Management of genital herpes simplex infections.

Genital herpes simplex infection is a common and troublesome condition that is more often due to herpes simplex type II virus than to type I virus. The first step in management is accurate diagnosis by virus culture or antigen recognition. General management involves explaining the natural history to the patient, giving advice on sexual behavior, contact tracing, and hygiene. Oral or intravenous acyclovir provides the most useful therapy for first attacks. Acyclovir cream has a similar effect with external lesions in mild attacks. A course of acyclovir, however, has no effect on subsequent recurrence. Recurrent attacks, being brief compared with first attacks, are less influenced by acyclovir therapy, which should be given early for maximal effect. Oral and intravenous therapy are effective in the treatment of genital and anal herpes simplex infection in patients with acquired immune deficiency syndrome. When oral therapy is used, doses may need to be increased. Acyclovir therapy is a valuable development compared with previously available antivirals for genital herpes simplex infection.

Genital herpes. A guide to pharmacological therapy.

The pharmacological therapy for genital herpes simplex virus (HSV) infection remains dominated by aciclovir, although a number of related compounds are currently under investigation. Recommended treatment for initial genital HSV infection is oral aciclovir 200mg 5 times daily for 5 days, with intravenous therapy reserved for complicated episodes. Although topical aciclovir may be of benefit, no improvement in the systemic symptoms is provided by this formulation. No preparation prevents the onset of recurrent episodes. The management of recurrent episodes is more controversial, with studies of episodic treatment with both topical and oral aciclovir yielding mixed and at times conflicting results. Episodic treatment with oral aciclovir initiated early by the patient appears to have the most favourable results, and if initiated at the onset of prodromal symptoms may abort the episode in some patients. In patients with frequent recurrences, suppressive therapy with oral aciclovir should be considered. A starting dose of 200mg 4 times daily appears to be the most effective, although 400mg twice daily may suffice. The total daily dose should be reduced as far as possible, and treatment should be interrupted on a yearly basis to determine the need for continuing suppression. The management and pharmacological therapy of genital HSV in pregnancy remains controversial and studies of oral aciclovir in late pregnancy are currently under way. Genital HSV infection may be particularly severe in the immunocompromised host and suppressive oral aciclovir should be initiated promptly. HSV resistance to aciclovir is an increasing problem in such patients, in particular those infected with HIV, and may necessitate treatment with intravenous foscarnet.

Quantitative methods for studies on vaginal flora.

Three recently described methods for quantitative sampling of the bacterial flora of the vagina were evaluated and none proved satisfactory. In a third of the samples, paired swabs showed large differences between the two weights of vaginal secretion collected by this method, and the recovery rate of bacteria deliberately added to test swabs was unsatisfactorily low. A calibrated loop gave a wide variation in the amount of secretion collected, due to variations in density and viscosity of the secretion. When secretion was collected with a calibrated pipette, it was often difficult to expel the collected volume from the pipette for testing. The simple weight-based method was devised in which a loop was used to collect an undefined volume of secretion for weighting in a tube of transport medium before homogenisation and quantitative bacteriological testing. Initial assessment indicates this to be a satisfactory method for quantitative studies of the vaginal bacterial flora.

Quantitative bacteriology of the vaginal flora in genital disease.

Samples from the posterior vaginal fornix of 102 women with various clinical conditions were analysed by a quantitative method. Aerobes were isolated from all but one of the specimens at a mean concentration of 7.2 log10 cfu/g and anaerobes from 92 specimens at a mean concentration of 8.1 log10 cfu/g. In most clinical conditions and in a control group of asymptomatic women, anaerobes outnumbered aerobes by about ten to one (one log10 unit). The most common organisms were aerobic and anaerobic lactobacilli, coryneforms, Staphylococcus epidermidis, Bacteroides spp. and anaerobic gram-positive cocci. Lactobacilli did not appear to confer any protective effect by excluding the presence of other organisms such as Gardnerella vaginalis or anaerobes. The isolation of anaerobic organisms from the vagina cannot be regarded as being of pathogenic significance without other supporting evidence.

Treatment of CMV retinitis in an AIDS patient.

We present a case of cytomegalovirus (CMV) retinitis in an AIDS patient who survived for 10 months after the start of his ocular problems. The retinitis responded to dihydroxy propoxy methyl guanine (DHPG) but relapsed four to six weeks after each course of treatment with progressive retinal destruction. One relapse was therefore treated with trisodium phosphoformate hexahydrate (Foscarnet). There are few reports of the use of this drug in the treatment of CMV retinitis with AIDS, but it appeared to be less effective in our patient than DHPG, possibly because of poor penetration of the blood-ocular barrier. A final course of outpatient maintenance therapy with DHPG failed to prevent a preterminal relapse of the retinitis. Fundus photographs demonstrated the resolution and relapse of the retinitis associated with each course of treatment. Maintenance therapy with DHPG would appear to be necessary to prevent relapse, but the logistics of this are difficult, and the effective dosage of DHPG is as yet uncertain.

