常見性病的診斷與治療

常見性病的診斷與治療 陰部皮膚病灶 ( 陰道滴蟲 陰蝨 疱疹 ) 高雄醫學大學附設中和紀念醫院婦產部陳渝潔主治醫師

性傳染病 透過性行為傳染的疾病 發生在性器官的傳染疾病 2

性傳染病 潰瘍型 梅毒 軟性下疳 皰疹 分泌型 淋病 披衣菌尿道炎 贅生物型 尖型濕疣 ( 菜花 ) 寄生蟲型 陰道滴蟲 陰蝨 全身瀰漫型 愛滋病 B 型肝炎 C 型肝炎 其他 子宮頸癌 鼠蹊淋巴肉芽腫 同時併有多病原菌, 如淋病併非淋病菌尿道炎, 淋病併梅毒等! 3

陰道滴蟲 4

陰道滴蟲 Trichomonas vaginalis Humen are the only nature host of T. vaginalis 佔 4~35% of vaginitis 5

Risk factors Trichomoniasis is virtually always sexually transmitted. Incubation period:4~28 days The organism can be identified in 30~40% of the male partners of infected women but self-limited and transient in men 6

臨床症狀 Asymptomatic Purulent, malodorous, thin discharge Burning Pruritus Dysuria, frequency Dyspareunia 7

Physical Examination Erythema of the vulva and vaginal mucosa Green-yellow frothy discharge (10~30%) Punctate hemorrhages on vagina and cervix (strawberry cervix) 8

診斷 -1 Microscopy (wet mount): the presence of motile trichomonads (50~70%) ph: elevated vaginal ph (>4.5) 9

診斷 -2 Culture: high sensitivity and specificity(>95%) Rapid antigen and nucleic acid amplification tests: high sensitivity and specificity OSOM Trichomonas Rapid Test Affirm VPIII Microbial Identification Test 10

診斷 -3 Cervical cytology: Sensitivity 51~63%, false positive 7% by conventional pap smear Sensitivity 61%, specificity 99%, false positive<1% by liquid-based pap smear 11

治療 The 5-nitroimidazole drugs (metronidazole or tinidazole): the only curative therapy of trichomoniasis Metronidazole or tinidazole, a single oral dose of 2 g Metronidazole 500mg twice daily for 5~7 days 性伴侶也需要一併治療 治療期間須禁止酒精類的攝取 Adverse effects: metallic taste & disulfiramlike reaction( 臉潮紅 心跳加快或心悸 頭痛 噁心及嘔吐 ) 12

陰蝨

陰蝨 Pthirus pubis 又稱 Pubic louse 一種寄生於人體毛髮的寄生蟲, 常見於陰毛, 也可於頭髮, 眼睫毛, 腋毛, 鬍鬚等毛髮中發現 長約 1~3mm, 肉眼下像灰白色的皮屑附著於毛髮上 傳播途徑主要是性交, 衣物或被褥也是常見的傳染途徑 潛伏期 : 3 至 10 天 14

陰蝨 Pthirus pubis 外觀 15

陰蝨 Pthirus pubis 生命週期 陰蝨的生命週期分成 : 卵 若蟲和成蟲 1. 卵 : 通常緊附於陰毛根部, 呈現白色或淡黃色, 孵化期約為一週 2. 若蟲 : 形態與成蟲相似, 但體形較小, 孵化後約 2~3 週長至成蟲 3. 成蟲 : 呈灰白色或褐色, 雌蟲比雄蟲大 一般陰蝨成蟲的壽命約 30 天, 但脫離人體後約兩日內死亡 16

陰蝨 Pthirus pubis 臨床症狀 陰部搔癢, 特別是夜間 陰部出現紅疹 丘疹 血痂或青斑 內褲上有鐵鏽色或褐色血點 陰毛根部發現蟲卵 陰毛處發現陰虱活動 17

陰蝨 Pthirus pubis 治療 剃除陰毛及肛周毛髮, 並將其焚燒 將被污染的衣物 床單 被罩清洗烘乾或煮沸 5 分鐘消毒, 或置入塑膠袋中密封靜置兩週 使用含有以下成分的藥膏或洗劑塗抹清洗患部 1. Permethrin cream 2. Lindane lotion 3. Crotamiton (Ulex cream) 4. Benzyl benzoate (B.B. lotion) 18

