Common Vaginal/Vulvar Conditions Study Notes

Common Vaginal/Vulvar Conditions

Ilana Vosk, MS, PA-C Primary Care II Wagner College PA Program

Introduction

• Vaginal discharge and discomfort are frequent complaints among women across various life stages.
• Vaginitis encompasses a range of vaginal disorders, often characterized by discharge or irritation.
• Establishing a baseline of normal findings is crucial for identifying pathogenic conditions effectively.

Normal Vaginal Flora

• The normal vaginal flora in reproductive-age women comprises numerous aerobic, facultative anaerobic, and obligate anaerobic organisms.
• The ratio of anaerobes to aerobes is approximately 10:1.
• These bacteria maintain a symbiotic relationship with the host and vary according to the vaginal microenvironment.

Composition of Normal Vaginal Flora

Gram-positive Aerobes:

• Lactobacillus
• Diphtheroids
• Staphylococcus aureus
• Staphylococcus epidermidis
• Group B Streptococci
• Enterococcus faecalis
• Staphylococcus spp

Gram-negative Aerobes:

• Escherichia coli
• Klebsiella species
• Proteus species
• Enterobacter species
• Acinetobacter species
• Citrobacter species

Anaerobic Gram-positive Cocci:

• Peptostreptococcus species
• Clostridium species

Anaerobic Gram-positive Bacilli:

• Lactobacillus species
• Propionibacterium species
• Eubacterium species
• Bifidobacterium species
• Actinomyces israelii

Gram-negative Anaerobes:

• Prevotella species
• Bacteroides species
• Bacteroides fragilis species
• Fusobacterium species
• Pseudomonas species
• Veillonella species

Vaginal pH

• The composition of vaginal flora influences vaginal pH.
• Glycogen, a nutrient produced in the vagina, is vital for various species within the vaginal ecosystem.
• Glycogen is metabolized into lactic acid, maintaining the vaginal pH within a range of $3.8-4.2$.
• Pre-pubertal and post-menopausal vaginal pH can range from $6$ to $7.5$.

Influences on Vaginal pH

• Alterations in vaginal ecology can influence the bacterial population.
• Hormonal changes, specifically fluctuations in estrogen levels, can shift the composition of vaginal flora.
• The use of broad-spectrum antibiotics may disrupt normal vaginal flora and encourage overgrowth of Candida species.
• Practices such as douching and unprotected sexual activity can elevate vaginal pH.

Epidemiology

• Approximately $8\%$ of Caucasian women and $18\%$ of African American women report symptoms such as vaginal discharge, odor, itching, and discomfort annually.
• Among these, $50\%$ of Caucasian women and $83\%$ of African American women seek medical consultation, primarily opting for over-the-counter (OTC) remedies.
• Bacterial Vaginosis (BV) has an overall prevalence of $29\%$ based on self-collected swabs.
• By the age of $25$, $55\%$ of females are likely to experience Vaginal Candidiasis, with $9\%$ reporting four or more episodes annually.
• Trichomoniasis is noted in $26\%$ of symptomatic patients at STI clinics and $7\%$ of asymptomatic patients screened.

Normal Vaginal Secretions

• Normal vaginal secretions are characterized as white and flocculent, consisting of:
  • Desquamated vaginal mucosa
  • Vaginal epithelium transudate
  • Mucous secretions from the endocervix
  • Endometrial gland secretions
  • Lactic acid
  • Bartholin gland secretions
  • Sebaceous gland secretions from the vulva
• The definition of "normal" varies from patient to patient.

Normal Vaginal Microbiota

• A healthy vaginal microbiome is predominantly composed of Lactobacillus species.
• Lactobacillus produces lactic acid, which helps maintain an acidic environment that is hostile to numerous pathogenic bacteria.
• Atopobium vaginae, Megasphaera, and Leptotrichia species are recognized as normal flora variants.