Meatoscopy: a simple technique to examine the distal anterior urethra in men.

A common problem is to determine the site of the base of meatal warts in men and if the lesions will be suitable for the treatments available in genitourinary medicine (GUM) or sexually transmitted diseases (STD) clinics. Formal endoscopy requires sterile conditions and is therefore an expensive procedure. A simple safe cheap alternative is meatoscopy using an auroscope with inflation. This allows inspection of the anterior urethra to a depth of 5 or 6 cm. With this technique 175 examinations were performed on 153 patients. Warts were confined to the lips in 27 (56%) of 48 patients with meatal warts; in an additional 5 patients with meatal warts the warts arose from deep in the fossa navicularis and in 16 patients with meatal warts there were additional warts in the fossa navicularis invisible on clinical examination. No urethral warts were seen in 103 patients without meatal warts, comprising 47 patients with external genital warts and 56 without any warts. It is concluded that meatoscopy should be undertaken in all patients with meatal warts to determine the site of their base and to assess if there are any more proximal warts. This should be done as soon as the meatal warts are seen, and urethritis has been excluded, so that appropriate treatment can be planned.

Diagnosis of chronic prostatitis: overview and update.

Symptoms and signs are unhelpful in the diagnosis of chronic prostatitis which in many cases continues to rest on comparison of white cells and organisms in urine samples collected before (VB2) and after (VB3) prostatic massage to express prostatic secretion (EPS), and particularly in the EPS itself, if this is obtained. A series of 195 patients is reviewed, 38 with chronic bacterial prostatitis (CBP), 66 with chronic non-bacterial prostatitis (CNBP), 55 with prostatodynia, and 31 with a history of recurrent urethritis without prostatitis. Demographic characteristics and history of recurrent urethritis were similar in all groups indicating that recurrent urethritis alone does not predispose to prostatitis. The upper limit of normal for the EPS while cell count was taken as 1000/mm3 in line with other reports. With this, the upper limit of normal for the estimate of white cells by simple microscopy appeared to be about 5/high power field (hpf) rather than the figure of 10 often quoted; with the latter figure, a number of cases of CNBP would have been missed. All microscopy was undertaken with the same microscope using a x 40 objective. Culture results showed a predominance of enterococci, and cultural and cytological findings in EPS and VB3 were comparable. On microscopy, clumping of white cells was associated with increased numbers-mentioned previously in the literature but not supported by data. Ejaculation just before examination was associated with reduced rather than the increased numbers of cells previously reported. Individual investigators should assess their own methods in determining upper limits of normal for cells. In a separate series of 8 patients with symptoms compatible with prostatitis, transrectal ultrasound scanning showed a prostatic cyst; aspiration was associated with relief of symptoms. It is concluded that transrectal ultrasound scanning (TRUS) should precede prostatic investigation by prostatic massage as this may save the prolonged treatment often necessary for prostatitis.

The legal framework covering the practice of genitourinary medicine in the UK: the Venereal Diseases Regulations.

The legal framework governing the practice of genitourinary medicine is traced from 1916 to the present. The first legislation, the Public Health (Venereal Diseases) Regulations of 1916 was comprehensive, and accompanied by guidance on setting up outpatient clinics and their supporting laboratories with practical advice on taking samples to support clinical diagnosis. Confidentiality was emphasized. The regulations led to the development of a nationwide network of clinics providing free care, open at times convenient to the public, and situated in general hospitals in large centres of population. Most of the principles still apply. Subsequent legislation centred on maintaining the confidentiality of all information obtained in relation to persons examined or treated for venereal disease, but allows transfer of details between healthcare providers to facilitate care and contact tracing. While the initial regulations stated that the venereal diseases were syphilis, gonorrhoea and chancroid, the legislation now covers all sexually transmitted diseases.

Does first episode genital herpes have an incubation period? A clinical study.

A restrospective survey of the notes of 146 patients with culture-positive first episode genital herpes simplex infection produced 37 men and 37 women in whom the incubation period could be established from their own and their partners' notes. In 9 patients the period was 1-12 days, in 20 men it ranged from 1 to 49 days and in 11 women from 1 to 28 days. In 7 patients it was much longer. In 28 patients a first episode of genital herpes developed during an ongoing monogamous relationship. These findings indicate that the incubation period of genital herpes may be longer than hitherto recognized and have implications for counselling and control.

