Genitourinary Disease and STDs Flashcards
PENILE DISORDERS:
Malformations
The most common malformations include
abnormalities in the location of the distal urethral orifice.
PENILE DISORDERS:
Hypospadias refers to an
abnormal opening of the urethra along the ventral aspect of the penis, and occurs in 1/300 live male births. The opening may be restricted and lead to an increased risk of urinary tract infections.
PENILE DISORDERS:
Epispadias refers to the
urethral opening on the dorsal aspect of the penis. This abnormality is less common, but also exhibits an increased prevalence of urinary tract infections in addition to predisposition to urinary incontinence.
Premalignant Lesions
Premalignant lesions of the penis appear as
white plaque-like thickenings, areas of redness or a mixture.
Premalignant lesions:
Histologically, they may reveal any level of
epithelial dysplasia, including carcinoma in situ.
Bowen disease is a synonym for
carcinoma in situ of the penis.
Bowen disease is not specific to the
penis but may occur on other cutaneous or mucosal surfaces. Its major clinical importance lies in the potential progression to invasive squamous cell carcinoma.
Carcinoma of the Penis
Squamous cell carcinoma of the penis accounts for
about 0.4% of cancer in males.
Squamous cell carcinoma and its precursor lesions are the
most common penile neoplasms. The lesion is extremely rare among men who are circumcised early in life.
Human papillomavirus (HPV 16/18) may be involved with development of
penile cancer, and circumcision may improve hygiene and lessen exposure to oncogenic viruses.
Penile cancer:
This cancer tends to arise in those over
40 and may be preceded by Bowen’s disease.
Penile cancer:
Normally, it begins as a
crusted plaque or nodule with irregular margins that usually develops a central ulceration.
Penile cancer:
Less frequently, it forms a
papillary mass.
Penile cancer:
Treatment is
surgical excision. 5-year survival is 66%. Widespread metastasis is rare; however local metastasis to inguinal lymph nodes reduces 5-yr survival to 27%.
DISORDERS OF THE SCROTUM
- Inflammatory processes, fungal infections, dermatoses
- Rare neoplasms; most squamous cell carcinoma
- 1st human cancer associated with occupational (environmental) factors (chimney sweeps)
Cryptorchidism refers to
failure of testicular descent from the abdomen to the scrotum.
Normally, the testes descend from the body cavity into the pelvis by the
third month of gestation and into the scrotum during the last two months of intrauterine life.
Cryptorchidism:
The diagnosis cannot be confirmed until
1 year of age because the timing of completion of the descent is variable.
Cryptorchidism is present
in
1% of the male population and may be unilateral or bilateral (10%).
Cryptorchidism:
Untreated bilateral cryptorchidism results in
sterility.
Cryptorchidism:
In unilateral cases, the contralateral descended testis may undergo
atrophy, also leading to sterility.
Cryptorchidism:
Failure of descent also is associated with a
3-5 times increased risk of testicular malignancy manifesting as intratubular germ cell neoplasia developing within the atrophic tubules.
Cryptochidism:
Surgical placement of
the testes into the scrotum (orchiopexy) before puberty reduces but does not eliminate the risk of cancer and infertility.
Orchitis refers to
inflammation of the testes.
Orchitis:
In most cases, the inflammation begins as a
primary urinary tract infection with secondary ascending infection of the testes.
Orchitis:
Epididymitis is more
common than orchitis.
Epididymitis:
——————- are common signs in affected patients.
Swelling and tenderness
Epididymitis
Frequently the origin is a
STD (sexually transmitted disease, to be discussed later in this handout) with other common causes including nonspecific orchitis, mumps, and tuberculosis.
Orchitis:
Orchitis complicates
mumps in 20% of infected adult males but rarely in children.
Orchitis:
In severe cases,
mumps-associated orchitis can result in sterility.:
Torsion occurs when the
spermatic cord (from which the testicle is suspended) twists, resulting in obstruction of venous drainage while leaving the thick-walled more resilient arteries patent.
Rapid, intense vascular engorgement and venous infarction follow unless the
torsion is relieved.
Neonatal torsion occurs either
in utero or shortly after birth, without know cause.
Adult torsion generally occurs in
adolescence secondary to an anatomic defect whereby the testis has increased mobility.
Torsion often occurs without
inciting injury and manifests with sudden onset of testicular pain.