Evaluation: The Wet Prep

• The specimen collected is placed in saline solution, and swirling is performed to dislodge particulates.
• A pipette is used to transfer droplets onto three slides for examination, including:
  • Wet mount
  • Potassium hydroxide mount
  • Gram stain
• Specimens should be examined immediately; if not possible, they should be analyzed within two hours.

Vaginitis

Bacterial Vaginosis

• Bacterial Vaginosis (BV) represents an imbalance in normal vaginal flora.
• The sequence: loss of vaginal acidity → loss of Lactobacilli dominance → alkalization of the vagina → overgrowth of pathogenic organisms is typical.
• Gardnerella vaginalis is most commonly implicated in BV.

Clinical Presentation (Indications)

• Key Buzzword: "Fishy odor" (especially after intercourse or douching).
• New or multiple sexual partners, frequent douching, IUD use, pregnancy.
• Can be associated with preterm premature rupture of membranes (PROM), preterm labor, pelvic inflammatory disease (PID), endometritis, and other STIs.

Signs and Symptoms (S/Sxs) / Clinical Findings

• Non-irritating, malodorous vaginal discharge (often described as "thin, grey-white").
• Vaginal mucosa and cervical epithelium often appear normal, without signs of inflammation.
• Absence of cervical motion tenderness (CMT) or pelvic pain.

Diagnosis

• Physical examination may allow for a clinical diagnosis.
• pH testing should be performed (typically >4.5).
• Wet prep analysis is conducted.
• Amsel's diagnostic criteria require that patients meet three out of four criteria, with a $95\%$ positive predictive value (PPV):
  • Thin, white, homogenous discharge
  • pH >4.5
  • Positive amine whiff test ("fishy odor" when $10\%$ KOH is added to discharge)
  • Presence of "clue cells" upon microscopic examination (vaginal epithelial cells covered with bacteria, blurring their borders).

Treatment / Differential Treatments

• Metronidazole $500$ mg orally, twice a day for $7$ days.
• Alternatively, Metronidazole gel $0.75\%$, $1$ full applicator ($5$ g) intravaginally at bedtime for five days.
• Or Clindamycin cream $2\%$, $1$ full applicator ($5$ g) intravaginally at bedtime for seven days.
• Patients are advised to avoid alcohol for $24$ hours post-completion of the Metronidazole therapy to prevent disulfiram-like reactions.
• No evidence supports the efficacy of lactobacillus probiotics.
• The cure rate is between $80-90\%$ within one week of treatment.

Yeast Vulvovaginitis

• Primarily caused by Candida albicans but can also involve other species such as Candida glabrata, Candida parapsilosis, Candida tropicalis, and Candida krusei.
• Candida species are normally present in the vagina.

Risk Factors for Pathogenic Overgrowth

• Antibiotic use, combination oral contraceptives, estrogen therapy, pregnancy, diabetes mellitus (DM), corticosteroid use, immune suppression.

Clinical Presentation (Indications) / Signs and Symptoms (S/Sxs)

• Genital burning, intense pruritus (itching), dyspareunia (painful intercourse), and dysuria (painful urination).
• The discharge is often described as thick, white, "curd-like" or "cottage cheese-like".

Clinical Findings

• Vaginal mucosa and cervical epithelium may appear erythematous (red) and friable (bleeds easily).
• Absence of cervical motion tenderness (CMT) observed.

Uncomplicated vs. Complicated Yeast Vulvovaginitis

Uncomplicated

• Typically sporadic or infrequent episodes.
• Symptoms are mild to moderate with a likely C. albicans presence.
• Usually occurs in non-immunocompromised patients.

Complicated

• Recurrent episodes (four or more in one year).
• Symptoms are severe and may involve non-albicans species (e.g., C. glabrata).
• Common in women with DM, HIV, debilitating conditions, or those receiving immunosuppressive therapy.

Diagnosis

• Physical examination might suggest a clinical diagnosis.
• Wet prep analysis demonstrates $60-70\%$ sensitivity.
• Microscopic findings may include budding yeasts, pseudohyphae, elevated WBC count, and clusters of epithelial cells.
• The pH is <4.5, and the amine "whiff" test is negative.
• Yeast culture may be ordered if non-albicans species are suspected or in recurrent/complicated cases.

