sign in sign up
<<
Home , Gonorrhea, Granuloma inguinale, Mycoplasma, Pediculosis pubis, Venereology

European European Urology 44 (2003) 1–7

Review SexuallyTransmitted (STDs)öA Synoptic Overview for Urologists Peter Schneedea,*, Peter Tenkeb, Alfons G. Hofstettera, Members1 of the Urinary Tract (UTI) Working Group of the Office (HCO) of the European Association of Urology (EAU) aDepartment of Urology, University of Munich, Marchioninistr. 15, D-81377 Munich, Germany bJohn Ference Del-Pesti Korhaz, Ko¨ves utca 2–4, H-1204 Budapest, Hungary Accepted 4 April 2003

Abstract The classical that cause venereal diseases, e.g. , , and inguinal only account for a small proportion of all known STDs today. Other bacteria and as well as yeasts, and epizoa must also be regarded as causative organisms of STD. Taken together, all sexually transmitted (STI) comprise more than 30 relevant STD . However, not all pathogens that can be sexually transmitted manifest diseases in the genitals and not all infections of the genitals are exclusively sexually transmitted. Concise information and tables summarising the diagnostic and therapeutic management of STDs in the field of Urology allow a synoptic overview and are in agreement with recent international guidelines of other specialities. Special considerations (i.e. HIV infection, pregnancy, infants, ) and recommended regimens may be looked up here. # 2003 Elsevier Science B.V. All rights reserved.

Keywords: STD; Viruses; Bacteria; Epizoa; Protozoa; Guidelines

1.Definitions and classification Other pathogens that lead to organ manifestations classified under other specialities can merely be men- STDs can be categorized as today curable and incur- tioned briefly in terms of their sexual transmissibility able. The common curable STDs are gonorrhea, and co-morbidity. With regard to further details on chlamydial, mycoplasmal and ureaplasmal infections, these pathogens, the reader should refer to guidelines syphilis, , chancroid, lymphogranuloma from appropriate specialist societies [11,15,17–22] and venereum and donovanosis. Even STDs caused by yeast, internet links [1–9]. Clinical pictures such as , protozoa and epizoa can be cured. The STDs that are genital ulcers, , and that can be preventable but not curable are the viral STDs and caused by various STD pathogens in men will not be include immunodeficiency (HIV), human treated in this overview. papillomavirus (HPV), /C virus (HBV,HCV), The following STDs in the field of Urology will be (CMV) and virus dealt with in a synoptic overview in groups and tables: (HSV). Bacterial STDs Only those genital infections which are indeed trans- 1. Syphilis mitted exclusively sexually will be dealt with below. 2. Gonorrhea 3. Chancroid * Corresponding author. Tel. þ49-89-7095-2971; 4. Donovaniosis/ Fax: þ49-89-7095-8890. 5. E-mail address: [email protected] (P. Schneede). 6. Chlamydial, mycoplasmal and ureaplasmal ure- 1 See Appendix A. thritis

0302-2838/03/$ – see front matter # 2003 Elsevier Science B.V. All rights reserved. doi:10.1016/S0302-2838(03)00193-3 2 P. Schneede et al. / European Urology 44 (2003) 1–7

