MANAGEMENT OF A VENEREAL CASE
M. P. Vora, M.B.B.S., D.V.D.,
Hon. Senior Venereologist, St. George’s Hospital, Bombay
A Monthly Journal of Medicine & Surgery
Vol. 64, No. 1 of January 1967;
Pages: 39 - 46.
I n detecting venereal disease in the early stages, the medical practitioner is the most important figure, for most venereal patients go to him for advice and treatment.
The treatment of venereal diseases is often considered to be very simple, but this is not so.
The management of venereal diseases involves accurate diagnosis, treatment and follow-up. These are common afflictions curable by comparatively simple methods, which are almost entirely within the scope of the venereologist whose special clinical knowledge, experience and training will inspire confidence in the patient and ensure his cooperation. For success, careful history-taking and physical examination are essential.
The venereologist should adopt a sympathetic and human attitude to these patients, without indicting them for having transgressed moral laws. He should realize that venereal infection is not necessarily the result of leading an immoral life or inevitable result of promiscuous sex-behaviour in every case and that it may be detected in the guilty and the innocent alike. There is a huge reservoir of infection among individuals most of whom are or will get married. In untreated, they will pass the disease on to their marital partners in normal sex life. Sexuality which is natural in humans should not be confounded with sensuality. The doctor should listen patiently, take not of every detail which may have a bearing on the patient’s condition and try to correlate the observed clinical condition with the history. He should even suspect the possibility of homosexual activity or sexual deviation in some patients.
There are many sexually transmitted diseases other than the venereal diseases, i.e. syphilis, gonorrhoea and chancroid. They are not so simple to manage as is often taken for granted, and may involve complicated procedures in correct diagnosis, and confirmation by laboratory tests, and also need education of the patient with regard to his disease, contact-tracing, case-holding, adequate treatment, tests of cure and maintenance of records for future reference.
Diagnosis of these diseases, especially in the early stages, is almost impossible from clinical impression alone. Treatment of those diseases on suspicion or without accurate diagnosis is definitely unsound, empirical and even risky.
In the diagnosis of a common genital ulcer it is hazardous to presume chancre or chancroid and institute treatment, in the hope of giving immediate relief to the patient. The clinical or spot diagnosis of a genital lesion, especially in the early stages as a chancre or chancroid is not only difficult but may also prove disastrous at times. Careful exclusion and confirmation by laboratory tests are essential.
The diagnosis of gonorrhoea is not always verified by laboratory tests, in patients with urethral complaints. Often the physician does not make sure whether there is any discharge and whether it comes from the urethra or the subpreputial sac or if there is an additional lesion, lave aside the etiological agent. Nobody can just look at the discharge and say it is gonorrhoeal. Such discharges in both sexes may be due to different causes. To presume gonorrhoea and start specific treatment is not correct in the modern scientific era. Demonstration of gonococci in the discharge is obligatory, before the diagnosis could be established.
In making a diagnosis, it is necessary to ascertain whether or not the other sexual partner, i.e., the wife or husband has been exposed to the risk of infection, either during the incubation period or after the appearance of the first sign or symptom. The likely source of infection and other contacts must also be ascertained.. These should be pursued with tact and firmness, without shirking responsibility, for the prevention and spread of these diseases. Unless the practitioner, attempts promptly to find out and treat the source of his patient’s disease and protects his intimate contacts, he will be held responsible for the spread of the disease in the general community; planned instructions and advice to the patient will often enlist his cooperation in detecting exposed sexual partners and protecting the members of his own family.
During the interview, the venereologist must tell the patient about the potential seriousness of the disease, the necessity of early accurate diagnosis and adequate treatment, the dangers of inadequate or imperfect treatment, the evil-effects of the disease on his marital partner and on their progeny, the imperative necessity for his cooperation in getting cured, avoiding sexual contacts till he is fully cured or made non-infectious and finally the prevention of infection in the future, if he ever happens to expose himself to the risk of such infection. Every patient, whether male or female, must be informed about the danger of contagion to himself and to others, the risk of infecting the eyes in gonorrhoea or syphilis through the careless use of infected house-hold articles. Special emphasis must be laid on the fact that disappearance of signs and symptoms of these diseases does not necessarily mean complete cure and that the patient continue to be under the care of the doctor till completely cured.