Treatment / Differential Treatments

• For uncomplicated cases: Over-the-counter topical antifungal treatment yields an $80-90\%$ cure rate (e.g., miconazole, clotrimazole), or a single oral dose of Fluconazole $150$ mg can be administered.
• For complicated cases: $7-14$ days of topical therapy is recommended, or Fluconazole administered every third day for a total of three doses (Day $1$, $4$, $7$).
• For severe cases: $7-14$ days of topical azole or two doses of Fluconazole $150$ mg taken $72$ hours apart are indicated.
• For non-albicans species, first-line therapy involves $7-14$ days of non-fluconazole azole treatment (oral or topical, e.g., boric acid, flucytosine).

Trichomonas

• Trichomonas is a flagellated protozoan parasite transmitted sexually.
• It causes vaginitis in women and sometimes urethritis in men; however, most males remain asymptomatic.
• The infection is associated with other STIs and can heighten the risk of HIV transmission.
• Infection during pregnancy is correlated with low birth weight, premature rupture of membranes (PROM), and preterm delivery.

Clinical Presentation (Indications) / Signs and Symptoms (S/Sxs)

• Vaginal discharge is malodorous, green-to-yellow, and frothy.
• Patients may experience vaginal irritation, pruritis, dysuria, and dyspareunia.

Clinical Findings

• A condition known as "strawberry cervix" may occur due to inflammation and punctate hemorrhages on the cervix (seen in approx. $10\%$ of cases).
• Vulvar and vaginal erythema and edema.

Diagnosis

• Wet prep analysis shows a $60-70\%$ sensitivity for detecting trichomoniasis, characterized by the presence of motile trichomonads as pear-shaped, flagellated organisms.
• Typical pH is >4.5
• The amine test may yield positive or negative results ($+/-$).
• The PCT (PCR) test has a sensitivity of $95\%$ (gold standard for diagnosis).

Treatment

• Metronidazole can be administered as a single $2$ g dose or $500$ mg twice a day for one week.
• Partners should also be treated simultaneously to prevent re-infection.

Atrophic Vaginitis

• This is an inflammatory process stemming from vaginal atrophy due to decreased estrogen levels following menopause (or other conditions causing hypoestrogenism).
• Reduced estrogen leads to alterations in the vaginal microbiome, resulting in diminished Lactobacillus species populations and the overgrowth of skin and rectal pathogens.
• Atrophic vaginitis develops in $10-50\%$ of postmenopausal women.

Clinical Presentation (Indications) / Signs and Symptoms (S/Sxs)

• Symptoms encompass vulvovaginal dryness, pruritus, dyspareunia (especially post-coital pain), abnormal vaginal discharge, recurrent urinary tract infections, urethral pain, hematuria, and urinary incontinence.
• Symptoms can be progressive or acute in nature.

Clinical Findings

• On physical exam, the vaginal mucosa may appear pale, thin, and dry, with a loss of rugae.
• Introital narrowing and urethral prolapse may be observed.
• Wet mount examinations may reveal high WBC numbers and reduced levels of Lactobacilli.

Treatment

• Localized estrogen therapy is recommended, usually as the first-line treatment.
• Premarin Vaginal Cream has been clinically verified to alleviate moderate to severe dyspareunia post-menopause.
• Administer estrogen at the lowest effective dose for the shortest duration necessary (vaginal creams, rings, tablets).
• Non-hormonal lubricants and moisturizers can also offer symptomatic relief.

STIs

Gonorrhea

• Caused by the bacterium Neisseria gonorrhoeae, which is a gram-negative diplococcus.
• Common infection sites include the urethra, cervix, pharynx, or anus in adults and can infect the conjunctiva in neonates.
• Gonorrhea has the potential to disseminate and is the second most commonly reported STI following chlamydia.
• Over $50\%$ of females harbor asymptomatic infections, whereas $90\%$ of males present symptoms.

