Dark-field microscopy is not widely available,

Late latent syphilis,latent syphilis of unknown

but DFA testing of a fixed smear from a lesion is

duration, or tertiary syphilis, can be treated

available at many commercial laboratories.

with benzthiazide penicillin injection repeated

Nontreponemal serologic testing with rapid

weekly for a total of three doses, or doxycycline

plasma reagin (RPR) orVenereal Disease Research

therapy extended for a total of 4 weeks. In preg-

Laboratory (VRDL) are the most common sensi-

nancy, desensitization to penicillin is recom-

tive methods of screening.14 All positive tests

mended if the patient has a penicillin allergy

should be confirmed with treponemal testing

because doxycycline is contraindicated.

using T pallidum particle agglutination (TP-PA)

Neurosyphilis or ocular manifestations are

or florescent treponemal antibody absorbed (FTA-

treated with aqueous crystalline penicillin G, 3–4

ABS).HIV can cause false-negative results by both

million units IV every 4 h for 10–14 days; or peni-

treponemal and nontreponemal methods.15,16

cillin G procaine, 2.4 million units IM once daily,

Positive treponemal antibody tests usually

plus probenecid, 500 mg orally four times daily,

remain positive for life and should not be used

with both drugs given for 10–14 days. Probenecid

to assess response to therapy. Nontreponemal

cannot be used in patients with an allergy to sulfa.

antibody titers, RPR and VDRL, correlate with

The CDC recommends consideration of treatment

disease activity. Disease activity should be fol-

with benzathine penicillin, 2.4.million units intra-

lowed with the same test at the same laboratory

muscularly once a week for 3 weeks after comple-

as the results are variable among laboratories

tion of the neurosyphilis treatment regimen to

and are not interchangeable. After treatment, a

provide comparable total duration of therapy to

fourfold decrease in VDRL and RPR titers at

that of late syphilis. Patients should be followed

3 months, and an eightfold decrease at 6 months

with nontreponemal antibody titers at 6 and

are expected.17 These tests usually become nega-

12 months. Patients with neurosyphilis require

tive 1 year after treatment.

repeat examination of CSF fluid 3–6 months fol-

The U.S. Preventive Services Task Force recom-

lowing therapy and every 6 months afterwards

mends that pregnant women and people who are

until normal results are observed.

at higher risk for syphilis undergo screening.18

People at higher risk for syphilis include men who

Lymphogranuloma Venereum

have sex with men and engage in high-risk sexual

behavior, commercial sex workers, persons who

Diagnosis

exchange sex for drugs, and those in adult correc-

tional facilities. The CDC recommends that test-

Lymphogranuloma venereum is caused by

ing for gonorrhea,chlamydia,HIV,hepatitis B and

Chlamydia trachomatis types L1, L2, and L3, and

C be considered for all patients with syphilis.

is extremely rare in the United States. The initial

manifestation is usually a single, painless ulcer

Treatment

on the penis, anus, or vulvovaginal area that

goes unnoticed. Patients usually present with

Benzthiazide penicillin G (2.4 million units

painful unilateral suppurating inguinal adenop-

intramuscularly as a single dose) remains the

athy and constitutional symptoms 2–6 weeks

treatment of choice for primary, secondary and

after resolution of the ulcer. Significant tissue

early latent syphilis.Other parental preparations

injury and scarring may lead to labial fenestra-

or oral penicillin are not acceptable substitutes.

tion, urethral destruction, anorectal fistulas, and

Patients should be informed about the Jarisch-

elephantiasis of the penis, scrotum, or labia.

Herxheimer reaction, which consists of head-

The diagnosis is mainly clinical and cultures

ache, myalgia, fever, tachycardia, and increased

arepositiveinonly30–50%ofcases.Compliment-

respiratory rate within the first 24 h after treat-

fixation or indirect-fluorescence antibody titers

ment with penicillin. Symptoms can usually be

can confirm diagnosis. A compliment-fixation

managed with bed rest and nonsteroidal anti-

titer ³64 is diagnostic of infection. Other causes

inflammatory agents. It may cause fetal distress

of inguinal adenopathy should be excluded.

and preterm labor in pregnant women. If the

patient has penicillin allergy, doxycycline

Treatment

100 mg by mouth twice daily or tetracycline

Treatment for LGV is doxycycline 100 mg twice

500 mg by mouth four times a day for 14 days

are alternatives.

daily or erythromycin 500 mg four times daily

344

Practical Urology: EssEntial PrinciPlEs and PracticE

for 3 weeks. Doxycycline is contraindicated in

large tense mass that is erythematous, painful,

pregnant and lactating women. Patients should

and warm to touch.

be followed clinically until symptoms resolve.

The diagnosis of urethritis in men is suggested

Sexual partners should be examined, tested for

by mucopurulent urethral discharge with >5

urethral or cervical infection, and treated if sex-

WBC per oil immersion field or first void urine

ual relations were held within 30 days of the

specimen with positive leukocyte esterase or

onset of symptoms.

>10 WBC per oil immersion field. Gonococcal

Aspiration or incision and drainage of buboes

urethritis can often be diagnosed by gram stain;

may be required to prevent femoral or inguinal

however, a negative Gram stain in the setting of

ulcerations. Azithromycin, 1 g once a week for 3

urethritis does not rule out gonorrhea.

weeks may be a potential alternative for treat-

Cervicitis is characterized by two major diag-

ment, but confirmatory data is insufficient.

nostics signs: purulent or mucopurulent endo-

cervical exudate and/or sustained endocervical

STIs that Cause Urethritis,

bleeding that is easily provoked by swabbing the

cervical os. Women may complain of post coital

Epididymitis, and Cervicitis

bleeding or abnormal vaginal discharge. The

following sections will address the most com-

mon causes of cervicitis, urethritis, and epi-

In the setting of STI risk, epididymitis is usually

didymitis in patients with STI exposure. The

caused by gonorrhea or chlamydia and patients

etiologic agent,classic manifestations,and CDC-

presentwithaswollenpainfulscrotum.Palpation

recommended diagnostic tests are summarized

may reveal a tender prominent epididymis or a

in Table 25.4. CDC-recommended treatment