When a patient seeks advice for a genital ulcer, the first thing is to ascertain if it is syphilitic or not. To do this, no antiseptic should be applied to the sore or other treatments instituted, as they will interfere with the detection of Treponema pallidum; the ulcer should be cleaned with normal saline and a drop of blood-serum from the lesion should be taken for examination for Treponema pallidum under dark-field microscopy. At the same time, a smear is made from the ulcer to examine for the presence of Ducrey’s bacillus, if chancroid is suspected. A serological test should be done as a routine in every case. If the first examination for Tr. pallidum is negative, it should be repeated on two successive days; it will then be possible to diagnose syphilis long before the serologic test for syphilis develops positivity. If the ulcer is secondarily infected or when painful inguinal lymphadenitis is present, the patient should be given one gram of a sulpha drug four to five times a day orally, for five to seven days, according to the severity of the condition. This will control the secondary infection, and help to prevent bubo-formation; also it does not militate against the early and accurate diagnosis of syphilis. This is equally effective for chancroid also.
The complaint of urethral discharge or burning micturition is very often a symptom of obscure origin. All patients, with that complaint do not necessarily suffer from gonorrhoea, as frequently presumed. On the contrary, most of them mean something else such as pollutions, prostatorrhoea, phosphaturia etc. Whenever such a complaint is reported, it is reasonable to keep in mind the likelihood of its being gonorrhoea; but it must be confirmed or ruled out by adequate physical and laboratory examination of smears, urine and cultures. Accurate diagnosis must be established before specific treatment is started; for, on this will depend subsequent procedures indicated by such a diagnosis. If a specific drug is given, before diagnosis is clinched, the confirmation and the institution of a proper treatment will become very difficult.
The successful treatment of gonorrhoea consists in paying due attention to the sex of the patient, bacterial confirmation, duration and anatomic extent of infection, the presence of complications, the choice of drugs and procedures of treatment. In using sulpha drugs or penicillin, suitable dosages over an adequate period in order to maintain an effective blood concentration level are of vital importance. The indiscriminate use of drugs in bacterial infections should be guarded against; otherwise it would prevent the development of antibodies, expose the patient to the danger of re-infection and promote the emergence of resistant strains of the organisms. For a fresh case of acute gonorrhoea in the male, one gram of sulphadiazine four to five times a day orally for five to six days or procaine penicillin-G 400,000 units I.M. daily on three consecutive days will be adequate. As a general rule, the dosage for treatment of the disease in the female, should be doubled. When penicillin is given for gonorrhoea, there is a danger of syphilis (if also present) being masked or getting modified in its early course. Moreover, residual urethritis, following treatment is not uncommon, where a primary mixed infection of the urethra has been contracted. In long-standing or complicated cases of gonorrhoea, the dosage for treatment must be trebled. Drugs alone will not eradicate the infection in such cases unless local therapy such as urethral irrigations, dilatations and prostatic massages are simultaneously instituted. These measures promote drainage, improve the local blood-supply and permit the effective application of chemotherapy. Instrumental treatment is required in nearly all cases of chronic or complicated gonorrhoea. Neither dilatations nor prostatic massage should however, be instituted until the acute stage has completely subsided. The course of treatment may have to be altered or repeated in some cases. The symptoms of gonorrhoea alone, such as epididymitis or arthritis should not be treated. The primary focus of infection is the main target and must not be lost sight of, in relieving symptoms of complicated gonorrhoea. When the infection fails to react favourably or urethral discharge persists inspite of routine therapy, the case should be reviewed from the bacteriological point of view for any deep-seated local complication and treatment suitably altered. If the cocci are found to be resistant, it will be wise to try another antibiotic such as oxytetracycline. It is futile to depend on penicillin for the cure of non-gonococcal urethritis, the treatment of which should be directed to the infecting agent. Trichomonas vaginalis responds to Metronidazole 250 mg. orally t.d.s. for 7 to 10 days.
When a patient has a painful swelling in the groin (bubo) a search and enquiry should be made for any lesion as the precursor. The tendency to give penicillin injections without first determining its etiology should be resisted, as by so doing the only available evidence of early and accurate diagnosis will be destroyed. If the bubo is soft and fluctuating, it should be aspirated rather than cut open for rapid healing.
Following a transitory genital ulcer, if a patient develops chronic indolent inguinal lymphadenitis, where the lymph nodes are large, matted together and are adherent to the overlying skin, which in turns becomes red, oedematous and grooved, and the whole mass can be palpated without much pain., lymphogranuloma venereum should be suspected and Frei’s intradermal test made to confirm the diagnosis. The complement fixation test with a titre of 1: 32 or above is considered positive. In about 20% cases of L.V., a false positive serological test for syphilis is likely to be had usually in low titre but becoming negative in about four weeks. If it persists or the titre rises, the possibility of a double infection should be considered. Penicillin has no effect. Sulpha drugs are quite effective in the early stages and broad-spectrum antibiotics in the later stages.
