Sexually Transmitted Diseases - I. I. Mavrov 2005

General Provisions, Principles, and Methods of Patient Examination
Objective Examination of Patients

A General clinical examination is carried out according to established protocols to assess the patient's overall health and to detect any involvement of Internal Organs or The Nervous system that may influence Diagnosis and Treatment Selection.

Objective Examination begins with an inspection of the Skin and mucous membranes. A more thorough examination is performed on the lower abdomen, the urogenital and perianal regions, the palms and soles, and the Oral Cavity, alongside Palpation of the Lymph Nodes AND an assessment of The Musculoskeletal System. Skin lesions (such as rashes, papules, excoriations, tumor-like formations, erosions, and ulcers) can serve as diagnostic markers for Syphilis, Chancroid, lymphogranuloma venereum, granuloma inguinale, genital viral infections, Molluscum Contagiosum, Scabies, and pediculosis, among others.

Joint pain, inflammatory signs, or other abnormalities may indicate Gonorrhea, syphilis, or Reiter's Syndrome. Enlargement or induration of the lymph nodes, particularly in the inguinal region, is commonly observed in syphilis, AIDS, lymphogranuloma venereum, and urogenital viral infections.

Next, the physician inspects the Hair on the pubic area, Scrotum, Perineum, and axillae to check for lice or nits. Further evaluation may proceed in several directions, including clinical-diagnostic and Laboratory tests that provide supplementary data (for example, suspected syphilis warrants dark-field Cell/15.html">Microscopy of native discharge smears and serological tests).

Patients undergo a neurological examination and, if necessary, evaluations by an ophthalmologist, otolaryngologist, general practitioner, radiologist, and other specialists. Subjective symptoms are recorded (such as headaches, limb pain, cardiac discomfort, various paresthesias, nausea, dizziness, urination and defecation disorders, and the onset of impotence), along with pupillary abnormalities (anisocoria, pupillary Reflexes, etc.), cranial nerve Functions (Cranial Nerves II, VII, VIII, IX, and others), coordination, deep tendon reflexes, superficial sensation, and mental status.

A wide range of neurological manifestations, sensory or auditory deficits, coordination issues, cognitive impairments (memory, calculation, writing, speech), and disorders affecting The Cardiovascular system, Liver, Spleen, Esophagus, intestines, Kidneys, Lungs, and other internal organs may be associated with syphilis, gonorrhea, chlamydial, mycoplasma, viral, or other urogenital infections. Obtaining laboratory confirmation of the preliminary diagnosis is critically important in such cases.

Recently, ultrasound Diagnostics and computed tomography have acquired particular significance in clinical practice.

Due to its non-invasive nature, ease of performance, absence of radiation exposure, and high diagnostic accuracy, ultrasound has secured a leading role in clinical practice for evaluating patients with urogenital disorders. This method offers extensive capabilities for visualizing internal organ structures (Uterus, fallopian tubes, kidneys, bladder, prostate, Heart, liver, etc.) and detecting even small mass lesions within the internal reproductive organs, sometimes in the absence of clinical symptoms. Ultrasound allows for the measurement of prostate size, configuration, echogenicity, consistency, and the presence of stones. It is also used to monitor the resolution of inflammatory tissue changes within the urogenital organs.

Computed tomography is rapidly becoming a standard diagnostic modality. Thanks to advanced image reconstruction, analysis, and quantitative evaluation, it is now possible to differentiate soft Tissues and visualize the finest bone details on scans.

Vast Prospects are also being opened by mathematical Methods for Processing large volumes of medical data, particularly computer systems for data collection, storage, processing, and retrieval, as well as MATHEMATICAL MODELING OF pathological processes and the optimal planning of treatment and research. These methods enable patient status assessment, timely treatment adjustments for individual patients, and assist clinicians in understanding The Nature and dynamics of disease progression.

Specialized software programs operating interactively with the physician can help determine the optimal timing, frequency, and dosage of medications, therapeutic Procedures, and other interventions, which undoubtedly enhances the quality of therapy and accelerates patient recovery.

