Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
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        Non-neoplastc Vulvar, Perineal, & Penile Lesions, Biopsy & Lab Testing
      

Vulvo-perineal

Especially when faced with the patient who has a genital/perineal "sore" that is painful and circumstances are suboptimal for biopsy and/or cytology "scapings", there are serological means that might make a diagnosis from the serum in a single "red top tube" blood specimen. Remember that STDs are not infrequently present as mixes of several STD organisms. In addition to the below info, check the specific disease info sheet pages at the CDC website and/or major reference lab websites. By a brief telephone call wiith your local pathologist, you may be able to submit smears, PCR swabs, culture specimen, serum, & a shave biopsy (for routine H&E and DIF) and ask for him/her to help progressively & cost effectively apply just the tests needed to cinch or rule out a diagnosis. Some of the below are NOT STDs but are in the STD diferential diagnosis (DDX).
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 DXable from serum? DXable from cytology? DXable from biopsy? DXable from other means?
acute vulvar aphthus ulcer in young females (tend to appear as with oral type)(not an STD) no Tzank neg. & flora looks unremarkable not needed tend not to be febrile or ill &, as with oral, can recurr
herpes , ulcer yes: serology & PCR Tzank prep or DIF smear yes we can do DIF for HSV I & II [S09-11046]
syphilis
(painless ulcer...chancre)
yes: RPR & FTA-abs no yes, may be difficult; expect plasma cell rich perivasculitis yes but dark field wet prep not worth the effort
chancroid, ulcer (Haemophilus ducreyi) yes: PCR Gram stain: gn cocco-bacilli; works best on smear of virgin, untreated lesion. penile peri-glans erosion; bubo groin node; expect ulcer to be rich in polys; [S16-1166]  
LGV (lymphogranuloma venereum...due to some serovars L1, L2, & L3 of Chlamydia trachomatis & primary lesion is painless herpetiform ulcer) yes: serology & PCR of smears or active tissue placed in M4 or M5 Mayo Clinic transport media usually not

(1) secondary stage groin node bubo = can bracket into "likely".

(2) tertiary stage proctitis.

 

granuloma inguinale (ulcer)

(Calymmatobacterium granulomatosis)

(only 100 reported cases per year in USA)

  Gram stain: gn pleomorphic bacillus Granulomatous; by smearing fresh cut surface of BX of ulcer edge, crush prep of biopsy portion, or swab smear of surface onto glass slide and stain with Wright's or Giemsa...see the small straight or curved pleomorphic bacilli with rounded ends and polar granules..."safety pin". When many are in a macrophage, the composite cell is a Donovan body. no node enlargement due to C. gran. but may get due to super-infection of other bacteria
Neisseria gonorrhea (exudate)   Gram stain: gn intracellular diplococcus swab PCR; culture  
Chlamydia     swab or tissue or saline washings PCR as with LGV  
herpes (HSV I & II) yes... HERE   yes and/or swab PCR Tzank & DFA smears & culture
HPV, trichomonas, bacterial vaginosis     liquid-based Pap smear sample  
HIV genital ulcer yes      
Behcet's (not an STD)        
cancer (not an STD)        
mono (EBV) ulcer3 (not an STD) yes   swab PCR; culture; biopsy might show balooning of epithelial cells  
CMV ulcer 3(not an STD) yes   swab PCR; culture; biopsy might show balooning of epithelial cells  
other non-STD viral     biopsy might show balooning of epithelial cells  
nutritional deficiency mucosal breakdown (not an STD)     biopsy might show balooning of epithelial cells  
Brucellosis ulcer 3(not an STD)        
other primary infectious organism associated ulcers3 (typhoid, etc.) (not an STD)        
Aphthosis: Lipschutz ulcer of teens & young women3; acute vulvar ulcer or ulcus vulvae acutum or apthous ulcer in older age groups. (not an STD) no nonspecific nonspecific but shallow acute ulcer & unimpressive as to any marginal epithelial hypertrophic hyperplasia Lipschutz said to be usually febrile
caustic causes3 (not an STD)        
Vulvar Crohn's Disease (not an STD)5 no no yes= granulomatous vulvitis physical exam swelling, edema, ulcers, pain, plaques, nodules & can have fissures & fistulae
dermatoses causes3 (fixed drug, EM, Stevens-Johnson syndrome, pemphigoid, inflammatory bowel disease, aphtosis) (not an STD)     yes; maybe even skin DIF battery [S09-11046]  
Lichen sclerosus et atrophicus (LS&A), (not an STD) no no yes...biopsy yes: expert dermatologist can accurately diagnose on physical exam
Penile & scrotal lesions
head balanitis: chronic inflammation & usually due to stenotic foreskin (phimosis)
balanoposthitis: chronic inflammation; if LS&A-like with inflammatory expansion of papillary dermis and subepithelial sclerosis = balanitis xerotica obliterans (BXO)
foreskin posthitis: chronic inflammation & usually due to stenotic foreskin (phimosis);
if LS&A-like with inflammatory expansion of papillary dermis and subepithelial sclerosis = balanitis xerotica obliterans (BXO) [L10-11335 in 6 y/o]
shaft molluscum contagiosum lesions; HPV lesions such as condyloma accuminata; all kinds of other skin lesions; sclerosing lipogranuloma
scrotum angiokeratoma; epidermal inclusion cysts (farely often become calcific nodules); sclerosing lipogranuloma; cold-exposure related fat necrosis of dependant aspect; Fournier's gangrene (variant of potentially deadly necrotizing fasciitis affecting perineum & genitals)

 

References:

  1. Specialty Labs website.
  2. eMedicine website, by topic via Google.
  3. European J.
  4. BXO see Wikipedia.
  5. Shu-li Li & Chunying Li, "Clinician's Corner, Vulvar Swelling, Plaques, and Nodules in a Young Adult Woman", JAMA 309(24):2596-2597, 26 June 2013.

(posted 3 August 2005; latest addition 28 June 2016)

 
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