When a patient has a chronic spreading nodular ulcer with soft granulations, its borders heaped up and rolled out, and healthy skin surrounding it, with no involvement of the regional lymph nodes, granuloma inguinale should be thought of and a smear made from the tissue to search for intracellular Donovan bodies in order to clinch the diagnosis. G.I. does not necessarily begin in the inguinal region. Neither penicillin nor sulpha drugs have any effect, Pentavalent antimony compounds, streptomycin, terramycin and tetracycline are all effective in treating G.I. The duration of treatment will depend on extend of the lesion.
Venereal warts often occur together or follow chancroid or gonorrhoea. Penicillin or sulpha drugs have no place in therapy. They need excision or cauterization, with chemicals or electricity and the focus of irritation should be removed. The presence of any one of these diseases should alert the physician to search or enquire for other infections, for more than one may be acquired by a single contact.
Syphilis becomes generalised even before the appearance of the primary sore; so the mere healing of the chancre is no indication of a “cure” of the syphilis. From the clinical point, the practitioner must think of syphilis in terms of a systemic disease which is nearly always active but progresses slowly and may show up at any time in some way in any tissue of the body. He should not regard syphilis only in terms of a disease of the genitalia or the skin. The importance of dark-field microscopy in the accurate early diagnosis of syphilis, and its superiority over the customary blood-test for syphilis, in the first few weeks of infection must be clearly kept in mind. A few days’ delay in arriving at a diagnosis of syphilis, may impair the patient’s chances of complete cure by 20 to 25% and increase the possibility of the spread of infection in the individual and also in the community; it may also hasten possible late nervous or cardiovascular complications. The venereologists should be quite conversant with the techniques and interpretation of the results of routine serologic tests for syphilis (STS). The value of this test depends on its sensitivity and specificity, though neither is absolutely 100% correct. So the results of this and other serological tests should always be in conjunction with history and clinical findings. Thus for instance, when the STS is positive but not supported by the history or clinical findings a diagnosis of syphilis should not be made nor antisyphilitic treatment (ATS) institutes at once. Great caution must be used before accepting an unsuspected single serologic positivity as a proof of syphilis. Both the Wassermann and the flocculation test (V.D.R.L.) etc should be done and it is desirable that one of them should be quantitative to serve as a base line. A verification test such as R.P.C.F. may sometimes be necessary to exclude false positives. A negative STS made in the first few weeks of the infection does not rule out syphilis; nor does a negative STS during treatment necessarily show that the patient is cured of syphilis. The overwhelming definite advantage of quantitatively titred STS over the usual qualitative STS should be remembered in assessing the response to treatment as also in predicting the activity or relapse of the infection. A steady rise in the titre means active syphilis.
In assessing the diagnostic value of the STS, the untreated should be differentiated from the treated case. The interval since the last treatment the type of syphilis under consideration a pregnant state if present, and other conditions likely to give positive STS results and the titre of the reaction should all be taken into consideration. A titre positivity in the untreated and a low titre positivity in the inadequately treated usually have the same significance. A clinical relapse may not invariably accompany or follow serologic relapse; however, they have an identical significance in the matter of therapy. The STS is relatively unaffected by the AST and the sero-resistance or fastness is a well defined phenomenon in late syphilitics. Ignorance of this fact frequently results in over-treatment. However, it is imperative to exclude the possibility of neurologic or cardiovascular involvement in these cases. Once the case has been adequately treated, mere serologic positivity oor a stationary or a low-titre fluctuating positivity is not an indication for additional treatment and need not be considered as a contraindication for undertaking any operative procedure indicated in a syphilitic. For, a complete serologic reversal to occur, it may take years especially in late syphilitics. The cell-count and protein level of the C.S.F. offer the best index to detect the presence of early neurosyphilis and to find the response to AST in neurosyphilis.