Viral STDs developing areas (India, Papua-New Guinea, Central 1. HPV lesions Australia, Southern ). Though only moderately 2. contagious it is transmitted most often when the dis- 3. Mollusca contagiosa ease is in its early stages. STDs caused by protozoa and epizoa 3.5. Lymphogranuloma venereum 1. Trichomoniasis This , also known as Durand–Nicolas–Favre 2. Phthirus pubis crab disease is relatively rare in developed countries. Lym- 3. Sacroptes scabiei infestation phogranoloma inguinale is most prevalent in South East Asia, Africa, Central and South America, and the 2.Images of the STDs Caribbean. It is characterized by a painful swelling of the lymph nodes, and elephantiasis of the genitals. Information and images of the STDs are provided by the Online Atlas and may be looked up 3.6. Chlamydial, mycoplasmal and ureaplasmal there (http://www.dermis.net/index_d.htm). urethritis trachomatis on one hand, , hominis and Mycoplasma 3.Bacterial STDs ( Ta b l e 1) genitalium probably on the other hand cause non- gonococcal urethritis and account for 30–50% and 3.1. Syphilis 10–20% of cases, respectively. 20–30% of men with Syphilis is one of the oldest and most infectious non-gonococcal urethritis have no organism detected. systemic STDs, particularly in its primary and second- infection is common in women, while ary stages. Unless treated, the infection will progress approximately 70% of men have symptoms like ure- through a series of stages, during which its symptoms thral discharge, , penile irritation and signs of often mimic those of other diseases and make diagnosis epididymoorchitis or prostatitis. difficult. There is a close interrelationship of syphilis and HIV infection, presenting high prevalence rates for 3.7. Other bacterial and yeast STDs both in commercial sex workers, drug addicts, parti- Gardnerella vaginalis causes painful bacterial vagi- cularly in developing countries. nosis. Men may carry the bacterium, but do not seem to be adversely affected by it. Additionally, bacterial 3.2. Gonorrhea vaginosis is not a STD per se, and the change in the An annual incidence of approximately 62 million balance of bacterial organisms that exist in the is new cases world-wide of gonorrhea is estimated, with not clearly understood. Other diseases most frequently the greatest number in South and South-East Asia, associated with are trichomoniasis followed by sub-Saharan Africa. A significant propor- and . Vulvovaginal candidiasis is not tion of infected people (up to 80% among women, 10% usually acquired through . Treatment among men) are asymptomatic. Co-infections with of male sex partners is only recommended in rare cases chlamydia and other STDs are very common and must of balanitis or in women who have recurrent infection. be specifically looked for in diagnostic investigations.

3.3. Chancroid 4.Viral STDs ( Ta b l e 2 ) Poor understanding of the epidemiology and natural history of the disease and the absence of a good lab test Here sexually transmitted viral infections that typi- make it difficult to undertake prevalence studies and to cally cause genital tract lesions such as HPV, HSV and estimate prevalence and duration of infection. It is MCV infections are focussed on. Other viral STDs, i.e. estimated that there are approximately 7 million new Acquired Immunodeficiency Syndrome (AIDS), hepa- cases of chancroid annually. The incidence of chan- titis, cytomegalic inclusion body disease, Epstein–Barr chroid varies greatly between countries and regions. virus-associated kissing disease may be looked up in the guidelines of other specialities. 3.4. Donovanosis/granuloma inguinale Donovanosis is a very rare genital ulcerative STD, 4.1. HPV-associated lesions primarily found in people who engage in or Condylomata acuminata caused by HPV infection is oral-anal contact. It is endemic in certain tropical and the most common viral STD world-wide. More than 30 Ta b l e 1 Bacterial STDs [1–9,11,18–22]

