FAMILY PHYSICIAN’S ROLE IN THE CONTROL OF V.D.
By Dr. M. P. Vora, M.B.B.S., D.V.D., I.M.S.(R)
Honorary Senior Venereologist
St. George’s Hospital, Bombay
Journal of the Indian Medical Association
Volume No. 46, No. 7, of April, 1, 1966, Calcutta
Page No. 370 to 373
The continuance of the spread of syphilis and gonorrhoea in spite of the great sensitivity of Treponema pallidum and Neisseria gonorrhoeae to penicillin remains a paradox. The recent steep rise in the incidence of these diseases poses a major problem for public health authorities all over the world.
The spread of venereal diseases can be controlled only by early detection and adequate treatment and follow up. The primary responsibility rests on the family physician, to which the patient comes first for advice. Physicians, who treat venereal diseases, must adopt a scientific approach to the problem and develop certain basic and standard procedures which are essential for their control.
The management of a venereal case needs adequate and painstaking care in history-taking and physical examination of the patient. It also involves complicated procedures, the inherent implications of which must be thoroughly grasped by the physician. These are discussed here briefly under different heads.
CHANGE IN THE ATTITUDE
It is generally not appreciated that venereal disease is not necessarily the result of leading an immoral life or the inevitable result of promiscuous sexual behaviour, for it may affect both the guilty and innocent alike. There is a huge reservoir of infected individuals in the community, most of whom are or will be married. Untreated, these diseases will be passed on to their conjugal partners through perfectly legitimate sexual activities. We must, therefore, treat these patients with sympathy, consideration, kindness and understanding. Only such an approach will encourage the V.D. patients to seek medical advice.
Correct diagnosis, especially in the early stages, is practically impossible on the clinical suspicion alone. Without laboratory aids, diagnosis of either sero-negative primary syphilis or gonorrhoea is rarely possible, however experienced a physician may be. It is also important in educating the patient with regard to his disease, and proper treatment, contact-tracing, case-holding and tests of cure.
As mentioned above, the earlier the diagnosis is made and treatment begun, the greater are the chances of a ‘cure’ in the shortest possible time and with the least chance of dissemination of infection both in the individual and in the community.
When a patient presents with a genital ulcer, the first important point to determine is whether or not it is syphilitic. One must therefore desist from the temptation of prescribing for the ulcer antiseptic applications or any treatment which is likely to interfere with the detection of Tr. Pallidum in the sore. Antibiotics at this stage delays diagnosis and institution of proper treatment. The ulcer should be cleaned with normal saline and a drop of serum from the lesion is taken and examined under dark field microscopy for Tr. Pallidum. It is very easy to diagnose syphilis by this examination several weeks before the blood test for syphilis becomes positive. At the same time, a smear should be prepared for H. ducreyi, if chancroid is suspected. A serologic test for syphilis should be done as a routine in every case. If the ulcer is secondarily infected or painful inguinal lymphadenitis is present, the patient should be given a sulphonamide preparation, 1g, four or five times a day by mouth, for 5 to 7 days, depending on the severity of condition. This will control secondary infection, prevent bubo formation and at the same time, will not militate against an early diagnosis of syphilis.
The complaint of urethral discharge or burning micturition is often a symptom of obscure origin. In such cases it is reasonable to maintain a high index of suspicion and think of gonorrhoea which should be confined or ruled out by adequate physical examination of the patient and bacteriologic examination of the smears prepared from the urethral discharge, urine and culture. On such results appropriate treatment should be undertaken. It is often helpful to find out if there is any purulent discharge, and whether it comes from the urethra or subpreputial sac or if there is any additional lesion.
When a patient complains inguinal swelling, one should always enquire and search for a genital lesion as a precursor, and attempt to arrive at a reasonable diagnosis before instituting any specific treatment. In his eagerness to give immediate relief to the patient, the physician is often tempted to use penicillin. This is harmful in the long run and must be resisted. For, such treatment will remove the only available evidence of accurate diagnosis.
The presence of any one of the venereal diseases should make one search for the others, because more than one infection may be acquired at a single exposure. Hence the tendency to neglect a thorough physical examination is strongly deprecated.