The practitioner should know what would be adequate treatment in any particular stage of syphilis, and what ill-effects will attend under, irregular or unsatisfactory treatment especially in the early stages of infection. Inadequate or irregular treatment in the early stages of infection will result in a temporary suppression of the disease and often lead to crippling nervous or cardiovascular disabilities later on. Patients with seronegative primary syphilis have decidedly a better prognosis than those with seropositive primary or secondary syphilis, a graded dosage is required for each of these three forms. No opportunity should therefore, be lost in diagnosing syphilis in its early stage by dark-field microscopy; prolonged study is necessary in the evaluation of results of treatment. While treating early syphilis, it is advisable to prolong AST beyond the period usually required to mobilize host resistance, which will be achieved in 16 to 20 weeks of treatment. Prolongation of the treatment helps to induce ‘cure’ or permanent latency in a minority of patients, who do not necessarily attain ‘cure’ following a short course of treatment. A therapeutic regimen of proved efficiency through long-term study on a large number of patients should be adopted. By using procaine penicillin-G arsenic (oxophenarsine hydrochloride) and bismuth in one combination or other, it is possible to achieve intensive antisyphilitic therapy on an ambulatory basis. A minimum of 4.8 million units and 6.0 million units of procain penicillin G for eight and ten days respectively are considered satisfactory for primary seronegative and early secondary syphilis. In late syphilis 9 to 12 million units may be needed. This should be followed by weekly bismuth alone or bismuth and arsenic. If metal therapy is contra-indicated, long acting penicillin-g like benzathine or benethamine 600,000 units twice a week intramuscularly should be given till the host resistance is mobilized. This procedure is specially indicated in patients, who are not likely to come back for regular quantitative serologic tests and for physical check ups after the short course of therapy.
The object of treatment of early Syphilis is to render the patient non-infectious as rapidly as possible and to effect a complete eradication of the infection in the shortest possible time. Hence intensive therapy is required. In late syphilis, it is essential to exclude by suitable tests any serious cardiovascular, nervous or laryngeal lesions before active treatment is initiated. Here the object of the treatment is to relieve the patient of his symptoms and to arrest the progress of the disease; leisurely rather than intensive schedules of treatment are prescribed. The study of the cerebrospinal fluid is obligatory in the late and latent syphilis, before starting treatment. In using antisyphilitic drugs, care must be taken to avoid, untoward reactions by careful examination and interrogation of the patient before staring each injection. Serious reactions can be prevented in syphilitics by the timely use of steroids, anti-histaminics and adrenaline.
The concept of abortive treatment in syphilis is quite unsound and often harmful. The short-term results may appear impressive but such a procedure often results in a mere suppression of the early signs and symptoms of syphilis. Its use violates the fundamental principle i.e., not to treat on presumption; and it enjoins a considerable period of observation, testing and anxiety which may normally be limited to three months.
Congenital syphilis is preventable, by early detection and treatment of maternal syphilis. The importance of performing a routine STS in every pregnant woman cannot be over-stressed. Once the diagnosis of congenital syphilis is made in one member, the other members of the family should also be examined.
When a practitioner is asked to advice on the fitness for marriage of a syphilitic person, he should be very cautious in estimating the risk of transmission of syphilis to the marital partner and its ill-effects on the progeny. Neither unqualified pessimism nor careless optimism is justifiable. Similar precautions are applicable in the case of persons treated for gonorrhoea.
When the treatment of the venereal patient is completed, he must be under observation and suitable tests must be made to make certain that the infection has been completely eradicated. Without a full bacteriological and serological follow-up the treated patient may still be a potential source to increase the pool of infection in society and cause untold harm. These patients should be under observation for 4 to 24 months, undergoing a series of tests. Proper records must be maintained, for evaluating the results of treatment.
Chancroid patients should be observed for 3 to 4 months, during which periodical physical examinations and serologic tests for syphilis must be made. A case of acute gonorrhoea should have similar follow-up observation and tests. Specimens of urine held for 4 or 5 hours and of secretion from accessory sexual glands must not show gonococci or pus cells. The presence of five or more pus cell per microscopic field (H.P.) indicates continued inflammation. Finally, culture and urethroscopy must be undertaken for confirmation. A treated case of early syphilis needs to be observed for two years, during which regular physical examination, 2 blood tests at intervals, CSF studies at the end of 6 and 24 months and a complete checkup of the cardiovascular and nervous systems should be completed before the patient can be certifies “cured”. In cases of early syphilis, seronegativity, six months following the treatment are considered satisfactory. Even though the blood STS may be consistently negative, the C.S>F. must be examined at the end of six months, to detect or/and eliminate early asymptomatic neurosyphilis.
The average venereal patient who is totally ignorant of the latency and carrier stage of these diseases, has an erroneous idea that he will be cured by one or two shots of penicillin and needs no other care or follow-up.