Enlarged Inguinal Nodes (BUBO)

Clinical Description

CAUSES:

• Both chancroid and lymphogranuloma venereum (LGV) can cause bubo.
• Exclude the following conditions which may also cause enlarged inguinal lymph nodes: septic skin lesions on thigh, foot, leg, toes, buttock, anus, perineum, scrotum, penis, labia, vulva and vagina, systemic infections e.g. Hepatitis B, HIV, infectious mononucleosis, syphilis, TB, bubonic plague, cat scratch fever, trypanosomiasis, lymphoma, leukemia, Kaposi's sarcoma.
• Exclude other conditions which may cause groin swelling unrelated to enlarged lymph nodes including: inguinal hernia, lipoma, a boil in overlying skin.
• Confirm presence of bubo by careful examination

Note: All patients with bubo should be carefully examined for signs of other STIs

Signs and Symptoms

• Painful or painless inguinal swelling(s)
• Inguinal swellings:
• unilateral or bilateral
• tender or non-tender
• STI-related Genital Warts
• fluctuant suppurating
• Genital ulcer

Investigations

• No investigations required, in view of the syndromic approach
• Recommended in managing STIs

Non-pharmacological

• Aspiration of fluctuant buboes using a wide bore needle through adjacent healthy skin every second or third day. An incision and drainage should not be attempted. If buboes persist, the patient should be referred.
• Sequelae such as strictures and/or fistula may require surgery.
• If bubo not present and other signs of STI not found, reassure, educate/counsel the patient
• Promote/provide condoms

Pharmacological

• If bubo present andgenital ulcer present: treat as for genital ulcer disease syndrome
• If bubo present, and painful, fluctuant or recent onset (under 2 weeks) and no genital ulcer present: treat patient and partner for LGV.
• Give Doxycycline 100mg 12 hourly with food for 14 days. If pregnant/ lactating, give Erythromycin 500mg 6 hourly for 14 days
• If bubo fluctuant, aspirate through adjacent normal skin (do not incise)
• If enlarged inguinal lymph node present, but not painful, fluctuant or of recent onset (under 2 weeks) and no genital ulcer present: look for other causes of inguinal swelling: e.g. generalized lymphadenopathy (rule out secondary syphilis and HIV), hernia, tumour.
• Refer for biopsy if indicated
• If bubo not present but other signs of STI found, treat accordingly 17.1. 7 GENITAL WARTS

Clinical Description

• These must be distinguished from condyloma of secondary syphills, molluscum contagioum and vulva cancer
• Besides local caustic applications, surgical removal or electrocautery may be used for

Treatment

• For more extensive growth
• When topical applications have failed
• When topical application is contra-indicated

Signs and Symptoms

• Small, flat, papular, pedunculated, flesh-colored swellings on the skin and mucous membranes of the genitals (penis, vulva, vagina, cervix, urethra, perianal region)
• Usually no symptoms
• Small painless swellings in the ano-genital region
• Itching or discomfort in the genital area
• May cause increased vaginal discharge
• Anal or vaginal bleeding during or after sex

Investigations

• Acetic acid solution (vinegar) test

Non-pharmacological

• Apply Compound Podophyllin Paint to the lesions once a week for 6 weeks
• Apply petroleum jelly to avoid normal tissue damage
• Use only for scattered growth
• When applied to vulval mucosa or urethral meatus warts, allow to dry before coming back into contact with normal epithelium
• Remove the paint by washing off after 4 hours

Note: Do not use this therapy during pregnancy

• If no effect after 4-6 weeks, stop treatment and consider alternative methods of removal
• Alternative to Podophyllin Paint, and for treating vulvar warts:
• Apply Silver Nitrate Stick (pencil) 24 hourly