Examination of male patients. Following the collection of general and sexual histories, an OBJECTIVE EXAMINATION OF the urogenital organs is performed. Inspection focuses on the skin, the presence of rash elements in the genital area suggestive of syphilis (erosive or ulcerative chancres, papules, fissures, etc.), the condition of the external urethral meatus (its diameter, presence of edema), the presence of hypospadias or epispadias, the state of the prostatic ducts, and the presence, character, and volume of urethral discharge. Examination of the paraurethral glands requires careful inspection of the external urethral meatus and the frenulum of the prepuce. The paraurethral ducts are located in the prostatic Urethra running parallel to it; they appear as branching tubules opening near the middle of the Base of the posterior urethra, measuring 0.5 to 14.5 cm in length and 0.1 to 1.0 cm in width. Infected paraurethral glands are usually asymptomatic for patients, yet they frequently serve as an uncontrolled reservoir for urogenital infection.

Next, the spongy portion of the urethra and the inguinal lymph nodes are palpated. After collecting urethral specimens for laboratory analysis, a two-Glass urine test is performed (the patient urinates sequentially into two separate glasses).

The scrotum is examined by assessing its size, Symmetry, skin condition, rugosity, Temperature (by palpation), and tenderness. The Testes, Epididymis, vas deferens, and Other components of the spermatic cords are palpated to determine their size, consistency, and pain sensitivity.

Subsequently, the Bulbourethral Glands, Prostate Gland, and Seminal Vesicles are examined.

The bulbourethral glands are examined with the patient lying supine with knees flexed. The index finger, palm facing upward, is inserted into the rectum. Upon reaching the apex of the prostate, the finger is hooked to apply pressure to the posterior rectal wall in an anterior direction. Simultaneously, the thumb of the same hand presses on the perineal skin lateral to the midline from front to back. In the presence of inflammation, a pea- to small nut-sized nodule can be palpated between the index finger and thumb (normally, the bulbourethral glands are not palpable). To obtain glandular secretion, the patient's bladder is filled with a 2% boric acid solution after urination, followed by vigorous massage of the gland using thumb movements across the perineum from the anal verge to the membranous urethra. After the massage, the patient voids 4–5 ml of urine containing the bulbourethral secretion into a sterile tube. Following centrifugation (10 min at 3000 rpm), the sediment is subjected to microscopic and microbiological analysis, including testing for gonococci, trichomonads, chlamydia, and mycoplasma.

The prostate gland is examined with the patient lying on their right side with legs drawn up toward the abdomen or standing with the torso bent forward. Digital rectal examination determines the shape, size, consistency, tenderness, and relation of the gland to surrounding tissues. The prostate is chestnut-shaped, and its borders are normally well-defined. A longitudinal median furrow palpable On the surface divides it into two equal lateral lobes (right and left). On palpation, the consistency of the gland is uniformly elastic. The presence of inflammatory infiltrates and a predominance of muscular tissue make the gland feel firm and elastic. Tenderness upon palpation indicates a pathological state. Asymmetry of the lateral lobes with localized firm, tender areas or nodular irregularities, along with flattening or indistinctness of the central sulcus, points toward pathological processes in the prostate. Following digital examination, the patient urinates while retaining a portion of urine in the bladder. The urethra is then flushed with physiological saline, and prostatic massage is performed to obtain expressed prostatic secretion. For this purpose, the index finger of the right hand, well-lubricated with petrolatum or glycerin, is slowly inserted into the rectum, and the prostatic lobes are massaged from above and laterally toward the midline. To facilitate the flow of secretion into the prostatic urethra, a few downward strokes along the median sulcus of the gland are recommended at the end of the massage. Upon completion, the patient voids into a sterile test tube. The initial portion of urine (no more than 10.0 ml) contains the prostatic secretion. This sample can be used to isolate gonococci, trichomonads, chlamydia, mycoplasma, Viruses, etc. After centrifugation (10 min at 3000 rpm), the urinary sediment undergoes microscopic and bacteriological analysis.