Testicular torsion is one of the few
urologic emergencies. If the patient undergoes surgical intervention within 6 hours of onset, there are good chances (90 – 100 %) the testis will remain viable.
Tumors of the testis are the most common causes of
firm, painless enlargements of the testis.
Approximately 95% of testis tumor cases arise from the
germ cells, with almost all malignant. 5 % arise from Sertoli or Leydig cells (sex cord-stromal tumors), and are generally benign.
The peak prevalence of testicular tumors is
15-34 years of age, and the number of cases diagnosed is increasing in frequency (6/100K).
As mentioned, a 3-5x increased prevalence of testis tumors is noted in
patients with cryptorchidism; but conversely, only 10% of patients with testicular cancer have a history of cryptorchidism.
Although no consistent hereditary genetic abnormality has been found for testis tumors, ———– has been noted in some kindreds.
familial clustering
Cancers of the testes typically are divided into
seminomas or nonseminomatous germ cell tumors.
Several separate types of ——— are known; but in most instances, these tumors are mixtures of more than one type.
nonseminomatous tumors
Two markers have proven to be helpful in diagnosis, staging and follow-up for these cancers:
α-fetoprotein and human chorionic gonadotropin (HCG).
These markers are rarely positive in seminomas but frequently beneficial in nonseminomatous tumors.
Seminomas arise from the
epithelium of the seminiferous tubules and remain localized for long periods. However, they may spread occurs via lymphatics.
Seminomas respond well to
chemotherapy and are extremely radiosensitive. Therefore, they are one of the most curable cancers.
Nonseminomatous tumors (E.g. Embryonal Carcinoma) spread
earlier, are less radiosensitive and utilize the hematogenous and lymphatic routes, with the lungs and liver often involved at the time of diagnosis. As Lance Armstrong can attest, treatment of testicular neoplasms is a modern medical success story. Of the 8K cases each year in the US, only about 400 die of their disease. Seminomas are extremely radiosensitive and respond well to chemotherapy. 95 % early-stage seminomas are cured; whereas 90 % of patients with nonseminomatous tumors achieve remission with chemotherapy (most are cured).
The prognosis of nonseminomatous germ-cell tumors has
improved dramatically since the introduction of newer chemotherapy regimens. Nevertheless, pure choriocarcinoma (< 1 %) is less chemosensitive and prognosis remains worse.
Prostatitis is clinically apparent
inflammation of the prostate which may be acute or chronic. The prostate will be enlarged and tender.
Bacterial prostatitis may be
acute or chronic and is caused by the same organisms which commonly produce urinary tract infections (E. coli).
Chronic nonbacterial prostatitis (90-95 % of cases), also known as chronic pelvic pain syndrome, is of
unknown etiology and doesn’t respond to antibiotics.
Both acute and chronic prostatitis present with
dysuria, urinary frequency, lower back pain and poorly localized suprapubic or pelvic pain.
Antibiotics penetrate the
prostate poorly, and the most common cause of recurrent urinary tract infections is the surviving bacteria.
Nodular hyperplasia of the prostate refers to
hyperplastic enlargement of the prostate, often associated with urinary symptoms.
Benign prostatic hypertrophy is a time-honored synonym, which is a misnomer and has been replaced with .
benign prostatic hyperplasia.
Nodular hyperplasia: The alteration is a common pathosis that begins during the
forties (20 % of men) and increases with age; 90% are affected by the eighth decade.
Nodular hyperplasia:
Stromal and glandular proliferation result in
enlargement. The central portions of the gland adjacent to the urethra (Inner periurethral zone) are involved most frequently;
Nodular hyperplasia
impingement on the prostatic urethra leads to
dysuria (difficulties in starting, maintaining and stopping the stream of urine).
Nodular hyperplasia
Clinical symptoms include
hesitancy, urgency, nocturia, and poor urinary stream.
Nodular hyperplasia
Residual urine in the bladder and chronic obstruction increases the risk of
urinary tract infection.
Nodular hyperplasia
No more than 10% of men require
surgical relief of the obstruction (TURP – Transurethral resection of the prostate) secondary to prostatic hyperplasia.
Nodular hyperplasia:
Medical management with
drug therapy may also be considered
Nodular hyperplasia:
Although the cause is unknown, ———— appear to have a central role in its development, since the process does not occur in ————-
androgens
males castrated prior to puberty or in those with genetic diseases which block androgens.