Management of genital herpes simplex infection.

Herpes simplex infection of the genitals is a common condition, more often due to herpes simplex virus (HSV) type 2 than to type 1 virus. There is a severe first attack followed by mild recurrences which are more common and more frequent after HSV-2 than after HSV-1 genital infection. Clinical features with prodrome, vesicles and erosions may be characteristic allowing rapid clinical diagnosis. When possible laboratory confirmation should be attempted. General management includes simple hygiene, avoidance of sexual transmission, use of condoms, and notifying partners. Oral acyclovir (Zovirax, Wellcome) is the drug of choice for initial attacks and should be considered for all women with this diagnosis. Intravenous acyclovir may be used for very severe attacks. Men with initial attacks may be treated with oral acyclovir but mild disease affecting only skin may be treated with 5% acyclovir cream. Recurrences are short so acyclovir has less effect. Frequent recurrences can be troublesome and may be suppressed by continuous oral acyclovir, or individual attacks may be aborted with intermittent therapy. Various systemic complications may occur; an important but rare problem is primary herpes in late pregnancy. Acyclovir is effective in the treatment of the troublesome herpes simplex disease associated with human immunodeficiency infection. Acyclovir is one of the more expensive treatments for sexually transmitted diseases. At present in many countries costs are being examined, and application of the principles outlined here should help to minimize cost and maximize care.

Meatoscopy: an important technique for assessing meatal warts in men.

A total of 506 meatoscopic examinations showed this is a simple, safe, rapid, well-tolerated, useful procedure to assess the extent of warts at the meatus and in the distal urethra of men. The procedure was performed in 307 patients. Sixty-five (52.5%) of 124 men with meatal warts had additional urethral lesions not readily treatable. All proximal warts were confined to the fossa navicularis. Meatoscopy assisted in immediate rational planning of therapy. In assessing patients without meatal warts, lesions in the fossa navicularis were observed in 4 (6.7%) of 60 men with external penile warts, 4 (7.8%) of 51 men with a history of 3 previous episodes of urethritis, and in 8 (23.5%) of 34 men who had been in contact with warts. No relation was found between the distribution of warts, demographic details of patients, or duration of warts; the effect of previous urethritis on development of warts was unclear. It was concluded, following 199 repeated examinations, that the procedure was not associated with recurrence or proximal extension. Only 2 minor adverse events were recorded. Meatoscopy is recommended as part of the assessment of men with meatal warts and men who have been in contact with warts. The procedure should be considered in patients with external warts but no meatal warts, and in patients with a history of 3 previous episodes of urethritis over 3 years.

Contrasting psychosexual problems of patients attending a genitourinary medicine clinic and a community-based clinic.

The presenting complaint in 100 consecutive patients attending the psychosexual session (PSS) attached to the Department of Genitourinary Medicine (GUM) in St Thomas's Hospital was compared with 100 consecutive patients seen at a community PSS attached to a family planning clinic in an outer London district. Patients attending the GUM PSS had a greater fear of infection and more relationship problems, but less erectile failure and loss of libido; there was also a higher proportion of men referred and more patients with no regular partner than in the community PSS. It is concluded that many patients with psychosexual problems sought help from the GUM clinic.

Herpes simplex virus infection in pregnancy and its management.

Neonatal herpes simplex virus (HSV) infection is considered to be rare in the UK, affecting less than 3 per 100,000 live births, but the true incidence is probably higher due to under-reporting. In contrast, neonatal HSV infection is more common in the USA affecting 1 per 7500 live births overall. Infection in neonates is frequently serious and may be fatal.

Sexually transmitted diseases in lesbians.

The limited published data support the assumption that lesbians are a low risk group for sexually transmitted diseases (STDs). However, there are virtually no contemporary data and the older papers do not take into account genital wart virus infection, now the third most prevalent STD in Britain. One of the dangers in assuming that lesbians are a 'safe group' for STD and allied disorders is that patients may not attend for regular cervical cytology and could be at risk of developing cervical cancer. In an unselected series of 27 lesbians attending a genitourinary medicine clinic, the most important findings were a relatively high prevalence of the viral STDs, herpes simplex and human papillomavirus. Additionally, 10 patients had abnormal cytology ranging from inflammation to dyskaryosis. There is a need for more information about the true prevalence of STDs in this group and evaluation of the risk factors for female-to-female transmission of infections. Lesbians should continue to have regular cervical smears, especially as many have had earlier heterosexual intercourse.

Aetiology of non-gonococcal urethritis: a possible relation to other infections.