Clinical Presentation (Indications) / Signs and Symptoms (S/Sxs)

• Many women may be asymptomatic.
• Urethral infections in men typically result in dysuria and a white/yellow/green urethral discharge, usually resolving within $1-14$ days.
• Symptoms of urethral infections accompanied by epididymitis result in testicular pain.
• Women may experience mild symptoms often misinterpreted as a UTI or vaginitis, which can include dysuria, increased discharge, and abnormal vaginal bleeding between periods.
• Symptoms related to rectal infections can include discharge, anal itching, soreness, bleeding, or painful bowel movements, with many cases being asymptomatic.
• Pharyngeal infections may present with sore throat symptoms or remain asymptomatic.

Clinical Findings

• In men, evident urethral discharge. In women, mucopurulent cervicitis may be observed.

Diagnosis

• NAAT (Nucleic Acid Amplification Test) is the gold standard for diagnosis from urine, vaginal, cervical, pharyngeal, or rectal swabs.
• For men with urethral discharge, Gram stain can reveal gram-negative intracellular diplococci.

Treatment

• Administer one single dose of intramuscular (IM) Ceftriaxone $500$ mg (or $1$ g if the patient weighs over $150$ kg).
• Erythromycin ophthalmic ointment is indicated for neonates as prophylaxis.
• Co-treatment for Chlamydia is often recommended even if not yet confirmed due to high co-infection rates (e.g., Doxycycline).

Gonococcal Arthritis

• Gonococcal arthritis develops when Neisseria gonorrhoeae disseminate to joints, resulting in septic arthritis.
• The clinical presentation includes two major forms: localized septic arthritis and arthritis-dermatitis syndrome.
• Approximately $0.5-3\%$ of patients with gonorrhea may develop this condition.

Risk Factors

• Factors predisposing to gonococcal arthritis include: Pregnancy, a history of pelvic surgery, use of IUD.

Clinical Presentation (Indications) / Clinical Findings

• Localized septic arthritis: typically affects a single joint (monoarticular, e.g., knee, ankle, wrist) with severe pain, swelling, erythema, and purulent effusion.
• Arthritis-dermatitis syndrome: classic triad often includes migratory polyarthralgia, tenosynovitis (inflammation of tendon sheaths), and sparse pustular or vesicular skin lesions (often on extremities).

Diagnosis

• Synovial fluid culture (often negative, but Gram stain/culture should be attempted).
• NAAT of synovial fluid is becoming more prevalent.
• Cultures from suspected mucosal sites (urethra, cervix, rectum, pharynx) are crucial for confirming disseminated gonococcal infection (DGI).

Treatment

• Treatment with Ceftriaxone is typically preferred either intravenously or intramuscularly for initial therapy.
• For severe presentations (e.g., purulent arthritis), intravenous administration of $1$ gm every $24$ hours is often preferred.
• Doxycycline $100$ mg orally twice a day for seven days is commonly added to address potential co-infection with Chlamydia trachomatis.

Gonococcal Conjunctivitis

• In neonates, transmission of Neisseria gonorrhoeae during delivery can lead to gonococcal conjunctivitis (ophthalmia neonatorum) following exposure to infected vaginal secretions.
• Even with cesarean delivery, the risk of vertical transmission exists.
• Gonococcal conjunctivitis should be considered in symptomatic neonates after the first day of life, especially between days $2-5$.
• Non-neonatal populations may present with similar symptoms upon engaging in sexual activity, whether or not they have genital complaints.

Clinical Presentation (Indications) / Clinical Findings

• Signs may include chemosis (conjunctival swelling), severe mucopurulent discharge, eyelid edema, tenderness of the globe, and preauricular lymphadenopathy.
• Untreated cases can rapidly progress to corneal ulceration and blindness.

Diagnosis

• Gram stain and culture of conjunctival exudates are essential.

