15- Genital Area

Cochonoma Vaginalis/Penis/Anus

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Difficult subject: the word "cochon" is French for pig, and this name implies a hotchpotch of unidentified skin lesions of various origins, including fungal, bacterial, viral, allergic, misuse of topical medications, etc.

Large painful lesions involving genital and/or anal area, with pus…  The lesion can be a few months old (sometimes years!) and the cause is multifactorial including self-medication and shyness (not daring to show a doctor…).

A big "wash" first with fluconazole 200mg 2x/day + gentamycin IM 160mg daily (+ acyclovir 800mg 5x/day if available but this is not really necessary).  Our experience teaches us also that such a lesion will never clear if we do not also give a high dose of dexamethasone for at least six days (4cc IM morning+2cc midday).  (If we do not dare to give dexamethasone -CMV context for instance- we use clobetazole cream 3-4x/day).

For local care: wash softly with normal saline and, if possible, leave open to air (no diapers).

If not clearly better after 4 days exchange genta for chloramphenicol 500mg 4x/day

Sometimes, we never find an effective treatment (not common).

Vaginal discharge

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If examination difficult or impossible:

Metronidazole 400mg 1 tab 3x/day

+

(Doxycycline 100mg 1tab 2x/day or ampicillin 500mg 4x/day)  (NB! ampicillin does not cover chlamydia/gonorrhea!)

If examination is possible:

- Offensive, fishy odor, gray-white, sticky:

metronidazole 400mg 1tab 2x/day for 5days

- White, curd-like:

candidiasis?  Local antiseptic/anti-mycotic (povidone iodine…) or clotrimazole (vaginal suppository) or fluconazole 200mg 2x/day...

- Yellow-green frothy:

Trichomonas?  Metronidazole 400mg 2tabs 3x/day for 4 days only

…+Acute pelvic inflammatory disease? 

Ampicillin IV 1g 4x/day + metronidazole 400mg to 1g 3x/day (or as rectal suppository)

- Nothing working and/or suspect chlamydia/gonorrhea

doxycycline 100mg 2x/day for 10 days

 

 

If acute condition (T°+++, lower abdominal tenderness, cervical motion tenderness, adnexal tenderness): "PID"

Metronidazole 400mg 3x/day + doxycycline 100mg 2x/day + ampicillin IM/IV 1g 4x/day.

Purulent discharge from penis:

• Chlamydia?  Gonorrhea?  Both?  (ghx099) Difficult to know.  [Doxycycline 100mg 2x/day + ciprofloxacin 500mg 1x/day] for 7 days is a solution (Syphilis is often associated with gono and we have to treat both even if no syph signs... but for HIV patient doxycycline is NOT the right way to treat syphilis...  See protocol "37-Syphilis")

NB Gonorrhea can become chronic and/or disseminate.  You can observe epididymo-orchitis, prostatitis, periurethral abscess, pelvic organs infection...  Skin also can be involve: "...The skin lesions, found mainly on the extremities, have a reddened surrounding areola and evolve through macular (1-2 mm in diameter), vesiculopustular, haemorrhagic, and necrotic stages.  They are virtually pathognomonic of disseminated gonococcal infection (...) There are usually between four and ten lesions, not particularly painful (...).  Frankly haemorrhagic bullae and erythema nodosum-like lesions have been described...”  (From "Oxford Textbook")  (pxx186) (pxx187) & See 30-Dermato.  In practice the most common extra genital sign is maybe arthritis (especially monoarthritis)

Genital ulcers/chancre (male and female) (also anal, rectal, oral...)

-Painful chancre (deep) with or without lymph node enlargement:

Chancroid?  (ghx003)  (ghx030)  (bxx023) ghx046- (deep clear border of chancre) ciprofloxacin 500mg 2tabs/day for 3days or erythromycin 500mg 4x/day for 7days

-Painless chancre (deep) with or without lymph node enlargement:

Primary syphilis?  Rare for terminal HIV patient...