Following the collection of expressed prostatic secretion, the seminal vesicles are examined. The patient undergoes thorough urethral irrigation with sterile physiological saline, after which the seminal vesicles are massaged individually. Massage begins inferiorly near the ejaculatory duct and gradually moves upward toward the body of the Seminal Vesicle. Initially, the pressure exerted by the massaging finger is light, progressively increasing toward the end of the Procedure to ensure more complete emptying of the vesicle. Upon completing the massage of one seminal vesicle (typically the left one first), the patient voids into a sterile test tube (no more than 10.0 ml) to collect the vesicular secretion mixed with urine. This sample is used directly to isolate gonococci, trichomonads, chlamydia, mycoplasma, viruses, etc. After centrifugation (10 min at 3000 rpm), the sediment is routinely examined microscopically and microbiologically. The secretion from the contralateral (right) seminal vesicle is obtained in the exact same manner.

Palpation of the seminal vesicles is performed with the patient in the knee-chest position, which facilitates better access. The examiner inserts an index finger into the rectum to identify the base of the prostate. The finger is then directed upward and outward along the anterior rectal mucosa in an oblique vertical line. Simultaneously, the left hand (or right hand for a left-handed examiner) with semi-flexed, cupped fingers is placed over the inguinal-iliac region of the anterior abdominal wall corresponding to the side being examined. By pressing down on the inguinal-iliac region, the seminal vesicle is pushed toward the intra-rectal finger, allowing it to be palpated first on one side and then the other.

Digital palpation of the seminal vesicles evaluates their shape, consistency, tenderness, mobility, relationship to surrounding tissues, and the presence of inflammatory infiltrates.

Palpation and, in particular, massage of the prostate and seminal vesicles should be brief and painless.

To determine the nature and extent of anatomical lesions, establish a topical diagnosis, and evaluate treatment efficacy in the absence of contraindications for instrumental examination, the urethra is inspected using a dry urethroscope while adhering to asepsis and antisepsis rules. The prostatic urethra, urethral crest with the seminal colliculus, and subsequently the membranous urethral mucosa are inspected. Attention is paid to the color, luster, smoothness, transparency, and elasticity of the mucosa, vascular prominence, bleeding tendencies, status of the glandular apparatus, and the presence of granulations, epithelial desquamation zones, or other urethral mucosal defects.

Urogenital infections frequently run an asymptomatic course; therefore, their detection requires repeated comprehensive examinations of both patients and their sexual partners, who serve as sources of infection.

Urogenital infections are also characterized by extragenital manifestations resulting from pathogen dissemination to other organs and tissues (e.g., Conjunctivitis, pharyngitis, proctitis). Visual examination using a magnifying glass (x 13, x 20) should focus on the condition of the mucous membranes of the eye, nasopharynx, oral cavity, and rectum, noting the presence or absence of infiltration, discharge, erosions, ulcers, fissures, or condylomatous lesions.

A less frequent but severe complication of primary urethritis and urethroprostatitis is Reiter's syndrome, which affects the joints, the conjunctiva and other mucous membranes, the skin, and, less commonly, various internal organs. Urogenital infections presenting with signs of urethritis, prostatitis, vesiculitis, or orchitis frequently lead to decreased sexual potency and various alterations in the spermogram. When Infertility is suspected, an ejaculate analysis is performed to assess the patient's reproductive capacity. Volume, viscosity, color, pH, sperm concentration per milliliter, progressive motility, and the proportion of pathological forms are determined. The presence or absence of pathological impurities (erythrocytes, leukocytes, microorganisms) in the ejaculate is also noted. A biochemical Analysis of the ejaculate is conducted, with fructose concentration and sperm utilization serving as key parameters.

Depending on the clinical findings, Additional Diagnostic Methods are employed (special analyses of tissue fluid, urine and Blood, urethrography, chromocystoscopy, joint radiography, electrocardiography, etc.). If necessary, consultants from other clinical specialties (urologists, ophthalmologists, rheumatologists, general practitioners, etc.) are involved.

The topography and presentation of the identified extragenital pathology necessitate Laboratory examination of other specimens, such as scrapings and smears from the conjunctiva and other mucous membranes, synovial membrane, as well as tissue and synovial fluids.