常見女性陰部潰瘍

女性陰部潰瘍之鑑別診斷 外型, 是否疼痛 病史 潛伏期 是否有鼠蹊部淋巴結腫大 實驗室診斷 20

常見造成陰部潰瘍的疾病 Primary syphilis (chancre) Chancroid (Hemophilus ducreyi) Genital herpes Granuloma inguinale Lymphogranuloma venereum Trauma 21

常見造成陰部潰瘍的疾病 ( 圖 ) 22

Clinical characteristics of infectious causes of genital ulcer disease GUD syndrome Etiologic agent Classic ulcer characteristics Incubation Pain Adenopathy HSV HSV type 2 in most cases, HSV-1 is less common Multiple small grouped ulcers; erythematous base. Occasionally, single lesions 2-7 days Usually painful; can be painless or pruritic Reactive painful nodes common Indurated, smooth firm borders 7-90 days Usually painless; rarely can be painful Firm, rubbery nodes Syphilis Treponema pallidum Clean base Heals spontaneously Not tender Regional Usually singular, although multiple chancres can occur Discrete 23

Clinical characteristics of infectious causes of genital ulcer disease- 續 GUD syndrome Etiologic agent Classic ulcer characteristics Incubation Pain Adenopathy Chancroid Haemophilus ducreyi Sharply circumscribed or irregular, ragged undermined edges Not indurated Base may have gray or yellow exudate 3-10 days Marked 50 percent with inguinal adenopathy Usually unilateral Often painful Multiple ulcers Usually not observed 5-21 days Usually painless More common in males Small and shallow Matted clusters LGV Chlamydia trachomatis L1-L3 Rapid spontaneous healing Unilateral or often bilateral Large painful fluctuant "buboe" Painful groove sign Granuloma inguinale (Donovanosis) Calymmatobacterium granulomatis ((Donovan body) Extensive, progressive 7-90 days Usually painless Pseudobuboes Granulation-like tissue Rolled edges 24

Primary Syphilis Chancre 硬性下疳 25

Secondary Syphilis Condylomata lata Soft, flat-topped, moist, pink-tan papules and nodules 26

陰部泡疹 Genital herpes

Genital Herpes 28

Genital Herpes 29

Genital Herpes 病原體 : Herpes Simplex Virus Type 1 HSV : oral lesions Type 2 HSV: genital lesions 26% of American females age 12 and older have suffered a genital HSV-2 infection 40% of adults are seropositive to HSV-1 The virus sensory nerve endings the dorsal root ganglion, where the virus develops lifelong latency.

臨床症狀 The three stages of lesions : Vesicle with or without pustule formation: burning, pain about a week Ulceration: painful Crusting Secondarily infected

診斷 Tissue culture: The gold standard High specificity, low sensitivity In recurrent disease, less than 50% of cultures are positive a negative culture result doesn t mean there is no herpetic infection Polymerase chain reaction (PCR) testing: 1.5 to 4 times more sensitive than culture Serologic type-specific glycoprotein G based assays: detect HSV-1 and HSV-2 Ab with a specificity 96% sensitivity of HSV-2 Ab testing ranges from 80 to 98%

治療 Antiviral therapy Acyclovir 400 mg three times daily for 7 to 10 days Analgesia: NSAID mild narcotic such as acetaminophen with codeine topical anesthetics : lidocaine ointment Local care: To prevent secondary bacterial infection Patient education: refrain from sexual activity when prodrome symptoms or lesions are present Latex condom use potentially reduce the risk for herpetic transmission 治療可以加速潰瘍癒合 減輕症狀但無法清除潛在病毒及預防復發

軟性下疳 Chancroid

Chancroid 35

Chancroid 36

Chancroid Ref. 2010 UpToDate, Inc. All rights reserved. 37

Chancroid 病原體 :gram-negative bacillus, Haemophilus ducreyi 潛伏期 :3 to 10 days Chancroid does not cause a systemic reaction, and no prodromal syndrome precedes the appearance of infection.

