mcga-shs_capt_guide_chap6.1.pdf

117

CHAPTER 6.1

The following diseases are transmitted by sexual contact:

gonorrhoea, chlamydia infections, chancroid, genital herpes,

trichomoniasis, syphilis, chlamydia lymphogranuloma,

granuloma inguinale, genital warts, pubic lice, scabies, viral

hepatitis B and human immunodeficiency virus,.

Sexually transmitted diseases in sailors are generally

acquired through unprotected casual and promiscuous

sexual contacts, often with prostitutes.

The most common symptoms of sexually transmitted

diseases include discharge, redness and swelling of the

genitalia, genital ulcers, lymph node enlargement, warts,

and the presence of lice or mites on or in the skin. In some

sexually transmitted diseases a single organ is affected. while

in others the infection spreads. throughout the body.

Clinical and laboratory facilities are necessary for accurate

diagnosis of sexually transmitted diseases. Since such

facilities are not likely to be available on board ship, the

medical attendant can make only a presumptive diagnosis,

based on rough clinical criteria. If the ship is more than one

day from port, the medical attendant should start antibiotic

treatment immediately when a sailor is thought to be

suffering from a sexually transmitted disease. The subjective

and objective symptoms, treatment, and response to

treatment should be carefully recorded.

On arrival in port, the patient should be referred as soon

as possible to a specialist who can perform the appropriate

diagnostic tests and, if necessary, give additional treatment.

If possible, all sexual contacts of the patient should be

traced and told to seek medical advice.

In case of any doubt concerning diagnosis or treatment,

RADIO MEDICAL ADVICE should be obtained.

Urethritis and urethral

discharge

Swollen scrotum

Balanitis and posthitis

Genital ulcers

Lymph node swelling

Vaginal discharge

Pelvic inflammatory

disease

Genital warts

Pubic lice

Scabies

Acquired

Immunodeficiency

syndrome

Proctitis

Treatment centres at

ports

Instructions for

medical attendants

Instructions for

patients

Prevention of

sexually-transmitted

disease

(See also:

Viral hepatitis B)

Urethritis and urethral discharge

Urethritis is characterised by a discharge from the orifice of

the urethra, a burning sensation and pain on urination, or an

itch at the end of the urethra. Urethritis may be caused by the

gonococcus (gonorrhoea) or chlamydia.

Gonococcal urethritis tends to produce more severe

symptoms than non-gonococcal urethritis. The incubation

time of gonococcal urethritis can range from I to 14 days,

but is usually 2–5 days. The discharge is generally abundant,

yellow, creamy and purulent.

Non-gonococcal urethritis is generally caused by

chlamydia, but in some cases, no causative organism can be

found. The discharge in non-gonococcal urethritis is usually

scanty, watery, mucoid or serous.

In men, a careful distinction must be made between

urethritis and balanitis or posthitis, in which there are

secretions from the glans penis and the prepuce (foreskin).

Wearing disposable gloves, carefully retract the prepuce to

determine the origin of the discharge or secretions.

In women, the same organisms that cause urethritis can

cause infection of the cervix of the uterus and the urethra. In

more than 60% of women with such infections, there are no

visible symptoms. In the remaining cases, the principal sign is

an increase in the vaginal discharge (see also Vaginal

discharge).

117

118

THE SHIP CAPTAIN’S MEDICAL GUIDE

Associated infections

Rectal infection

The organisms that cause urethritis can also infect the rectum. The main symptoms are a

discharge of pus, sometimes mixed with blood, and itching around the anus.

Conjunctivitis

Male and female patients with urethritis may also develop an infection of the conjunctivae of

the eye.

Treatment

It is not generally possible to make a definitive diagnosis of the cause of urethritis without

laboratory facilities. Treatment must therefore be effective for both gonococcal and non-

gonococcal infections, and must take account of the facts that the patient may be infected with

more than one type of organism, and that some strains of gonococcus are resistant to penicillin.

Patients should be given Ciprofloxacin 250 mg as a single and Doxycycline, one 100 mg capsule or

tablet twice daily for 7 days.

This treatment should be effective for all urethral and rectal infections. If the patient also has

conjunctivitis, 1% tetracycline ointment should be applied to the eye 3 times daily for one

week. About one week after completion of treatment, the patient should attend a specialist

clinic to verify that he is no longer infected.