Examination of female patients. The examination begins by taking a history of Complaints, general medical history, and reproductive history. The clinician inquires about The Nature of sexual activity, the timing of the last sexual intercourse, the nature and dates of the last menstruation, pregnancies, deliveries, and abortions. It is essential to clarify the presence or absence of intermenstrual bleeding, pain in the ilioinguinal and lumbar regions, the circumstances under which they appeared, and the duration of these complaints.

Urogenital infection is typically a multifocal disease. The most frequent sites of localization for gonococci, trichomonads, chlamydia, Mycoplasmas, gardnerellae, and other microorganisms are the cervical canal and the urethra. Gonococci, trichomonads, and chlamydia affect the paraurethral ducts, the Vestibule of the Vagina, the Bartholin glands, the uterus, the fallopian tubes, and potentially the Urinary Bladder and upper Urinary Tract. A frequent complication of gonococcal or chlamydial salpingitis is Peritonitis. Urogenital infection—whether sexually transmitted or originating from a urogenital source—may also present with various extragenital manifestations (proctitis, pharyngitis, conjunctivitis, etc.). A frequent complication of chlamydiosis is Reiter's syndrome, which predominantly presents with joint involvement.

Following the collection of sexual and general history, including data on past urogenital and systemic diseases, as well as the status of the cardiovascular, nervous, and endocrine systems, the clinician proceeds to clinical and instrumental examinations.

First, a careful inspection of the external genitalia, perineum, and perianal region is performed, along with palpation of the inguinal lymph nodes.

During the examination of the urethra, special attention is paid to the external urethral meatus and the paraurethral ducts. Then, after thoroughly cleaning the external meatus (using a dry, sterile cotton swab or one moistened in sterile saline and squeezed out), the index finger is inserted into the vagina (with the palmar surface facing the Pubic Symphysis) and the urethra is gently massaged from posterior to anterior along its length to express its contents. Concurrently, the same finger assesses the tenderness of the urethra upon pressure and any potential thickening, which is frequently observed in chronic inflammatory processes. The expressed urethral contents, as well as superficial scrapings of the urethral mucosa obtained using a grooved probe or curette, are used for microscopic and bacteriological analyses, including the detection and isolation of gonococci, trichomonads, chlamydia, mycoplasmas, Fungi, viruses, etc.

To determine the nature and extent of anatomical Changes in the urethra, urethroscopy is performed using a dry urethroscope. The conditions for this procedure are identical to those for male patients. However, given the short length of the female urethra, the obturator-closed sheath is introduced along the curve of the subpubic arch to a depth of no more than 3–3.5 cm. During the advancement of the sheath, its distal end must be lowered by 30–40°. Urethroscopy allows for the detection of soft or transitional infiltrates, granulations, Morgagni crypts, epithelial defects, etc.

When examining female patients, attention should be directed to the paraurethral ducts. Material for their investigation—aimed at detecting gonococci, trichomonads, chlamydia, and other microorganisms—is obtained by scraping the external urethral meatus following gentle massage. The resulting scraping contains secretions from the paraurethral ducts and epithelial Cells from their orifices.

When examining the vestibular area of the vagina, primary attention is paid to the Clitoris and its surrounding folds, as well as the inner surfaces of the Labia Majora and minora (assessing for discoloration, edema, friability, papules, erosions, ulcerations, etc.). In the presence of weeping or erosive papules and ulcers, the discharge is examined for *Treponema pallidum*. If gonococcal, trichomonal, chlamydial, or other infections are suspected in the vestibular region, scrapings of the discharge are collected for laboratory analysis from the crypts, the folds surrounding the clitoris, and affected areas on the inner surfaces of the Labia minora.

The Bartholin glands are examined via palpation, and their excretory ducts are inspected. To locate the duct orifice, the corresponding labium minus should be retracted using a spatula after preliminary fixation of the gland, while the index finger holds the edge of the hymen. Typically, upon pressure with the thumb of the same hand placed externally on the labium majus, a drop of slightly turbid mucus can be obtained from the irritated excretory duct orifice. This mucus is examined for the presence of gonococci, trichomonads, chlamydia, ureasmas, gardnerellae, viruses, fungi, etc.