症狀 Erythematous papule pustular ulcerates within 48 hours The edges of these painful ulcers : irregular with erythematous nonindurated margins The based of these painful ulcers:red and granular, typically soft. The most common locations in women include the fourchette, vestibule, clitoris, and labia. Approximately half of patients will develop unilateral or bilateral tender inguinal lymphadenopathy.

診斷 細菌培養 : sensitivity for culture is less than 80% Before obtaining either specimen, superficial pus or crusting should be removed with sterile, saline-soaked gauze.

Recommended Treatment of Chancroid (CDC (2006) ) Azithromycin 1 g orally Ceftriaxone 250 mg intramuscularly Ciprofloxacin 500 mg orally twice daily for 3 days Erythromycin base 500 mg orally three times daily for 7 days

腹股溝肉芽腫

Granuloma inguinale 43

Granuloma Inguinale (Donovanosis) 病原體 :the intracellular gram-negative bacterium Calymmatobacterium (Klebsiella) granulomatis. mildly contagious, requires repeated exposures, Long incubation: weeks to months.

症狀 Painless inflammatory nodules:highly vascular, beefy red ulcers, bleed easily on contact. Secondarily infected:painful Lymph nodes:usually uninvolved

診斷 Diagnosis is confirmed by identification of Donovan bodies during microscopic evaluation of a specimen following Wright-Giemsa staining. no FDA-approved PCR tests for C granulomatis DNA.

Recommended Treatment of Granuloma Inguinale (CDC (2006) ) Doxycycline 100 mg twice daily for a minimum of 3 weeks and until lesions have completely healed Azithromycin 1 g orally once a week as above Ciprofloxacin 750 mg orally twice daily as above Erythromycin base 500 mg orally four time daily as above Trimethoprim-sulfamethoxazole DS orally twice daily as above

性病性淋巴肉芽腫 48

性病性淋巴肉芽腫 Lymphogranuloma venereum 致病原 : the L1, L2, and L3 serovars of Chlamydia trachomatis (small gram-negative bacterium) 盛行地區 : 熱帶 亞熱帶地區 好發族群 : 男同性戀 HIV 患者 49

Epidemiology In Singapore, a retrospective study of 531 cases of genital ulcer disease presenting at the Department of STD Control 91.6% were due to venereal causes and 8.4% were due to non-venereal causes. The venereal causes of genital ulcers genital herpes (71.5%) chancroid (15.8%) primary syphilis (3.4%) lymphogranuloma venereum (1%) Ann Acad Med Singapore 1995; 24:510. 50

Risk factors HIV carrier concurrent ulcerative disease a previously diagnosed sexually transmitted infection unprotected anal sex recent travel abroad meeting sex partners on the internet 51

Pathophysiology LGV is predominantly a disease of lymphatic tissue LGV induce a lymphoproliferative reaction. The primary infection site the draining lymph nodes abscess formation 52

LGV 疾病進程 第一階段 : 受感染處產生潰瘍或黏膜發炎, 潛伏期約 3 至 12 天, 這些症狀幾天內會自行痊癒 第二階段 : 腹股溝淋巴結腫大 (inguinal syndrome), 形成 groove sign, 最終會產生潰瘍及破裂 此外也可能產生肛門發炎性腫大 化膿及廔管 (anorectal syndrome) 第三階段 : 如果之前症狀未能妥善治療, 可能會產生陰部象皮腫大 肛門廔管或狹窄 不孕症等 53

Inguinal syndrome in lymphogranuloma venereum Groove sign 54

LGV 診斷 Taking an accurate sexual history Thinking of the possibility of LGV Lab exam Culture: 不易施行 Serologic tests:a titer of >1:256 rules in the diagnosis, < 1:32 rules it out Nucleic acid amplification testing: 準確率最高 55

LGV 治療 藥物治療 Doxycycline (100 mg PO BID for 21 days) Azithromycin (1g PO once weekly for three weeks) Aspiration of buboes 性伴侶的治療 : Doxycycline (100 mg PO BID for 7 days) Azithromycin (1g PO a single dose) 56

Thank you for your attention! 57