Swollen scrotum

A swollen scrotum can be defined as an increase in volume of the scrotal sac, accompanied by

oedema and redness. It is sometimes associated with pain (or a history of pain), urethral

discharge, and a burning sensation on urination (see Urethritis and urethral discharge). The

swelling of the scrotum is usually confined to one side.

Among ships’ crews most cases of swollen scrotum are caused by inflammation of the

epididymis, produced by sexually transmitted organisms. Such a cause should be strongly

suspected in patients with urethral discharge or a recent history of it. The onset of epididymitis

is often acute, but in some cases, it may develop over 24–48 hours. There may initially be an

‘unusual sensation‘ in the scrotum, which is rapidly followed by pain and swelling. The pain is of

a dragging, aching nature.

This condition must be distinguished from testicular twisting (see testicular pain, Chapter 7).

In the latter case, the testis can become non-viable within 4–6 hours of onset of vascular

obstruction. This condition occurs most frequently in children and is very rarely observed in

adults over the age of 25. The presence of a history of urethritis would exclude the diagnosis. In

cases of testicular twisting the testicle is often slightly retracted and elevation of the scrotum

does not decrease the pain. This condition needs urgent referral. Other conditions that may

lead to scrotal swelling include trauma (injury), inguinal hernia, mumps, and tumours.

Balanitis and posthitis

Balanitis is an inflammation of the glans of the penis, and posthitis is an inflammation of the

prepuce. The two conditions may occur simultaneously (balanoposthitis). Lack of good

hygiene, in particular in uncircumcised males, is a predisposing factor, as is diabetes mellitus.

In balanitis and balanoposthitis, a mild to profuse superficial secretion may be present. This

must be carefully distinguished from urethral discharge. Wearing disposable gloves, retract the

prepuce in order to determine the origin of the secretion.

Other signs include itching and irritation, causing considerable discomfort. Sometimes, the

penis is swollen and retraction of the prepuce may be painful. Redness, erosion (superficial

defects), desquamation of the skin of the prepuce, and secretions of varying aspects and

consistency can be observed.

Treatment

The glans of the penis and the prepuce should be washed thoroughly with warm water

antiseptic three times daily. Fluconazole 150 mg as a single dose should be given. If there is no

improvement within one week, the patient should be referred to a specialist ashore.

Chapter 6.1 SEXUALLY TRANSMITTED DISEASES

119

Genital ulcers

Genital ulcers are a common reason for consultation, particularly in tropical countries. If not

treated appropriately serious complications may arise from some of these conditions. Ulcers

may be present in a variety of sexually transmitted diseases, including chancroid, genital

herpes, syphilis, chlamydial lymphogranuloma, and granuloma inguinale.

The prevalence of these diseases varies according to geographical area. In Africa and South-

East Asia, for instance, chancroid is the most common cause of genital ulcers, whereas in Europe

and the USA, herpes genitalis is most common. Chlamydial lymphogranuloma and granuloma

inguinale are much less common, and occur mainly in specific areas of the tropics. Chlamydial

lymphogranuloma is endemic in West Africa and South-East Asia, while granuloma inguinale is

prevalent in east Africa, India, certain parts of Indonesia, Papua New Guinea, and Surinam. Each

of these diseases is described in more detail in the following pages.

Patients with one of these diseases usually complain of one or more sores on the genitals

or the adjacent area. If the ulcer is located on the glans penis or on the inside of the prepuce,

uncircumcised males may complain of penile discharge or of inability to retract the prepuce.

In females, ulcers may be situated on the vulva, in which case the patient may complain of a

burning sensation on urination.

Disposable gloves should be worn when examining the ulcers. The medical attendant

should note the number and the characteristics of the lesions and the presence of lymph node

swellings in the groin. Painless, indurated lesions can generally be attributed to syphilis;

painful sores that bleed easily are attributable to chancroid; vesicular lesions that develop

into superficial erosions or small ulcerations probably indicate herpes infection. Double

infections are not uncommon, however, the clinical symptoms are often not sufficiently

discriminatory to enable a definite diagnosis to be made without the help of laboratory tests.

Knowledge of the relative importance of each disease in the area is crucial for a specific

therapeutic approach. The recommended regimen is therefore aimed at curing the most

frequently encountered diseases, chancroid and syphilis.

Treatment

Give simultaneously: 2.5 million units of benzylpenicillin, in one dose, intramuscularly and

ciprofloxacin 250 mg orally. If the patient is allergic to penicillin, give Doxycycline 100 mg, by

mouth, 2 times a day for at least 2 weeks.