Treatment

• Neonatal prophylaxis includes either erythromycin ($0.5\%$) ophthalmic ointment or tetracycline ($1\%$) ophthalmic ointment.
• For symptomatic or high-risk neonates, administer a single dose of Ceftriaxone ($25$ mg/kg to $50$ mg/kg; maximum $125$ mg) intravenously or intramuscularly.
• Alternatives include Cefotaxime ($100$ mg/kg IV/IM) and provide single dose treatment.
• Non-neonatal symptomatic cases can generally be managed outpatient with a single IM dose of Ceftriaxone ($1$ gm) along with treatment for possible co-infection with Chlamydia trachomatis.

Chlamydia

• Chlamydia trachomatis is responsible for the highest number of STIs and the majority of infection-related blindness worldwide.
• Its infections contribute to visual impairment in approximately $1.9$ million individuals globally.
• As a gram-negative cocci, it predominantly infects the female cervix, resulting in various manifestations such as cervicitis, urethritis, pelvic inflammatory disease, perihepatitis, or proctitis.
• Untreated chlamydial infections in women escalate the risk of infertility and ectopic pregnancy.
• Infants born vaginally from mothers infected with genital Chlamydia may develop conjunctivitis and/or pneumonia within $5$ to $14$ days after birth.

Clinical Presentation (Indications) / Signs and Symptoms (S/Sxs)

• Approximately $70\%$ of females are either asymptomatic or experience mild symptoms such as vaginal discharge, bleeding, abdominal pain, and dysuria.
• Men may experience dysuria and a clear or mucoid urethral discharge.
• A minority may exhibit cervicitis with discharge and easily inducible endocervical bleeding (cervical friability).
• Some women may experience postcoital or intermenstrual bleeding.

Diagnosis

• NAAT (Nucleic Acid Amplification Test) is the gold standard for diagnosis on urine, vaginal, cervical, rectal, or pharyngeal samples.

Treatment

• Doxycycline $100$ mg twice a day for one week is the recommended treatment.
• For pregnant individuals, Azithromycin $1$g is administered as a single dose.

Trachoma

• Trachoma, the leading infectious cause of blindness globally, is spread via direct or indirect contact with eye or nasal secretions, particularly in preschool-aged children.
• The transmission can occur through flies that carry the discharge.

Clinical Presentation (Indications) / Clinical Findings

• Repeated infections can result in scarring of the eyelid's inner surface, leading to inwardly turned eyelashes (entropion) that rub against the cornea (trichiasis) and cause corneal scarring and eventual blindness.
• Initial findings include conjunctival follicles and papillae.

Treatment

• The "SAFE" strategy for prevention and treatment: Surgery for trichiasis, Antibiotics (Azithromycin), Facial cleanliness, Environmental improvement.

Pelvic Inflammatory Disease (PID)

• PID refers to the inflammation of the upper genital tract due to an infectious process affecting the uterus, fallopian tubes, and/or ovaries.
• Predominantly, ascending infections from lower genital tract infections are involved.
• The primary pathogens include gonorrhea and chlamydia, with $10-15\%$ of women with one of these STIs progressing to PID.

Clinical Presentation (Indications) / Signs and Symptoms (S/Sxs)

• Patients may present with lower abdominal pain, pelvic pain, abnormal vaginal discharge, dyspareunia, and abnormal vaginal bleeding.
• The classic triad includes lower abdominal pain, cervical motion tenderness, and adnexal tenderness.

Risk Factors

• Increased risk occurs with: Intercourse with multiple partners or having a partner with multiple partners, being sexually active under the age of $25$, a history of STIs or PID, frequent douching, unprotected sexual contact.

