15- Genital Area
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).
gfx003- gfx010// gfx009//gfx011//
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:
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:
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.
discharge from penis:
- Chlamydia? Gonorrhea?
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
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
ulcers/chancre (male and female) (also anal, rectal, oral...)
-Painful chancre (deep) with or without lymph node enlargement:
(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
(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)
Inguinal lymph node enlargement (male)
Chancre and/or abnormal testis in area (ghx023)
Chancroid? Syphilis? Orchitis?
See supra & protocol "37-Syphilis"
No chancre and/or abnormal testis in area
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!
warts (also anal) - Condylomata "Acuminata" & "Lata"
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"
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"
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"
see 30-skin protocols
Allergy (Stevens Johnson, Lyell, etc.) See 06-Allergy
- Paraphimosis //ghx055, 056, 057,
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)
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 "
"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.
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