STDs Causes Symptoms Diagnosis Treatment

Syphilis Primary stage (lues I): Microscopic and fluorescence Primary/secondary stages: Benzathine (spirochete bacterium), (not painful) at the location where examination of the tissue taken 1 2,4 Mio IU i.m.; or Clemizolpenicillin G 1 90% by sexual the bacterium entered the body, from a chancre or sore may identify Mio IU i.m. for 14 days. No comperative trials contact, transmission by usually with regional . the spirochete. Serologic tests: have been adequately conducted to guide non-sexual contact is rare. Secondary stage (lues II): 2–12 weeks Screening by combination of the the selection of the optimal penicillin regimen Syphilis is classified as acquired or later the Treponemas spread throughout Venereal Disease Research Laboratories (i.e. the dose, duration and preparation). congenital. The the body, causing a rash, small open Test (VDRL) or Rapid Plasma Reagin Persons allergic to penicillin: ranges between 10 an 90 days. sores, flu-like fever, swelling of (RPR) and Treponema Pallidum 2 100 mg p.o. for 14 days. lymph nodes, condylomata lata. Hemagglutionation Test (TPHA); 4 500 mg for 14 days. Latent and tertiary stages (lues III): Confirmation by IgG Fluorescence Late or unknown stages: Benzathine Symptoms and infectiousness disappear; Treponema Antibody Absorption Test penicillin. 2,4 Mio IU i.m. on day 1, 8, 15. one third of untreated persons will (IgG-FTA-Abs) or 19-S-IgM-FTA-Abs. or Clemizolpenicillin G 1 Mio IU i.m. for .Shed ta./Erpa rlg 4(03 1–7 (2003) 44 Urology European / al. et Schneede P. progress to the tertiary stage where Follow-up testing by VDRL-test or 21 days. Persons allergic to penicillin: the bacteria attacking the patients 19-S-IgM-FTA-Abs-test 3, 6, 12 months Doxycycline 2 100 mg p.o. for 28 days. heart, eyes, brain, nervous system, and annually for another 4 years Erythromycin 4 500 mg p.o. for 28 days. bones and joints. Gummatous syphilis. after treatment. Some HIV infected Management of sex partners: Persons who were Final Stage (lues IV): Heart diseases, patients can have atypical serologic exposed within the 90 day preceding the blindness, insanity, paralysis and death test results. diagnosis of primary, secondary, or early latent syphilis in a sex partner should be treated pre-sumptively. Gonorrhoea Caused by a bacterium Initial symptoms within two weeks: Microscopic examination of World-wide, different strains of gonorrhoea have ( gonorrhoeae), fever, chills, painful swelling of the Gram-/methylene blue-stained and become resistant to penicillin. Due to the resistances which enters the body by genitals and prostate in men. specially cultured samples will found in different countries and co-infections with mucous membranes of the , Men report burning during urination, readily confirm the clinical diagnosis other STDs such as , , mouth, throat and urethral pus and painful bowel by visualization of diplococci in (1 0.125 g i.m.), (1 2 g i.m.) eyes. Gonorrhoea is nearly always movements in rectal infections. leucocytes. Amplified antigen detection or combinations with or Erythromycin transmitted by direct sexual contact. In women, infections of the tests or nucleic acid amplification should be preferred. Infection aquired in Transluminal spread of infection uterus and fallopian tubes are tests offer high sensitivity and Northern may be treated with may occur to involve the epididymis common, resulting in sterility, provide confirmation of the Ciprofloxacin (1 500 mg p.o.), Ofloxacin and prostate. Haematogenous , and pelvic diagnosis in asymptomatic patients. (1 400 mg p.o.) or Levofloxacin 1 250 mg dissemination is uncommon. inflammatoy disease. Newborns’ Follow-up: Patients who have Cefixime (1 400 mg p.o.). If chlamydial eyes might be affected. After the uncomplicated gonorrhea and who infection is not ruled out or for population in bacteria enter the bloodstream, the are treated with any of the which chlamydial infection accompanies 10–30% disease can affect the joints, heart recommended regimens do not need of gonococcal infection dual ( and brain. Asymptomatic infection follow-up testing. Patients who have 1 g p.o. single dose or Doxycyclin 2 100 mg for of the urethra is rare (<10%). symptoms that persist after 7 days) is recommended. Management of sex treatment should be evaluated by partners: All sex partners of patients who culture for antimicrobial have N. gonorrhoeae infection should be susceptibility. evaluated and treated for N. gonorrhoeae and C. trachomatis infections if their last sexual contact was within 60 days before symptoms or diagnosis of infection in the patient. Patients should be instructed to avoid sexual intercourse until therapy completed. 3 4 Ta b l e 1 (Continued )