Presentation and Physical Exam / Clinical Findings

• Common presentation involves lower abdominal pain and fever (>38.3^ ext{o}C).
• Possible accompanying symptoms include nausea/vomiting and cervical motion tenderness (CMT) (also known as the "chandelier sign" due to extreme discomfort).
• Physical exams may reveal a friable cervix and mucopurulent cervicitis. Adnexal and uterine tenderness are also key findings.
  ##### Diagnosis
• Clinical diagnosis is often established, but confirmatory tests may be required to identify the infectious agent.
• Elevated ESR (erythrocyte sedimentation rate) or CRP (C-reactive protein).
• NAAT for Neisseria gonorrhoeae and Chlamydia trachomatis.
• Transvaginal ultrasonography is favorable for ambiguous PID cases, showing findings like hydrosalpinx, pyosalpinx, endometritis, tubo-ovarian abscess, oophoritis, or free pelvic fluid collections.
• Laparoscopy is the acknowledged gold standard for PID and FHCS diagnostics.
  ##### Treatment / Differential Treatments
• Admission may be necessary for patients with certain conditions, including suspected tubo-ovarian abscess, pregnancy, nausea, vomiting, high fever, questionable outpatient compliance, or failure of outpatient treatment.
• For outpatient management, administer Ceftriaxone $500$ mg (or $1$ g if the patient weighs over $150$ kg) in a single dose IM, along with Doxycycline $100$ mg PO twice daily for $14$ days (and potentially Metronidazole if BV or Trichomonas is suspected).
• For inpatient management, the regimen typically includes Doxycycline $100$ mg (PO/IV) twice daily and Ceftriaxone $1$ g IV daily, along with Metronidazole $500$ mg IV twice daily.
• In pregnant patients, replace Doxycycline with Azithromycin $1$g PO once.

Fitz-Hugh-Curtis Syndrome (FHCS)

• Fitz-Hugh-Curtis syndrome is characterized by inflammation of the liver capsule with adhesion formation resulting in right upper quadrant pain, representing an uncommon chronic manifestation of PID, particularly in childbearing-aged women.

Epidemiology

• PID commonly affects sexually active women aged $15-30$ years.
• The United States sees approximately $750,000$ cases each year.
• FHCS is a rare outcome in PID, affecting around $4\%$ of adolescents, with Chlamydia trachomatis as the most frequently implicated pathogen.

Etiology

• The development of Fitz-Hugh-Curtis syndrome is viewed as a complication of PID.
• Microbial spread can occur through: Spontaneous ascending infection, lymphatic spread, hematogenous spread.

Clinical Presentation (Indications) / Signs and Symptoms (S/Sxs) / Clinical Findings

• Key Buzzword: "Violin string" adhesions (seen on laparoscopy).
• Symptoms may include RUQ (right upper quadrant) abdominal pain caused by perihepatic inflammation and adhesion formation between the liver's anterior surface and the abdominal wall, which typically intensifies with movement and breathing, mirroring other acute abdominal disorders.
• Patients may also report lower abdominal, pelvic, or back pain, in addition to symptoms including fever, chills, nausea, vomiting, vaginal discharge, dyspareunia, dysuria, cramping, or postcoital bleeding.
• Physical exam may show RUQ tenderness, rebound tenderness, and guarding.

Diagnosis

• A CT scan may show increased perihepatic enhancement, along with signs consistent with PID.
• Laparoscopy is the acknowledged gold standard for PID and FHCS diagnostics, revealing edema, exudates on tubal surfaces, ectopic pregnancies, or tubo-ovarian abscesses.
• FHCS diagnosis may be established through direct visualization of adhesions between the diaphragm and liver or liver and the anterior abdominal wall (the "violin string" appearance).

Treatment

• Treatment for FHCS parallels PID management strategies.
• Antibiotic therapy produces favorable outcomes in approximately $75\%$ of PID cases.
• Current guidelines for complicated PID emphasize a regimen of Ceftriaxone, Doxycycline, and Metronidazole.
• Hospitalization is advised for patients with diagnosis uncertainty, pregnancy, severe illness, pelvic abscess observed via imaging, inability to tolerate oral ingestion, immunodeficiency, or lack of clinical improvement after $72$ hours of treatment.
• Patients exhibiting persistent fever, chills, or cervical motion tenderness after treatment should be reassessed for surgical intervention opportunities (e.g., adhesiolysis).