The vagina is examined manually (digital palpation) and by means of specula. Palpation is performed using the index and middle fingers of the right hand, inserted into the vagina in a spread position. These are used to determine the width of the introitus, elasticity, and tenderness, as well as to examine the vaginal surface, mucosal mobility, presence of folds, scars, papillomatous growths, etc. The state of the fornices—their depth, symmetry, and configuration changes—is also assessed. Upon visual inspection of the vagina using a speculum, attention is focused on the condition of the walls, their coloration, the presence of erosions, ulcerations, or other mucosal defects, as well as the nature, color, and quantity of discharge. Discharge or scrapings for microscopic and bacteriological analyses from the vaginal walls, the mucosa of the posterior fornix, erosions, and ulcers are collected using a grooved probe, a platinum/tungsten loop, or a small curette.

Using specula and palpation, the state of the vaginal portion of the cervix is evaluated, including its shape, size, consistency, the shape of the external os of the cervical canal, the presence and nature of its discharge, and the integrity or alteration of its mucosa (ulceration, eversion, erosion, etc.).

Valuable information regarding the state of the cervix and the vaginal mucosa can be obtained via colposcopy, which allows for the detection of focal and diffuse epithelial changes invisible to the naked eye—a matter of great significance in urogenital infections. Colposcopy enables the monitoring of cervical lesion dynamics during cervicitis and provides an objective Assessment of the efficacy of the administered therapy.

To collect specimens from the cervix and its canal, the vagina is exposed using a speculum, and the cervix is carefully and thoroughly cleared of excess mucus (using a dry sterile cotton swab or one moistened with sterile saline). A thin metal swab holder is then introduced into the canal as far as the internal os to gently remove the mucous content. Subsequently, using a Volkmann's blunt spoon or another suitable metal instrument, a scraping is taken from the mucosa of the cervix and its canal. Impression smears from various Regions of the cervix and tissue fluid from erosions are also collected for investigation. Scrapings, smears, and tissue fluid are utilized for microscopic and bacteriological analyses.

To determine the condition of the uterine body, fallopian tubes, and Ovaries, bimanual examination is employed: the index and middle fingers of the right hand are inserted into the vagina, while the left hand is placed on the anterior abdominal wall in the pelvic region. By approximating the fingers of both hands, the clinician assesses the position, shape, volume, mobility, consistency, and tenderness of the uterus and its adnexa, which facilitates the detection of pathological alterations.

Depending on clinical indications, additional diagnostic methods are frequently utilized, and consultants from other clinical specialties (gynecologists, obstetricians, ophthalmologists, urologists, rheumatologists, otolaryngologists, proctologists, general practitioners, etc.) are engaged.

Examination of pregnant women is conducted with extreme caution, limiting The Scope of diagnostic procedures. Specifically, all endocervical manipulations are contraindicated during Pregnancy. Care must be exercised when introducing vaginal specula and performing manipulations on the cervix, which are necessary for diagnosing active infection and preventing perinatal transmission to the newborn.

Examination of children. The examination of pediatric patients, much like that of adults, begins with eliciting complaints, taking The history of the disease, and inspecting the external genitalia, perineum, perianal region, and other areas.

First and foremost, a detailed obstetric METABOLISM/13.html">History of the child must be gathered, paying special attention to the possibility of birth trauma. It is necessary to determine whether the mother exhibited signs of Sepsis during delivery and whether the child experienced perinatal or neonatal infection. Information regarding childhood illnesses must be collected meticulously to rule out chlamydial, mycoplasmal, or viral infections capable of causing Pneumonia, vulvovaginitis, encephalopathy, aseptic meningitis, etc. HEAD or Central Nervous System trauma, as well as Epilepsy, must also be excluded in the child.