STDs Causes Symptoms Diagnosis Treatment

Chancroid Bacterial disease caused by 3–14 days after contact, a tender Usually diagnosed by microscopic Chancroid has become resistant to penicillin, ducreyi, which is bump develops where the bacteria examination of a smear sample Tetracycline and Erythromycin in some cases. transmitted by direct sexual contact. entered the body. The bump transforms (Gram-stained). This should be Preferred treatments now involve Azithromycin Uncircumcised men are more likely into one or more shallow sores, which confirmed by a culture. The presence (1 1 g p.o.), Ceftriaxone (1 0.25 g i.m.) to contract the disease than will break open and become the typical of other STDs has to be ruled out. or Ciprofloxacin (2 500 mg p.o. for 3 days) circumcised men. painful soft chancre. The lymph nodes PCR testing is possible. Test for or Erythromycin 3 500 mg for 7 days. in the groin are pus-filled (bubos), HSV performed on the ulcer Bubos may need to be drained. and often burst through the skin. exudates usually is negative. Donovanosis/ A chronic, mildly contagious STD Red, vulnerable, easily bleeding sores Generally diagnosed by visual Azithromycin (1 1 g per week, for 3 weeks) Granuloma caused by an intracellular bacterium on and around the genitals and anus observation of the external symptoms. or Erythromycin (4 500 mg p.o. for 3 weeks) inguinale (Calymmatobacterium granulomatis) are typically noticed one week to Gram-stained samples will show the or Doxycycline (2 100 mg for 3 weeks) several months after initial exposure to bacteria, which can be cultured or Trimetho-prim-Sulfamethoxazole (2 1 the bacteria. In men the lesions appear under special conditions only. (800/160 mg) die for 3 weeks) or Ciprofloxacin .Shed ta./Erpa rlg 4(03 1 (2003) 44 Urology European / al. et Schneede P. first on the head or shaft of the . Donovan bodies are found in 2 750 mg for 3 weeks or until all lesions The sores are not very painful, but macrophages on tissue crush have completely healed. Sometimes wound can spread throughout the groin and preparation or . Co-infections resection is necessary. Scars left by the sores cause . In extreme cases, with other STDs are known. are regarded as precancerous. Therefore, their dissemination can give rise to annual examinations are recommended. . Lymphadenopathy is unusual. Lymphogranuloma Caused by First symptoms may be a sore The chlamydia have to be cultured Doxycycline (2 100 mg for 3 weeks) venereum (serotypes L1–L3), which is spread resembling a , blister or soft in special cultures (Mc Coy cells) and Erythromycin (4 500 mg for 3 weeks) by direct sexual contact, particularly bump at the point of infection 3–30 and can be diagnosed by fluorescence (And Sulfamethoxazole can be used as well.) in homosexuals who engage in anal days after exposure. 1–2 weeks later, antibody tests. Complement fixation Buboes may require drainage. sex. Proctocolitis and perianal or the lymph nodes swell, creating a titers 1:64 are consistent with the perirectal fistulas and strictures painful, pus-filled bulge. The disease diagnosis of Lymphogramuloma may result. progresses slowly causing fever, venereum. throbbing pain and breaking of the skin, leaving masses of scar tissue. Chlamydial, Non-gonococcal uretritis is caused 7–21 days after contact signs and The diagnosis of urethritis should Single dose Azithromycin (1 g) or Doxycycline –

mycoplasmal and by Chlamydia trachomatis symptoms are mainly due to urethritis by confirmed by demonstrating (2 100 mg for 7 days); Erythromycin 7 ureaplasmal (serotypes D-K) in 30–50% and and complications like anorectal polymor-phonuclear leucocytes in (4 500 mg for 7 days); Ofloxacin (2 200 mg urethritis Ureaplasma urealyticum and discomfort, reactive arthritis and Gram-stained urethral smears or first for 7 days); Levofloxacin 2 500 mg for 7 days. /genitalium (Reiter‘s syndrome), pass urine specimens. Diagnostic Roxithromycin (2 150 mg for 7 days); in 10–20%, respectively. prostatitis and epididymoorchitis. tests include cell cultures (sensitivity (2 250 mg for 7 days. Abstinence All patients who have urethritis range 40–85%), direct antibody from sexual intercourse for 7 days is recommended. should be evaluated for the presence assays (sensitivity range 50–90%), Sex partners (within 60 days) should be evaluated, of gonococcal and non-gonococcal Enzyme- immunoassays (sensitivity tested and treated. infection. Some cases of presistent range 20–85%) and PCR/ LCR or recurrent urethritis are due to techniques (sensitivity range 70–95%). . First pass urine specimens can be used for PCR/LCR, and urethral swabs will be needed for the other tests. Cooled (4–8 8C) special transport vehicles and cell cultures are mandatory. Ta b l e 2 Viral STDs [10,12,15–17,22]