Lymphogranuloma Venereum (LGV)

• LGV is an ulcerative STI attributable to Chlamydia trachomatis, which can be transmitted through vaginal, oral, or anal intercourse.
• It is uncommon in the U.S. yet prevalent in tropical and subtropical regions.
• The infection tends to affect individuals aged $15-40$, with increased cases among those living with HIV.

Stages of Lymphogranuloma Venereum

Primary Stage

• Typically arises $3$ to $12$ days after exposure, with lesions potentially taking up to $30$ days to appear.
• Patients may develop painless genital ulcers or papules, measuring $1$ to $6$ mm, potentially also occurring in the mouth or throat.
• These are often unwittingly overlooked due to their subclinical and painless nature, resolving spontaneously within a few days.

Secondary Stage

• Occurs $2-6$ weeks post-primary stage, characterized by unilateral or bilateral tender inguinal and/or femoral lymphadenopathy (buboes).
• Patients may also present with anorectal syndrome (proctitis or proctocolitis-like symptoms for those with anal exposure).
• A range of generalized symptoms such as fever, aches, and headache may be present.
• The "groove sign" (a depression over the inguinal ligament, separating enlarged inguinal and femoral lymph nodes) may be observed.
• Cervical and oral lymphadenopathy could emerge, with potential systemic complications including pneumonia and hepatitis.

Late Sequelae

• Arise mostly when the disease remains untreated, leading to lymph node necrosis, rupture, and anogenital fibrosis, which may result in strictures or anal fistular formation.
• In extreme cases, genital elephantiasis (permanent lymphedema) can occur.

Diagnosis

• NAAT of lesion exudate or bubo aspirate is the preferred diagnostic method.
• Serological tests can support the diagnosis.

Treatment

• Doxycycline $100$ mg BID for $21$ days, or Erythromycin $500$ mg QID for the same duration as treatment options.
• Aspiration may be necessary for pus-filled buboes (do not incise and drain, as it can delay healing or create a fistula).

Chancroid

• Chancroid, an extremely rare sexually transmitted infection both in the United States and globally, is caused by Haemophilus ducreyi.
• This small gram-negative rod necessitates specific media for culturing, often unavailable in many labs, and significantly contributes to the heterosexual acquisition and transmission of HIV.
• Genital ulcers related to chancroid can raise HIV infection risk by up to $300$-fold for each unprotected sexual encounter.

Clinical Presentation (Indications) / Signs and Symptoms (S/Sxs)

• The disease primarily impacts younger populations aged $21-30$ years, particularly among sex workers and younger males in developing countries.
• Many females remain asymptomatic carriers, perpetuating transmission.
• The incubation period is generally $4$ to $10$ days.
• Infection sites commonly in men being the prepuce and glans of the penis, and in women being the labia, introitus, and perianal regions.
• An erythematous papule develops at the inoculation site, progressing into a pustule, and subsequently, to a painful ulcer with soft, irregular, undermined margins termed a "soft chancre".
• Multiple ulcers may develop due to microtrauma or contact between adjacent areas, leading to "kissing ulcers".
• In $25\%$ of cases, these lesions can advance to painful regional lymphadenitis and suppurative buboes, which risk superinfection if left untreated.

Diagnosis

• A steadfast diagnosis requires isolating H. ducreyi on specialized media.
• Presumptive clinical diagnoses may be made if the case exhibits:
  • Presence of painful genital ulcers.
  • Clinical findings consistent with chancroid (ulcer appearance and regional lymphadenopathy).
  • Negative treponemal tests excluding Treponema pallidum infection (syphilis).
  • Successful exclusion of Herpes simplex virus (HSV) through negative PCR or culture of the exudate.

Treatment

• Without intervention, genital lesions associated with chancroid may resolve spontaneously within $1-3$ months.
• Risks include progression to painful regional lymphadenitis and suppurative buboes in some cases.
• Treatment involves single-dose administration of either Azithromycin $1$ gm orally or Ceftriaxone $250$ mg intramuscularly.
• Alternative treatments include Ciprofloxacin $500$ mg orally BID for $3$ days or Ery