Guidelines 2016 -Granuloma Inguinale
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. DEFINITION
Granuloma inguinale (donovanosis) is a chronic granulomatous bacterial infection with the intracellular gram-negative bacterium Klebsiella granulomatis usually involving the genitalia and surrounding tissues and probably spread by sexual contact.
II. ETIOLOGY
A. Usually found in tropical and subtropical areas such as India, Papua New Guinea, the Caribbean, central Australia, and southern Africa
B. K. granulomatis (a difficult-to-grow, encapsulated bacillus organism)
C. Incubation period: 5 to 6 weeks (some say anywhere from 1 to 12 weeks)
III. HISTORY
A. What the female patient presents with
1. Painless papular or nodular ulcerative lesions arising on the vulva; in the vagina, urethra, anal area, inguinal region; or on the perineum with proliferation of granulation tissue and local destruction with scar tissue formation; single or multiple
2. Beefy red proliferative lesion of fourchette with elevated rolled borders; bleeds easily
3. Inguinal adenopathy (caused by secondary infection)—bilateral
4. Malodorous vaginal discharge
B. What the male patient presents with
1. Lesion same as in the female and appearing on penis, scrotum, groin, or thighs
2. In homosexual males, lesions on anus and buttocks
GRANULOMA INGUINALE 301
C. Additional information to be obtained
1. History of STI or PID
2. History of chronic illness
3. Has patient recently been out of the country? Where (especially India, Papua New Guinea, the Caribbean, central Australia, southern Africa)? Is patient or patient’s partner from, or has either visited, southeastern United States?
4. Sexual preference, sexual practices (anal intercourse, sex toys)
5. Last sexual contact
6. Birth control method, current medications
7. LMP
IV. PHYSICAL EXAMINATION
A. Vital signs
1. Temperature
2. Blood pressure
3. Pulse
4. Respirations
B. External examination
1. Observe vulva for lesions (papular, nodular, or vesicular), beefy red nodules that develop into a rounded, elevated, velvety granulomatous mass; sharply defined rolled borders; signs of secondary infection
C. Vaginal examination (speculum)
1. Inspect vaginal walls for lesions
2. Inspect cervix for lesions
D. Bimanual examination
V. LABORATORY EXAMINATION
A. Giemsa-stained smears of ulcer (diagnosis is confirmed by visualization of the Donovan bodies, large mononuclear cells with intracytoplasmic vacuoles containing the organism)—scrape at base of ulcer to get the tissue crush preparation or biopsy. There are no FDA-cleared PCR tests available; some laboratories have assays that have conducted a CLIA verification study.
B. Syphilis serology
C. HSV culture
VI. DIFFERENTIAL DIAGNOSIS
A. Syphilis
B. Herpes simplex
C. Lymphogranuloma venereum
D. Chancroid
E. Carcinoma
F. Fungal infection
G. Genital amoebiasis
302 VAGINAL CONDITIONS
VII. TREATMENT
A. Medication
1. Doxycycline 100 mg orally twice a day for 21 days
B. Alternative regimens
1. Erythromycin base 500 mg orally four times a day for 21 days
C. In pregnancy and lactation
1. Erythromycin base 500 mg orally four times a day for 21 days
D. General measures
1. No sexual contact until treatment is completed
2. Stress the importance of completing course of medication
3. Stress the importance of examination of sexual contacts (within 60 days preceding onset of symptoms)
VIII. COMPLICATIONS
A. Scar tissue secondary to slow-healing formation
B. Secondary infection, a common occurrence that results in gross tissue necrosis of genitalia
C. Deformity of genitalia
D. Dyspareunia
E. Systemic infection
F. Massive edema of vulva; penis (may be chronic)
IX. CONSULTATION/REFERRAL
A. Consult with physician prior to treatment if disease is suspected
B. If no response to treatment as discussed previously in 7 days, contact the CDC or state health department
X. FOLLOW-UP
A. After completion of 2 to 5 days of medication
B. Follow clinically until signs and symptoms have resolved
C. Annual follow-up visits because the disease can reappear, and there is a possibility of scar carcinoma
See Bibliographies.
Websites: www.cdc.gov/std/tg2015/tg-2015-Print.pdf; www.cdc.gov/PowerPoint/ Granuloma_inguinale.ppt