Chlamydia trachomatis can be identified in up to 60% of cases of nongonococcal urethritis (NGU) and the aetiology of most of the remainder is obscure. This paper reports a role for other genitourinary (GU) infections such as candidiasis, warts and herpes simplex, in the causation of NGU. One hundred and ten men fulfilled the entry criteria which included the probability that their contacts would attend the department. Fifty-four of the 110 men had GU infections other than NGU; 56 had no other infections. NGU was detected in 31 (57%) of cases with other GU infections and 8 (26%) were chlamydiae-positive: in contrast NGU was found in only 10 (18%) of those with none of the other infections and 3 (30%) were chlamydiae-positive. Chlamydiae-negative NGU was, therefore, more common in those with other GU infections. Forty-five (86%) of 52 contacts of 41 patients with NGU had various GU infections such as candidosis and anaerobic vaginosis, in contrast with other GU infections in only 7 (23%) of 30 contacts of men with no other GU infections. Other GU infections in patients and their contacts appeared significantly related to the presence of chlamydiae-negative NGU.

Azithromycin vs doxycycline in the treatment of non-gonococcal urethritis.

Azithromycin is a novel azalide macrolide active against Chlamydia trachomatis and Ureaplasma urealyticum. High persistent tissue concentrations allow short courses or even single doses to be considered. Sixty-two patients were studied, 19 received azithromycin 1 g in a single dose, 22 received azithromycin 500 mg in a single dose on day 1 followed by 250 mg once daily for 2 days and 21 received doxycycline 200 mg in a loading dose followed by 100 mg every 12 h for 7 days. Efficacy of these 3 regimens was compared in the treatment of non-gonococcal urethritis (NGU). Clearance of C. trachomatis from post-treatment cultures was satisfactory with all regimens. Response defined as the absence of symptoms and reduction in polymorphonuclear leucocytes in a Gram stained smear of urethral secretion to less than 5 cells per hpf (x 100 objective) was statistically better for the 3 day regimen of azithromycin than for the other 2 regimens. All treatments were well tolerated. Three days or single doses of azithromycin compared to 7 days of tetracycline (or 10-14 days as is often prescribed) have obvious advantages for patient compliance.

Use of the Cytobrush for concurrent cytology and chlamydia sampling: a comparison of immunofluorescence and culture for detection of chlamydia.

Five hundred and thirty-three women attending a genitourinary medicine clinic underwent concurrent cytology and Chlamydia trachomatis screening using a Cytobrush (Medscand AB). In each case, the same Cytobrush was used to give a sample for direct immunofluorescence and culture. 11.1% of samples were positive by immunofluorescence, while 10.6% were positive by culture. This was a close agreement (Kappa = 0.875). The ability of the same instrument to be used for both cytology and chlamydial screening, where direct immunofluorescence is used for detection of chlamydiae, may allow more widespread screening for chlamydia to be practical.

Single dose treatment of trichomoniasis.

Oral treatment for trichomonas vaginalis infection is now well established. In a previous paper, we established the value of a high single dose regimen of metronidazole for this condition by demonstrating its efficacy in a double-blind controlled study. Tinidazole is another accepted trichomonacide. By means of a single-blind controlled trial, we demonstrate that a 2 g single dose of tinidazole is as effective as a 2 g single dose metronidazole in the treatment of vaginal trichomoniasis. The cure rate for tinidazole was 95% and for metronidazole it was 97.5%. No side-effects were reported with either regimen.

Prostatitis.

Prostatitis, especially chronic prostatitis, is sometimes regarded as an obscure, ill-defined condition, perhaps because the anatomical location of the gland and ill-defined symptoms make diagnosis difficult. Treatment may appear time consuming and tiresome for doctor and patient, but by following established principles, diagnosis is often simple and management straightforward.

The chronic prostatitis syndromes.

Three chronic prostatitis syndromes are recognised, chronic bacterial prostatitis (CBP), chronic nonbacterial prostatitis (CNBP), and prostatodynia. All may occur in men of military age, and may tax the patience of medical officers and patients whose capacity for full duty will be impaired. Diagnosis depends on identifying micro-organisms in CBP and white cells in CNBP in prostatic secretion (EPS) expressed by prostatic massage. In prostatodynia there are clinical features of prostatitis but no evidence of inflammation. Prostatic massage should be preceded by trans-rectal ultrasound which may show prostatitis and other pathology, and has simplified the investigation of these syndromes. Management includes a high fluid intake, regular bowels with a soft stool, regular prostatic drainage by ejaculation and limited alcohol intake. Antimicrobials are indicated for CBP and probably for CNBP, and need to be continued for at least three months in many cases. Other measures for treating CNBP are less well established. Prostatodynia is an ill defined syndrome which requires careful evaluation and patients may need psychiatric therapy.