EDUCATING THE PATIENT
Educating public with regard to venereal diseases is a very useful weapon against their spread. At present, there is a good deal of ignorance, superstition, secrecy and prejudice on the part of the general public. Because of the mode of transmission of infection, the word V.D has long been a taboo in most homes. Few schools or institutions offer any information on the subject. Ignorance of the disease hampers all attempts to control V.D. Due to ignorance; the patient often tries to conceal the first signs and symptoms of the disease and takes recourse to self-medication on their friend’s advice, or even goes to quacks for treatment. Finally he accepts the disappearance of early signs and symptoms as ‘cure’ year after year; this has increased the reservoir of infection, endangering the health of the nation.
The conspiracy of silence must be brought to an end. Every patient needs to be told about the potential danger from these diseases, and their infectious nature. He should be advised to avoid sexual contacts until he is cured or made non-infectious. He must understand the dangers of inadequate and irregular treatment, the latent nature of the disease, and the disastrous effect on the marital partner and future progeny. He should be advised how he can guard himself against the infection in the future, if he even happens to expose himself to such risks. It should be impressed upon him that the disappearance of signs and symptoms does not mean ‘cure’ and that he must follow the advice of his physician until he is declared as cured. Lack of knowledge about the disease among the people, coupled with easy access to contraceptives and increasingly promiscuous sexual relations, creates a condition in which venereal diseases can spread like an epidemic. No physician however hard pressed for time, should lose the golden opportunity to enlighten his patient on the subject.
CASE-TRACING OR CONTACT INVESTIGATIONS
How often does a physician try to ascertain whether or not the other sexual partner, e.g., the wife or husband if the patient is married, has been exposed to the risk of infection, and to find out the likely source of infection and other contacts? These aspects should not be dismissed lightly but pursued with tact and firmness.
Case-tracing is a tough job for a medical social worker or an epidemiologist, whose specialized task is to trace as speedily as possible the chain of venereal infection from patient to patient until all contacts have been found, investigated and treated. The most common questions to be asked are: “what about the person you caught the disease from?” and “what about the people whom you may have given it before coming here?” The medico-social should try to obtain the names of all the people with whom the established case had contacts. This information must be treated as strictly confidential. The chief object of this inquiry is to help such contacts before the disease has permanently damaged their health, and before they can spread it to others. Epidemiologists must try to break the chain of infection as quickly as possible.
Adequate epidemiological control could reduce the incidence of these diseases. Experience, however, indicates that this is seldom carried out outside recognized clinics. A private practitioner has to face many difficulties in undertaking contact investigations of a venereal case, such as lack of time, patient’s non-cooperation, deliberate lies or denials of exposure, and unfruitful nature of physical and bacteriological examination of the female, especially in chronic gonorrhoea. However, the trouble is worth taking. If a private practitioner could find the source of infection and contacts of his patient and place them under treatment, the incidence of venereal diseases will be reduced to a great extent. Frequent failure to trace the source of infection is the most important single factor in the failure to control V.D.
Venereal diseases can be cured by timely and adequate treatment. Irregular and inadequate treatment, especially in the early stages of infection, often results in the emergence of resistant strains of organisms which may produce permanent disabilities in the future date. Most patients lack patience and demand ‘immediate’ cure. In their ignorance, they often consider it unnecessary to continue the treatment, as soon as the visible signs and symptoms have disappeared. They do not understand the significance of ‘latency’ or ‘carrier- stage’ of the diseases, which often damage the vital organs of the body. Because of the failure of most of these patients to complete regular and adequate treatment and follow up tests of cure, it has now become the standard procedure to employ a ‘social worker’ to achieve what is called ‘case-holding’. The practitioners should impress upon their patients the urgent need for their cooperation and induce them to undergo the full course of treatment and tests of cure.
