Definition
Pruritis vulvae is marked and persistent vulval itch without apparent primary cutaneous cause. The vulval skin, particularly on the labia, is lichenified and there may be secondary infection, inflammation or local tissue reaction.
Investigation and diagnosis
Primary infective inflammatory and dermatological conditions should be excluded before the diagnosis is made. Differential diagnosis includes HPV infection, vulval intraepithelial neoplasia (VIN) and non-squamous metaplasia.
Management
Avoid vigorous washing with soap. Periodic bathing in saline and the application of bland creams may alleviate symptoms. Hydrocortisone 1% cream can be used for severe episodes but prolonged application of steroids may lead to atrophy.
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Paediatric infections are usually asymptomatic; infected children are more likely to become chronic carriers. Symptomatic infection is less likely to lead to a chronic carrier state.
The incubation period is from 60 days to 6 months. Acute illness frequently presents with malaise, nausea and vomiting. Other symptoms may include arthralgia, rash, myalgia, headaches, photophobia, pharyngitis, cough and coryza. Dark urine and light coloured stools precede jaundice by 1 to 2 weeks and jaundice usually persists for 1 to 4 weeks. Tender hepatosplenomegaly may be noted.
Infection, whether asymptomatic or causing an acute illness may be followed by recovery, a carrier state, chronic hepatitis or cirrhosis. Primary hepatic carcinoma may be a late complication.
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Donovanosis is a mildly contagious, chronic progressively destructive infection caused by Calymmatobacterium granulomatis, a gram-negative, oval bacillus in which polar bodies are often prominent. The organism develops intracellularly and is difficult to culture. This disease occurs in tropical countries including Papua New Guinea and, although uncommon in Australia, appears to be endemic in Aboriginal people in northern and central parts of the country.
Donovanosis should be distinguished from other causes of genital ulceration including syphilis, chancroid, lymphogranuloma venereum, severe herpes, cutaneous amoebiasis and anogenital neoplasm by appropriate tests. The diagnosis is established by the demonstration of С granulomatis in smears from scrapings or biopsies from lesions. Smears can be made by pressing a clean glass slide on the cut surface of a biopsy. The organisms can be identified as bipolar rods in large mononuclear cells and are best seen in giemsa-stained smears.
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Penicillin susceptible infection
Amoxycillin sodium 1 g intravenously every 6 hours until oral amoxycillin (500 mg 3 times daily for at least 7 days) can be given. Patients (other than pregnant females) who are sensitive to penicillin can be treated with spectinomycin (see below). Pregnant females should be treated with erythromycin
Penicillin resistant infection (first line treatment where PPNG is endemic) Cefotaxime 0.5 to 1 g intravenously three times daily for at least 10 days or Ceftriaxone 1 g intravenously once daily for 7 days or Spectinomycin 4 g in a single intramuscular dose daily (Dose may be divided between 2 gluteal sites).
Gonococcal conjunctivitis
Untreated gonococcal conjunctivitis in neonates is highly contagious and may rapidly lead to blindness. Systemic antibiotics are required e.g.:
Benzylpenicillin 30 mg/kg intramuscularly every 6 hours for 3 days (for penicillin sensitive infections) or Ceftriaxone 25-50 mg/kg intravenously or intramuscularly daily for 3 days (for PPNG) for 7 days or Spectinomycin 40 mg/kg intramuscularly daily for 3 days (for PPNG).
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An equivalent criterion for the diagnosis of cervicitis is the presence of 15
to 20 or more polymorphonuclear leucocytes per oil immersion high power field in 5 or more fields in a satisfactory area of a properly prepared cervical smear. This is not valid during menstruation when large numbers of polymorphs are normally present.
Swabs from the endocervical canal, urethra and anal canal should be examined by smear (gram stain) and culture for the presence of polymorphonuclear leucocytes and gonococci.
For chlamydia, swabs from the endocervical canal and urethra should be examined by smear and direct techniques; culture is only available in some larger centres. Good specimens are important for the diagnosis of chlamydia. Swabs should be taken from the cervical mucosal surface under direct vision. A cytobrush can be used to obtain good specimens.
Swabs of the lateral vaginal wall are suitable for examination by smear and culture for yeasts. Swabs of the urethra or posterior vaginal fornix can be examined by wet mount or culture for trichomonads.
Swabs of vesicle fluid and the ectocervix may be examined by direct microscopy, immunofluorescence or culture for herpes simplex virus.
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