STDs Causes Symptoms Diagnosis Treatment

Genital HPV low-risk genotypes Typically growing without symptoms External warts are usually diagnosed An update of the guidelines in dermatology, warts (i.e. HPV 6 or HPV 11) transmitted untreated genital warts can spread and visually. Application of acetic acid , gynecology and urology [17–19] by intimate sexual contact. Warts multiply into large clusters. Giant solution (5%) causes the warts and unanimously recommends treatment options develop within 3 weeks to 8 months. warts (Buschke Lo¨wenstein tumours) are subclinical flat HPV lesions to whiten, for medically prescribed self-treatment and Immunodeficiency leads to rapid and rare. Genital warts may cause a variety making identification much easier. for exclusively -managed treatment. extensive growth of HPV lesions, of health complications depending on A magnifying instrument should be Topically applied drugs such as Podophyllotoxin and is associated with higher rates where they are located. Symptoms may used to diagnose subclinical lesions. (0.5% solution or gel) or Imiquimod 5% cream of cancer. range from discomfort and pain, to For demarcation of urethral HPV lesions, are suitable for therapy at home. Medically bleeding and difficulty in urination. fluorescence urethroscopy had been used applied treatment involves trichloracetic acid by analogy with the acetic acid test of the (TCA), cryotherapy, electro-, laser outer genitals [13,14]. Both the acetic acid treatment and surgical excisions of the HPV test and fluorescence urethroscopy are lesions. Irrespective of the therapy used, HPV .Shed ta./Erpa rlg 4(03 1 (2003) 44 Urology European / al. et Schneede P. limited in specificity. A tissue biopsy or may persist in the adjacent tissues, resulting Pap smear may be taken to determine in recurrences and the need for further courses whether the HPV lesions are cancerous. of treatment. The development of HPV Routine HPV type analyses have not may offer new perspectives in therapy. been recommended up to now. Generally, both sexual partners should be tested for warts. Genital Herpes simplex viruses (HSV 1 (30%) Symptoms can vary. Initially flu-like Sometimes the diagnosis can be made by Herpes is incurable. Systemic antiviral drugs herpes and HSV 2 (70%)) can cause genital symptoms, swelling of lymph nodes, physical examination alone. Cell culturing (Acyclovir 3 400 mg or 5 200 mg per os, lesions 2–20 days after infection. Most chills, fever may be noticed. (HSV is a labile virus and successful Famciclovir 3 250 mg per os, Valacyclovir cases of recurrent genital herpes are Fluid-filled blisters are then followed by virus culture depends on maintaining the 2 1 g per os) may be used to reduce the caused by HSV-2. Herpes virus invades eruption and ulceration of the skin; cool (4 8C), rapidly transporting specimens discomfort from the sores. Healing might the body via breaks in the skin or both are painful. Clusters on the to the laboratory and avoiding be increased, and pain as well as viral shedding moist membranes of the penis, vagina, genitals, buttocks and adjacent areas are freeze-thaw cycles) and type analysis can be reduced. Treatment of first clinical episode urethra, anus, or cervix. All typical. Other symptoms may include by immunofluorescence tests are standard (for 7–10 days) or recurrent episodes of genital practices of intercourse may transmit tenderness, aching pain, itching, options for diagnosis. Fluorescence tests herpes (for 3–5 days) requires initiation of therapy –

