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I. HERPES GENITALIS
A. Etiology
1. Herpes simplex hominis, all enveloped DNA virus
2. virus is usually transmitted sexually
3. Incubation 2-20 days; average 6 days
B, Incidence
1. It is the most common cause of vulvar ulcers, second only to gonorrhea as a reason for patients' visits to sexually transmitted disease (STD) clinics
2. virus type II antibodies have been found in 20% of control patients and 100% of prostitutes
3. Number of cases that occur annually: 500,000
4. Approximately 25 million cases in the United States
C. Signs and symptoms
I. Sudden onset of painful erythema and swelling of the vulva
2. Purulent, odorous discharge
3. Followed by diffuse swelling and clear vesicles
4. Later, the vesicles break, and there is ulcer formation. With an initial infection, lesions last 15-21 days and vital shedding 8-10.4 days
5. Cystitis. dysuria, and urinary retention may be associated
The recommendations in this outline do not dictate an exclusive course of treatment or procedure to be followed and should not be construed as excluding other acceptable methods of practice important to consider variations taking into account the needs of the individual patient, resources, and limitations unique to the institution or type of practice tha: may be appropriate
6. Malaise, myalgia, and low grade fever sometimes occur
7. Many subclinical cases occur
D. Diagnosis
1. Inspection of vulva, vagina, and cervix
2. Routine pap smear of lesion and/or cervix; will detect 60-80 %; cytologic changes
a. Glassy, degenerated appearance of the nuclei
b. Acidophilic nuclear inclusions (cowdy type A)
c. Less commonly, multinuclear giant cell with either balloon
degeneration or inclusion bodies in its nuclei
3. Biopsy of the lesion
4. Culture of the lesion
5. A four-fold increase in antibodies may be helpful
E. Treatment
1. Acyclovir (Zovirax): a cyclic nucleoside analogue preferentially transports
into infected cells and competitively inhibits viral DNA
2. Future possibilities a. Interferon b. Vaccine
3. Symptomatic relief
a. Sitz bath (4 oz Betadine)
b. Topical anesthetics
c. Oral analgesics
d. Keep area clean and dry (1) Corn starch (2) Baby powder (3) Use a hair dryer
e. Phenazopyridine tablets (Pyridium) may be useful
F. Recurrentent HSV genitalis
I. Lesions last for an average of 10 days, with pain and viral shedding for 5
days
2. Recurrence can occur with menses, stress, fever, or pregnancy
3. During a latent period, the virus resides within paraspinal ganglia
4. At intervals, it travels along the axon to the surface
5. Over time, it seems the recurrences become less frequent; they peak during
the early adult years
6. Eighty percent have prodromal symptoms prior to lesions
7. Recurrence is four times more common during pregnancy
G. Herpes in pregnancy
1. In patients with a history in themselves or their partner document
the expected date of confinement (serial ultrasound may be helpful) and start
weekly exams at 34-36 weeks
2. Women without clinical evidence of infection at labor should be allowed w give birth vaginally
3. If there is clinical or cultural evidence of and the bag of waters
(BOW) ruptures, try to perform a C-section within 4 hours. In the prigrice
of a C-section is indicated, even if the membranes have been
ruptured over 4 hours
H. Cancer
1. Virus infection could induce atypical metaplasia and dysplasia, and this influences the receptivit,:' of the epithelium to potential mutagens, such as sperm
2. No definite conclusions can be drawn as of yet
11. CONDYI.,OMA ACUMINATUM
A. Etiology
1. A recognized disease entity since antiquity, it antedates syphilis and
gonorrhea
2. The cause was recognized in 1968 as a