When patients with syphilis are treated with penicillin, the so-called Jarisch-

Herxheimer reaction may occur (see Syphilis). Bed rest should be advised for patients

suffering from very painful genital ulcerations and lymph node swelling, and for those

feeling severely ill.

As soon as treatment has started, patients should no longer be regarded as infectious

and no special hygienic measures need to be applied. On arrival at the next port patients

should be referred to a specialist together with all relevant information concerning their

medical history.

Chancroid

Chancroid, almost always acquired during sexual intercourse, is caused by a bacterium. The

incubation period (the time following the infecting contact to the initial appearance of

symptoms) is short, usually averaging 3–5 days. The lesions are usually only seen in men; in

women, clinical lesions are rare, but ulcers may be located in the vagina. The first lesion

usually appears as a small inflamed bump, soon forming a blister or pustule, which breaks

down within 2–3 days to become a very painful ulcer.

The classic chancroid ulcer (primary lesion) is superficial and shallow, ranging from a few

millimetres to 2 cm in diameter. The edge usually appears ragged and is surrounded by a red

zone. The base of the ulcer is covered by a necrotic exudate and bleeds easily. In contrast to

the syphilitic chancre, the lesion is soft, and extremely painful and tender.

In males the most frequent sites of infection are the inner and outer side of the prepuce

and the groove separating the head from the shaft of the penis.

About l~2 weeks after the appearance of the primary lesion, the glands in the groin

become enlarged, painful, and tender (buboes) (see Lymph node swelling, and Lymphatic

120

THE SHIP CAPTAIN’S MEDICAL GUIDE

inflammation, Chapter 7). At first, the swellings appear hard and matted together, but they

soon become painful and red. Some time later, the lymph nodes may enlarge, become

fluctuant, and discharge pus.

Treatment

Give the patient Doxycycline 100 mg 2 times daily for 7 days. If the buboes persist or become

fluctuant, RADIO MEDICAL ADVICE should be sought.

Genital herpes

Genital herpes is caused by a virus; the disease can follow an asymptomatic course, the virus

being harboured within the nerves to the skin without producing symptoms. Usually,

however, genital herpes in men appears as a number of small vesicles on the penis, scrotum,

thighs, or buttocks. The fluid-filled blisters are usually painful, but sometimes produce only a

tingling sensation. Within a day or two the blisters break, leaving tiny open sores which take

1–3 weeks to heal. Lymph glands near the site of infection may react by becoming swollen

and tender.

In most cases, a clinical diagnosis can be made on the basis of the appearance of the lesions,

in particular at the blister stage. At specialised clinics, laboratory tests may be used to confirm

the diagnosis.

After the sores are healed, the virus remains dormant in the body. Weeks or months later,

there may be recurrence of the active infection. These recurrent attacks tend to become less

frequent with time and to be less severe than the initial attack, and the lesions tend to heal

more quickly.

Treatment

A definite cure for genital herpes is not yet available. Lesions should be kept clean by washing

the affected sites with soap and water, followed by careful drying. Analgesics may be given to

reduce discomfort.

If you are in any doubt about whether the diagnosis of genital herpes is correct, the patient

should be managed as described under Genital ulcers.

Syphilis

Syphilis is caused by a spirochaete which enters the body through the mucous membranes of

the genitals, rectum, or mouth, or through small cuts or abrasions in ordinary skin.

The clinical course of syphilis is usually divided into three stages. The lesions of the primary

and secondary stages are usually painless and cause little disability. They may heal without

treatment, and the disease can lie dormant in the body for several years. In the late stages

syphilis can cause serious damage to the brain, spinal cord, heart, and other organs.

The first stage, primary syphilis, is characterised by the presence of a sore (or chancre) at

the point where the spirochaetes enter the body. There is a delay of 10–90 days (average 3

weeks) after contact before the onset of any visible sign of infection. Following the

appearance of the initial chancre, there can be an additional delay of a few weeks before

the blood test for syphilis will become positive. The typical chancre occurs in the groove

separating the head from the shaft of the penis. However, a chancre may occur anywhere

on the body where there has been contact with an infected lesion. Such lesions are usually

single, but there may be more than one. The primary chancres are often smooth and clean-

looking on the surface. Sometimes the lesion ulcerates and leaves a reddish sore with the

base of the ulcer covered by a yellow or greyish exudate. Unless there is also infection with

other bacteria or with herpes virus, the ulcer will be painless. The lesion has a characteristic

firmness (like cartilage) when felt between the thumb and forefinger (gloves must be

worn)