Nodular hyperplasia:
It is thought that an increase in local, intraprostatic concentrations of androgens and androgen receptors contribute to the
pathogenesis of this condition.
Carcinoma of the prostate is the most common cancer of men over
50 years of age, with the peak prevalence between 65-75.
Adenocarcinoma of the prostate accounts for
25 % of cancers in this demographic (men over 50), but Many of these cancers are small, asymptomatic, progress slowly and are found incidentally at autopsy or when examining nodular hyperplasia specimens.
The prevalence of this occult form approaches 30% in men between 30-40 years of age and 50% in men over 80.
Carcinoma of the prostate:
Although the cause is unknown and the function of hormones in the pathogenesis of carcinoma of the prostate is not fully understood, significant evidence suggests
androgens contribute significantly to the development of this cancer.
Carcinoma of the prostate:
Androgen supplementation should be viewed with
caution, and frequent sexual activity has been associated with improved prostate health.
Carcinoma of the prostate:
—— also have been suggested.
Hereditary and environmental contributions
Carcinoma of the prostate:
The clinically evident carcinomas invade
adjacent structures and metastasize via both the lymphatics and the bloodstream.
Carcinoma of the prostate:
Regional node involvement occurs
early.
Carcinoma of the prostate:
Osseous metastasis is the most common form of
hematogenous spread and the metastases may be radiolucent but are more commonly radiopaque.
Carcinoma of the prostate:
Initial diagnosis from discovery of metastatic foci is not
rare.
Carcinoma of the prostate:
Both the incipient and clinically evident cancers usually begin in the
peripheral zones of the posterior lobe of the prostate; therefore, dysuria is not frequently an early sign.
Carcinoma of the prostate:
Prostate specific antigen (PSA) represents a useful marker in the management of
prostate cancer, but is elevated in both normal prostate and those affected by cancer, prostatitis, or nodular hyperplasia.
Carcinoma of the prostate:
PSA is of limited value when used as an
isolated screening test, but its value is enhanced considerably when combined with digital rectal examination, transrectal sonography, and needle biopsy.
Carcinoma of the prostate:
In addition to being beneficial in the initial diagnosis, PSA also is important in
staging of the neoplasm and judging response to treatment.
Localized cancer of the prostate is treated by
y surgery and/or radiation.
Hormone therapy is utilized for the
advanced carcinomas.
Carcinoma of prostate:
The prognosis depends upon the
anatomic extent and spread of the tumor. The 10 year survival overall is approximately 98 %. Despite all treatments, patients with dissemination have a 10-40% 10-year survival rate.
NEOPLASMS OF THE URINARY BLADDER
The most common tumor is
urothelial cell carcinoma, which represents 90% of neoplasms of the bladder. This typically occurs in men between the ages of 50 and 80 years and the dominant presenting manifestation is painless hematuria.
Urothelial cell carcinoma:
Predisposing factors include
cigarette smoking, chronic cystitis, infection with Schistosomiasis, and exposures to various carcinogens.
Urothelial cell carcinoma:
The tumor is preceded by a
premalignant precursor lesion which often has a papillary growth pattern, but can also be flat.
Urothelial cell carcinoma:
Tumor cells generally
lack cohesion and are shed into the urine, making cytology a reasonable method for detection.
Urothelial cell carcinoma:
The degree of
atypia and extent of invasion predict prognosis.
Urothelial cell carcinoma
Treatment modalities include
transurethral resection, immunotherapy and radical cystectomy.
SYPHILIS
Syphilis is a venereal disease that is produced by a
spirochete, Treponema pallidum. Greater than 24,000 cases reported in the U.S. in 2015.
Syphilis:
There is a strong racial disparity with
African Americans affected 30X more often than whites. The peak of incidence is between 20-24 years old, followed by 15-19 years old.
Syphilis”
Humans are the
only natural host.
Syphilis:
Transmission is by
direct contact; transplacental transmission readily occurs.
Syphilis:
The infection produces
The infection produces two types of antibodies: a nonspecific antibody, syphilitic reagin, and a specific antibody, treponemal antibody.
Syphilis:
The reagin can be detected by
several simple screening serologic tests (VDRL: venereal disease research laboratory, RPR: rapid plasma reagin), but these are not specific for syphilis.
Syphilis:
Up to 15% of positive screening tests for syphilis reagin are
biologic false-positive results.