THE FULL COURSE OF TREATMENT
The great importance of the principle of meeting out the full course of treatment with adequate dosage spread over an adequate period for effective therapy of venereal diseases cannot be overemphasized. Indiscriminate use of drugs or therapy must be avoided at all costs. For it deprives the patient of his body-defence build-up, promotes emergence of resistant strains of organism and makes the vital organs of the body more susceptible to the ravages of the infection. As a result, a good opportunity for early diagnosis and permanent cure is lost, and a sub clinical infection is left behind to do the mischief. Anti-venereal drugs should be prescribed only when called for. They should be given in the optimum dosage spread over a period sufficient to maintain an effective blood concentration for the requisite period. It is also essential that the physician should be well acquainted with the standard treatment schedules for venereal diseases.
Success in the treatment of gonorrhoea depends upon accurate bacteriological confirmation, data about duration and extent of infection, presence of complications, and choice of drugs and procedure of treatment. A fresh case of acute gonorrhoea requires sulphadiazine, 1 g, four to five times a day orally, for 5 to 6 days, or procaine penicillin, 400,000 units, I.M., daily for three consecutive days for adequate treatment. When penicillin is given for gonorrhoea, there is a danger of masking syphilis or modifying its early course, if a double infection has been contracted at the same exposure. In long-standing or complicated case of gonorrhoea, chemotherapy alone will not eradicate the infection unless the local therapy, such as the urethral dilatations, prostatic massage, etc. is employed at the same time. However, these latter measures must not be employed until the acute process has completely subsided. Penicillin is no cure for non-gonococcal urethritis. In treating gonococcal arthritis or epididymo-orchitis, the treatment of the primary focus of infection must not be overlooked.
One must bear in mind that healing of the primary genital lesion, chancre, does not mean cure of syphilis. A case of primary syphilis needs at least 6 mega units and of secondary syphilis 9 mega units of procaine penicillin, administered in ten and fifteen days respectively. Serious complications of syphilis and gonorrhoea and their late sequelae can be prevented, if every case is adequately treated in the early stages of infection.
TESTS OF CURE
Tests of cure are essential for every case of V.D. treated. Treatment, however perfect even at the hands of an expert, is not a guarantee of permanent cure in every case, unless it is followed by periodic physical check up and laboratory tests spread over a long period. In the absence of a full bacteriological and serologic check-up, one is likely to help increase the pool of infections in the society.
A case of chancroid needs observation for 3 to 4 months, the maximum incubation period for syphilis. During this period, the physical examination of the patient and the serologic test for syphilis has to be carried out at regular intervals to exclude the possibility of syphilis. A case of acute fresh gonorrhoea should have a follow up for a similar period, during which various tests for the cure of gonorrhoea, including the serologic test for syphilis are to be carried out. Urine held for about 4-5 hours should be free from pus cells and gonococci. Presence of more than five pus cells per microscopic field (H.P) is an indication of continued inflammation. Secretions from accessory sexual glands need to be examined and cultured for confirmation of cure.
A case of early syphilis treated needs an observation period for at least two years, during which time regular physical examination of the patient, blood tests for syphilis, cerebrospinal fluid examination and full check-up of the cardiovascular and nervous systems should be carried out before the patient can be declared cured. Sero-negativity within six months of treatment is considered satisfactory in early syphilis. Steady rise in titre of the serologic test for syphilis indicates either failure of treatment or impending relapse. Increase of protein and lymphocytes in the C.S.F. is an indication of early neurosyphilis which can only be detected by timely examination of the C.S. fluid.
MAINTENANCE OF RECORDS
As patients with venereal diseases needs surveillance or observation period extending from 4 to 24 months, when they have to undergo series of tests, proper records must be kept for evaluation of treatment, to understand the serologic trends, and declared the patients as ‘cured’. It is not possible to declare a V.D. patient ‘cured’ on the strength of single negative examination, either physical, bacteriological or serological or the combination of all. ‘Cure’ should be based on the results of a series of observations on physical health, and bacteriological and serologic tests.
A specific remedy does not always ensure eradication of the disease. Inadequate and improper use of the remedy may readily lead to drug resistant forms of the disease, as well as to symptomless carriers of the infection. This is one of the reasons for the increase in the incidence of venereal diseases. Control of contagious diseases depends upon complete cure of the infected individuals, along with detection of the sources of the disease and their treatment along with other contact cases.