Often there will be one or more rubbery, hard, painless, enlarged lymph nodes in one or

both groins, or in other regions if the sore is not on the genitals. In the presence of a

secondary infection, the nodes may be tender. Usually these lesions will heal spontaneously

within 6 weeks. At the chancre stage, the patient is highly contagious

Chapter 6.1 SEXUALLY TRANSMITTED DISEASES

121

The secondary stage of syphilis usually develops about 6–8 weeks after the appearance

of the primary chancre. In fact, the primary syphilitic chancre may still be present at the

time of onset of the secondary stage. However, the secondary stage may be the first

manifestation, occurring some 10–14 weeks after the infected contact. The most consistent

feature of secondary syphilis is a non-itching skin rash, which may be generalised in the

form of small, flat or slightly elevated pink spots, which gradually darken to become dark

red in colour. They may be particularly localised on the palms, soles, or genital areas. A less

frequently encountered sign is patchy loss of scalp hair. Patients with secondary syphilis

may complain of malaise (not feeling well), headache, sore throat, and a low-grade fever

(38.5 C). The presence of these symptoms plus a generalised rash and/or a rash involving the

palms and the soles, which does not itch, and is associated with enlarged small lymph nodes

in the neck, armpits and groins, should arouse suspicion of secondary syphilis. Other signs

of the secondary stage may be the occurrence of moist sores, particularly in the genital

area, or of flat, moist warts in the anogenital region. It should be noted that moist lesions

of secondary syphilis are teeming with spirochaetes and are thus highly infectious. In the

untreated patient the diagnosis is confirmed by microscopic examination of the lesions and

by a blood test for syphilis.

The symptoms of the secondary stage will eventually disappear without treatment. The

disease then enters the latent (hiding) phase, before reappearing as tertiary syphilis many

years later.

Treatment

Patients with suspected syphilis should be given 2.5 million units of benzylpenicillin in a single

dose, administered intramuscularly. If the patient is allergic to penicillin, give either 100 mg of

Doxycycline by mouth, 2 times a day for 14 days or 500 mg of erythromycin by mouth, 4 times a

day for 14 days. The patient should be referred to a specialist clinic at the next port of call.

Caution. When treated with antibiotics, about 50% of patients with primary or secondary

syphilis will develop the so-called Jarisch-Herxheimer reaction, which usually appears 6–12

hours after the injection. This reaction is characterised by fever, chills, joint pain, increased

swelling of the primary lesions, or increased prominence of the secondary rash. It is caused by

the sudden destruction of a great number of spirochaetes and should not give rise to alarm.

Analgesics may help to reduce the symptoms.

Chlamydial lymphogranuloma

Chlamydial lymphogranuloma is a systemic disease of venereal origin. The incubation time

ranges from 4 to 21 days. The primary lesion is usually an ulcer, a vesicle, a papule or a pustule,

not more than 5–6 mm in size and often located on the groove on the head of the penis in the

male patient. Commonly single, the lesion is painless, transient, and heals in a few days without

scar formation. in most cases, the patient does not even notice this primary ulcerative lesion.

After the lesion has healed, the commonest symptom in heterosexual men is acute swelling of

the lymph nodes in the groin, often on one side only. The swelling starts as a firm hard mass,

which is not very painful, and usually involves several groups of lymph nodes. Within 1–2 weeks,

the glandular mass (bubo) becomes attached to the skin and subcutaneous tissue and painful

fluctuation occurs, followed by formation of pus. Not all buboes become fluctuant, some

evolve into firm masses. Perforation of a bubo may occur, whereupon pus of varying aspect and

consistency will be discharged. If not treated, chlamydial lymphogranuloma can produce severe

scarring in the urogenital and rectal regions.

Treatment

Rest in bed is recommended for patients with chlamydial lymphogranuloma. An ice-bag may be

applied to the inguinal region for the first two or three days of treatment to help relieve local

discomfort and tenderness.

The patient should be given 100 mg of Doxycycline by mouth, twice daily for at least 2 weeks

or 500 mg of erythromycin by mouth, 4 times daily, for at least 2 weeks. Fluctuating buboes

require aspiration. If the bubo persists, RADIO MEDICAL ADVICE should be sought.

Plik z chomika:

Inne pliki z tego folderu:

Inne foldery tego chomika: