soreness. Infection may be asymptomatic and painless. Lesions may appear from between 2 weeks to 2 years (or longer) after infection with the virus. In men warts may be found on shaft of the penis, urethral meatus, prepuce, perianal region and anal canal. In women they may be found at introitus, labia majora and minora, perineum, vagina or cervix (may be unnoticed if in vagina or on cervix).

Laboratory tests: HPV cannot be cultured, therefore diagnosis is made from observation of clinical features. The virus may be present subclinically and may be infectious in this state.

Treatment. This is aimed at removing the wart lesions as the virus cannot be eradicated and remains in the body for life after the initial infection. Lesions may be painted with podophyllin, podophyllo-toxin or trichloracetic acid (self treatment is not recommended unless prescribed by a doctor). Gryotherapy or cautery of lesions may be used.

Complications: Recurrence of infection and possible changes on cervical smear in women. Warts may get very large in pregnancy and all patients with genital warts should be screened for other sexually transmissible infections. This is the commonest sexually transmissible infection seen in British and American GUM clinics.

Genital herpes

Organism: Herpes simplex virus (HSV) Type 2. Genital herpes may also result from infection with HSV Type 1 which usually causes facial herpes. Auto-inoculation is possible with herpes.

Indications: Vary from mild to severe and usually appear within 2 — 20 days of direct contact with virus, through either penetrative or oral sex. Other symptoms include itching, burning, blister formation at area of discomfort, flu-like illness, enlarged inguinal glands. If there is a blister on cervix, women may develop vaginal discharge or rarely retention of urine. When the blister bursts, a shallow painful ulcer is present before healing begins. Acquisition of the virus can occur without visible lesions appearing.

Laboratory test: Swab from the ulcer or fluid from blister. In ulcer-forming genital infections, syphilis must always be excluded.

Treatment: The virus remains in the body for life and may recur. Antiviral drugs are the best available therapy at present. This does not eradicate the virus but if given early may damage viral replication. Poor compliance with therapy due to the frequency of medication, has been reported.

If recurrences are more frequent than once per month, antiviral therapy may be given for extended periods to suppress the virus. Painkillers are given for systemic effects, e.g. paracetamol or aspirin. Rest is important if an episode is severe.

Notify partner: Partner notification is advisable after diagnosis because infection may recur and it is possible to pass on the virus without clinical signs and symptoms being present (silent shedding), especially around the time of recurrence. If herpes lesions are present at the time of childbirth, a caesarian section may be performed.

Hepatitis

Organism: Several recognized viruses cause hepatitis and these may be transmitted in various ways. Hepatitis B is recognized as being sexually transmissible. Hepatitis G may be sexually transmissible but the evidence for this is not conclusive at present. Although hepatitis A is generally foodborne, it may also be sexually transmitted if there is oral — anal contact.

Indications: These are similar for all viral hepatitis infections and include tiredness, fatigue, fever, dark urine, anorexia and jaundice. In some people nothing may be noticed. Careful history-taking may suggest the likelihood of exposure to virus.

Laboratory tests: Specific serological test should be requested and tests for other sexually transmissible conditions should be considered, including offering an HIV test, depending on the risk.

Treatment: There is no effective cure for any of the viral hepatitis infections, therefore identifying risk activities and offering vaccination for hepatitis B is important. There is no vaccination for hepatitis B at present, although interferon, in combination with Ribavirin, may be effective in some people with confirmed infection.

Notify partner: This would need to be considered if the patient was a carrier of infection, identified by laboratory tests.

Complications: Rarely, chronic hepatitis (active or not) may develop, or a severe illness, such as cirrhosis of the liver or carcinoma. People with hepatitis G may develop chronic illness. Patients with active hepatitis disease require referral to gastro-enterologist, or a specialist unit for liver disease.

Human immunodeficiency virus (HIV)

Organism: Retrovirus, HIV 1 or HIV 2

Indications: At the time of infection usually none, though some people get a flu-like illness called a sero-conversion illness. After infection with HIV people usually remain symptom-free for a number of years, although they are infectious to others through blood and body fluids (semen and vaginal fluid and, in lactating women, breast milk). HIV can damage the immune system to the extent that people develop acquired immune deficiency syndrome (AIDS).

Laboratory tests: Specific serological test, HIV Antibody Test, with follow-up confirmatory test if positive. Viral load and GD4 counts if the antibody test is positive.

Treatment: Highly active antiretrovival therapy (HAART) can slow the progress of the disease, preventing opportunistic infections. The choice of drugs and time of commencement are discussed between the doctor and patient in partnership. Adherence to treatment is important, and requires regular monitoring and support. Currently drugs are required for years. There is as yet no cure for HIV.

Notify partner: Health Advisors or HIV Councillors work closely with HIV positive people to support and encourage them to notify current, past and future sexual partners of the potential risk. Improving treatments may encourage people to undertake testing. HIV is not a notifiable disease.

Complications: Damage to the immune system, weight loss, diarrhoea, AIDS-related illnesses, psychological effects of living with a life threatening illness, social and relationship consequences of living with a disease that may be transmitted to others. Some of the drug treatments have side effects such as nausea, diarrhoea and skin sensitivity.

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