Parents and the child should be thoroughly questioned regarding the potential regular use of cosmetic ointments, creams, or steroid-containing medications. It is essential to ascertain whether the child suffers from chronic diarrhea, Urinary Incontinence, or perineal pruritus, in order to rule out chronic perineal irritation and stimulation of hair growth in that area. Information regarding genital discharge, abdominal pain, and potential pelvic masses is also required. The age of onset of Puberty in other family members should be determined to rule out a hereditary predisposition to various disorders.

Next, a physical examination is performed. For this purpose, the child's height and weight are compared against age- and sex-matched normative growth charts, head circumference is measured, and the skin is inspected for rashes, café-au-lait spots, neurofibromas, etc. The Development of the Mammary Glands, external genitalia, and pubic hair is evaluated according to established developmental stages (Table 26).

A comprehensive neurological examination is performed, including fundoscopy and visual field assessment. To rule out Disorders of the genital organs, rectum, or pelvic masses, a vaginal and rectal examination is required.

If central nervous system pathology is suspected in the child, Electroencephalography and Skull radiography are necessary. For the evaluation of SOFT TISSUE TUMORS and inflammatory processes in the internal reproductive organs, computed tomography, echography, and Ultrasonography (US) are considered the most effective modalities. Bone age is determined via radiographs of the HAND AND WRIST bones (their development typically corresponds to the chronological age).

Class="center">Table 26 Stages of development of the mammary glands, external genitalia, and pubic hair (after Marshall — Tanner)

To assess vaginal maturation and estrogen secretion when plasma estradiol levels cannot be measured, a vaginal smear is used. To evaluate complete versus incomplete precocious puberty, luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels are determined.

The examination of boys is performed similarly to that of adult men, but following a simplified protocol that excludes the analysis of prostate and seminal vesicle secretions. For microscopic and Bacteriological examination, the first portion of morning urine (5.0–10.0 mL), epithelial scrapings from the urethral mucosa, and, in some cases (such as balanoposthitis), from the corona glandis can be used.

During the examination of girls, the inner surfaces of the labia majora and the vaginal vestibule are inspected, and the condition of the hymen and the external urethral meatus is assessed.

Vaginoscopy is performed to visualize the vagina and the vaginal portion of the cervix in order to determine the nature and extent of the inflammatory process. The rectal mucosa is examined with caution.

In cases of urogenital infections in girls and adolescents, the urethra, vagina, cervix, and rectum may be affected. Specimen collection for laboratory analysis is performed According to the localization of the inflammatory process.

To detect and isolate microorganisms, discharge and mucosal scrapings from the urethra are obtained using a urethral swab, a grooved probe, or a small curette. Vaginal specimens are collected in the same manner; the instrument used is inserted along the posterior vaginal wall toward the posterior fornix. Cervical specimens for laboratory analysis are typically obtained using a swab or scraping. When the vaginal vestibule is involved, a swab or scraping is taken from the groove between the hymen and the labia minora. Rectal specimens (after preliminary cleansing of the rectum by irrigation with a warm saline solution) are obtained using a double catheter connected to an irrigator.

The evaluation of newborns requires an understanding of the entry portals for perinatal infection, which can include the mucous membranes of any cavity-forming organ. The more common manifestations of neonatal chlamydiosis, gonorrhea, or similar infections include conjunctivitis, vulvovaginitis, rhinitis, nasopharyngitis, pneumonia, and occasionally enteritis.

For the Laboratory Diagnosis of chlamydial or gonococcal inflammatory processes of various localizations, secretions, lavages, Touch preps, and scrapings of the affected mucous membranes are used. Specialists from various clinical backgrounds (ophthalmologists, otolaryngologists, etc.) are frequently involved in the assessment of newborns.

In newborns and prepubertal children, genital discharge is frequently the result of fluctuating estrogen levels; therefore, it is essential to understand the physiological and pathological mechanisms underlying its appearance.

Bacterial flora of the intestinal and nasopharyngeal tracts is the primary cause of discharge in older school-age children and adolescents. However, other causes, such as foreign bodies and various other factors, must also be considered.

Serological tests are utilized for the diagnosis of congenital syphilis and herpetic infections. The necessity for these tests is determined by clinical findings and observation.