HSV. HSV may be passed on to the burning or tingling. Painful urination can be done without viral amplification within the first day of lesion onset. Patients 7 baby during birth as well. and a sensation of abdominal pressure in the , but sensitivity is only who have frequent recurrences (i.e., 6 recurrences are known. fair. PCR and LCR amplification of HSV per year) may be treated by suppressive therapy: show much better sensitivity, but the i.e. Valacyclovir (1 500 mg p.o./die for techniques are too expensive 16 weeks) Acyclovir 2 400 mg or Famciclovir for routine use. 2 250 mg, for 16 weeks. Supressive therapy reduces the frequency of genital herpes recurrences by 70–80%. Do not use topical creme. The sex partners of patient who have genital herpes likely benefit from evaluation and counselling. Mollusca Caused by Typical blisters can be flesh-colored, The blisters are distinctive, providing Blisters will regress spontaneously under contagiosa virus. 2–3 months after infection, a waxy white, pink, yellow or clear. typical criteria for visual diagnosis. the control of the immune system. If not, and rounded blister with a dimple on the Itching is common, but pain is rare. The diagnosis can be confirmed by surgical removal by laser, cryotherapy, top develops. Scratching, picking Clusters of lesions may develop. light microscopy or electron microscopy electro-surgery or chemical treatment is or breaking spreads the virus. of taken from a blister. recommended. 5 6 P. Schneede et al. / European Urology 44 (2003) 1–7 million people will develop genital warts every year. examination will improve the sensitivity. Generally, HPV belongs to the same group of viruses that produce treatment should involve both sexual partners. A single common skin warts. However, HPV can also be closely dose of Metronidazole (2 g p.o.) should be effective. An associated with intraepithelial neoplasia and cancer in alternative regimen is Metronidazole 2 500 mg for both genders. Most HPV infections are subclinical or 7days[11,22]. latent—that means that they are not directly visible or that they can only be diagnosed by laboratory testing. 5.2. Phthirus pubis crab infestation Visible signs of the disease include condylomata, Phthirus pubis is a tiny that infects the pubic Bowen’s disease, bowenoid papulosis, Buschke hair of its victims and feeds on human blood. They use Lo¨wenstein tumors and genital cancer. Though men crab-like claws to grasp the hair of its host and can and women are equally susceptible to infection, crawl several centimeters per day. Female lice lay 2–3 women suffer a much higher risk of developing the eggs daily and affix them to the hairs (nits). During HPV-associated malignancy. direct sexual contact, the can move from one partner to the other. Itching in the pubic area is a telltale 4.2. Genital herpes sign. Microscopic examination of the lice or the nits Genital herpes is a chronic, lifelong viral infection, can confirm this. Treatment involves application of 1% and afflicts up to 80% of adults. There are five different gamma benzene hexachloride ointment or lotion. The types of herpes viruses. Although they are all spread by scalp is treated with shampoo. Patients with direct skin-to-skin contact, only herpes simplex pubis should be evaluated for other STDs. 1(HSV1) and herpes simplex 2(HSV2) are considered to be STDs. HSV1 has been found historically on the 5.3. Sacoptes scabiei infestation mouth, and can increasingly be isolated in genital is a whitish-brown, eight-legged infections. This probably reflects changes in sexual that burrows into its host to lay its eggs. This practices. Herpes is incurable today. The associated burrowing causes a skin irritation or rash. The , symptoms may never be manifested or they may their feces and eggs cause a progressive sensitivity in come and go periodically throughout a person’s the host after about two weeks, producing the char- lifetime. There are even more people who have no acteristic . Finding a mite or identifying its bumps symptoms. and burrows will corroborate any observed diagnosis. There are a variety of topical that will 4.3. Mollusca contagiosa clear . These include lindane, pet- Mollusca contagiosa are self-limiting viral infec- roleum jelly and 5% sulfar mixture. tions of the skin which are spread by sexual contact as well as manual and casual contact. Children are often infected. High prevalence (13%) of mollusca is noticed in HIV-positive adults, probably justifying Appendix A.Members of the mollusca to be classified under the STDs. Individual UTI Working Group blisters may disappear on their own after several months. Kurt G. Naber (Chairman), MD, PhD, apl. Professor, Department of Urology, St. Elisabeth, St. Elisabeth-Str. 23, D-94315 Straubing, Germany. 5.STDs caused by protozoa and epizoa Bo Bergman, MD, PhD, Assoc. Professor, Depart- ment of Urology, Karolinska Hospital, PO Box 5.1. Trichomoniasis 60500, S-17176 Stockholm, Sweden. Trichomoniasis is caused by the parasitic protozoon, Michael C. Bishop, MD, FRCP, FRCS, Professor, Trichomonas vaginalis, and is often diagnosed in Consultant Urologist, Department of Urology, Not- patients that are infected with other STDs. Trichomonas tingham City Hospital, Hucknell Road, Nottingham, can be transmitted by direct sexual contact or by NG5 1PB, UK. infected body fluids. Symptoms in men are uncommon, Truls E. Bjerklund Johansen, MD, PhD, Professor, and typically include discharge from the urethra and Telematk Central Hospital, N-3906 Porsgrunn, painful or difficult urination. The protozoon can be Norway. found by dark-field microscopy of specimens from Henry Botto, MD, PhD, Assoc. Professor, Service the vagina, urethral secretions or in the sediment of d’Urologie, Hopital Foch, 40 rue Worth, BP 36, urine. Culturing these samples before the microscopic F-92151 Suresnes Ce´dex, France. P. Schneede et al. / European Urology 44 (2003) 1–7 7