-Painful superficial sores without lymph node, (start as small blisters ghx063):

Herpes?  (ghx008)  (ghx036) (Very common).  If secondary infection (pus) (ghx005) (ghx003), start first with cloxacillin 500mg 4x/day or genta IM 240mg daily, Then, only acyclovir cream

-Multiple sores with severe itching (especially night time) and without lymph node enlargement:

Scabies? See 28-Scabies

-Not painful+ silicone+ chronic+...  Can be ischemic ulcer following bad silicone injection...  (ghx080)  (ghx081)  (ghx082)//

 

Inguinal lymph node enlargement (male)

Chancre and/or abnormal testis in area

(ghx023) (ghx028...)  Chancroid?  Syphilis?  Orchitis?  See supra & protocol "37-Syphilis"

No chancre and/or abnormal testis in area

Look for infection on legs first to exclude banal lympangitis...  Think about other "normal" causes of lymph node enlargement in HIV+ patient after.  See protocol "30-Lymph Nodes“..  Attention, syphilis is still possible!

Genital warts (also anal) - Condylomata "Acuminata" & "Lata"

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Granular warts.  Condyloma Lata has a large root with flatter flesh and a less granulous appearance than Condyloma Acuminata.  C.Acuminata looks more like a "cauliflower" and C. Lata more like a "big granulous papule".  Confusion is very easy, especially if lesions are still immature.

Condyloma Lata is a symptom of syphilis and has to be treated as syphilis (see 37-Syphilis)

Condyloma Acuminata can be treated with podophilin if available, but a doctor should demonstrate the procedure the first time because errors can cause painful deep wounds!  But...  (As is the case for gonorrhea/chlamydia), association of C. acuminata with syphilis is common.  It is perhaps therefore sometimes better to treat C. Acuminata as "asymptomatic Syphilis"!

See also "37-Syphilis"

 

 

Scrotal hernia

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The intestine descends into the scrotum and you can hear peristalsis in scrotum.  You can also feel the peristalsis if you hold scrotum in your hand...  Intestine will escape from the hand if you press softly on scrotum (="reduction" of hernia)

There is nothing to do for HIV dying patient if there is no pain/occlusion.  But if you see signs of intestinal strangulation (occlusion/peritonitis/pain...) good luck!?!  Antibiotics + soft reduction???  ... It is normally a job for surgeon...  Mild hernia is more dangerous than large hernia because strangulation is easier.  Mild hernias can be reduced for prevention of strangulation, especially if patient feels some discomfort.

 

 

"Normal skin diseases"

Tinea (ghx012) (ghx031).... see 30-skin protocols

Scabies ghx006- ghx007- ghx009- ghx013- ghx027- ghx029- See 28-Scabies

Allergy (Stevens Johnson, Lyell, etc.) See 06-Allergy

 

 

...Rare & fantasy...

- Paraphimosis //ghx055, 056, 057, 058// ghx059, 060//

If a patient can get paraphimosis without surgery, it means that the same patient can also recover without surgery... but the technique used is "difficult"!

First give a strong painkiller (tramadol or other central pain killer).  When drug is acting, take "swollen" area of penis in your palm and press it slowly as a sponge.  Do not be fearful because of the patient’s pain, press more and more strongly for about 5 minutes... till you feel that there is no swelling anymore.  Then pull the foreskin into the right position again.  After the patient recovers, he must learn how to exercise his foreskin (each day " quickly retract and come fast forward" a few times) (if foreskin is not retracted and brought forward fast enough, paraphimosis will start again!).  A few weeks of daily exercises and the foreskin will be large enough... no need of circumcision or danger of new paraphimosis...  EXCEPT IF HE HAS A WOUND JUST ON THE NARROW PART OF FORESKIN (herpes for instance!)

- Old untreated paraphimosis???  (ghx041)  (ghx043)???

Not so rare...  A frank discussion with the patient will make known the true story.  Do not think too quickly that it is a tumor...  But I have to admit that confusion with "silicone fantasy" is possible...

 

- "Pleasure pearl "

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"Para-doctor" inserted a "stone" under skin.  It is a common practice in many countries... just to give "more pleasure" to partners...  Do not think too quickly about a "cold abscess".  A frank discussion with the patient will make known the true story.  If there is no infection, nothing to do of course.

- Other "surgical" + "paramedical" + "cultural" + infectious" (...) soup.

//ghx037-038-039-040// this patient was confused and died quickly after he arrived in the ward... I made conjectures for diagnosis...

BUT!  A few weeks after, another patient //ghx050-051-052-053// arrived with the same kind of penis!  He was not confused...  Read text under the photos....

Other silicone fantasy

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