Mete Cek, Assoc. Professor, Chief, Taksim Teaching Bernhard Lobel, MD, PhD, Professor, Service Hospital Istanbul, 4. Gazeteciler Sitesi A 18/2, d’Urologie, Hopital Pontchaillou, Rue Henri le Levent 80630, Istanbul, Turkey. Guilloux, F-35033 Rennes, France. Magnus Grabe, MD, PhD, Assoc. Professor, Depart- Juan Palou Redorta, MD, PhD, L’Institut d’Urolo- ment of Urology, Malmø University Hospital, Ing. giea, Fundacio Puigvert, Universitat Autonoma de 42, SE-20502 Malmø, Sweden. Barcelona, E-08025 Barcelona, Spain.

References

[1] http://www.rki.de. HPV lesions of the urethra. J Eur Acad Dermatol Venereol 2001; [2] http://www.ias.se. 15:121–5. [3] http://www.daignet.de. [15] Von Krogh G, Lacey CJN, Gross G, Barrasso R, Schneider A. [4] http://www.hiv.net. European course on HPV associated : guidelines for [5] http://www.AIDSfinder.org. primary care for the diagnosis and management of [6] http://www.cdc.gov/hiv/dhap.htm. anogenital warts. Sex Transm Infect 2000;76:162–8. [7] http://www.hc-sc.gc.ca/hpb/icdc/bah/index.html. [16] Schneede P. Leitlinie zur Diagnostik und Therapie von Genitalerk- [8] http://www.phls.co.uk. rankungen durch Humane Papillomviren (HPV) Leitlinie der [9] http://www.cdc.gov/std. Deutschen Gesellschaft fu¨r Urologie. Urologe A 2001;40:511–20. [10] Schneede P. Sexuell u¨bertragbare virale Infektionen. In: Hofstetter [17] Weissenbacher ER, Schneider A, Gissmann L, Gross G, Heinrich J, A, editor. Urogenitale Infektionen. Berlin: Springer; 1999. p. 383– Hillemanns P, et al. Recommendations for the diagnosis and 414. treatment of HPV infections of the female tract. Eur J Infect [11] Petzoldt D, Gross G, editors. Diagnostik und Therapie sexuell Immunol Dis Obstet Gynaecol 2001;4:1–12. u¨bertragbarer Krankheiten. Leitlinien 2001 der Deutschen STD- [18] Stary A. European guideline for the management of chlamydial Gesellschaft. Berlin: Springer; 2001. infection. Int J STD AIDS 2001;12:30–3. [12] Schneede P. Genital human papillomavirus infections. Curr Opin [19] Horner PJ. European guideline for the management of urethritis. Int J Urol 2002;12:57–61. STD AIDS 2001;12:63–7. [13] Schneede P, Leunig A, Hillemanns P, Wagner S, Hofstetter AG. [20] Bignell CJ. European guideline for the management of gonorrhoea. Photodynamic investigation of mucosa-associated human papillo- Int J STD AIDS 2001;12:27–9. mavirus efflorescences. BJU Int 2001;88:117–9. [21] Goh BT, van Voorst Vader PC. European guideline for the [14] Schneede P, Mu¨nch P, Wagner S, Meyer Th, Stockfleth E, Hofstetter management of syphilis. Int J STD AIDS 2001;12:14–26. A. Fluorescence urethroscopy following instillation of 5-aminolevu- [22] Centers for Disease Control and Prevention. Sexually transmitted linic acid: a new procedure for detecting clinical and subclinical diseases treatment guidelines 2002. MMWR 2002;51:1–78.