Syphilis:
The more difficult and expensive specific treponemal antibody tests (FTA: fluorescent treponemal antibody absorption test) should be performed following
positive screening tests. The specific treponemal tests remain positive for life, even following successful treatment.
The histopathologic hallmark of syphilis is a .
lymphoplasmacytic infiltrate associated with obliterative endarteritis, a specific type of vasculitis.
Syphilis:
The natural course involves three stages:
1) primary, 2) secondary and 3) tertiary.
Syphilis:
Primary syphilis is characterized by the
painless chancre which arises at the site of entry 9-90 days (mean of 21 days) after exposure.
Syphilis: Primary;
Glans penis in the male and the vulva or cervix in females are
common sites. Lips, fingers, oropharynx and anus are also possible sites.
Syphilis: Primary
The chancre begins as a
reddened papule that quickly ulcerates; the organisms may be seen only in special stains or in smears that are examined under a dark field microscope.
Syphilis: Primary
Serologic tests begin to become positive after
1-2 weeks of infection and are positive in the vast majority by 4-6 weeks.
Syphilis: Primary;
Because of the early negativity of the screening tests, dark-field examination of the exudate is
extremely important in the diagnosis of early primary syphilis.
Syphilis: Primary;
Non-syphilitic spirochetes can be found within the
normal oral flora and this makes the dark-field method of limited use for primary oral lesions.
Syphilis: Primary;
———- occurs during this stage.
Spirochetemia
Syphilis: Primary;50% of the females and 30% of the males either
never develop or do not detect the chancre. Chancres heal in 4-6 weeks
Syphilis: Secondary
In about 25% of untreated patients, healing of the chancre is followed within
2 months by secondary syphilis presenting with generalized lymph node enlargement combined with widespread mucocutaneous lesions that are maculopapular, scaly or pustular and even involve the palms and soles.
Syphilis: Secondary:
Oral and vaginal areas of localized spongiotic mucositis are called
mucous patches.
Syphilis: Secondary:
Elevated large broad plaques (condyloma lata) can form
in moist skin areas such as the axillae, inner thighs and anogenital area.
Syphilis: Secondary:
=————- are not rare and often noted in the oral cavity, pharynx and external genitalia.
Mucosal condyloma lata
Syphilis: Secondary:
All sites are
infectious. The rash can be extremely subtle and may be ignored. All serologic tests are positive.
Secondary syphilis:
Virtually all untreated cases of secondary syphilis
clear over several weeks, leading to latent syphilis. These patients are asymptomatic, yet all serologic markers are positive. The majority never develop progressive disease. Some have relapses of secondary disease, while others progress to tertiary syphilis.
Tertiary syphilis:
Tertiary syphilis arises in
30% of untreated patients usually after a latent period of 5-20 years. It may affect any part of the body, but it shows a predilection for the cardiovascular system (80%) and the CNS (10%).
Tertiary syphilis:
The aorta may develop
scarring, weakening and dilation secondary to obliterative endarteritis.
Tertiary syphilis:
Brain atrophy produces
dementia.
Tertiary syphilis:
Rubbery gray-white areas of total necrosis (gumma) may be seen most frequently in
mucocutaneous tissue and bone.
Nasal and palatal bones are not uncommon sites.
Tertiary syphilis:
The gumma is due to
hypersensitivity to products of the spirochete and to ischemia from obliterative endarteritis.
Tertiary syphilis:
Treponemes are difficult to find in
tertiary syphilis, and this stage is much less infectious.
Tertiary syphilis:
With treatment, gummas will become areas of
scar; the cardiovascular and neural damage is irreversible.
Tertiary syphilis:
The nonspecific serologic screening tests typically are
negative.
Tertiary syphilis:
Once exposed to syphilis, the highly sensitive specific treponemal antibody tests are
positive for life.
Although the treponemes may be transmitted across the placenta at any time during pregnancy, fetal signs of infection typically do not develop until after the
fourth month of pregnancy.
Treatment within the first four months of pregnancy will generally
prevent clinical complications.
Although the chance of transmission is greater from newly infected mothers, the fetus may receive the spirochetes if the mother contracted the disease within the last
five years.
The more active the maternal disease, the
better the chance of fetal infection.
In the absence of treatment, up to 40% die in utero, typically after the
fourth month.
Congenital syphilis can be divided into three patterns:
stillbirth, infantile and late.
Infantile syphilis refers to liveborn infants that at birth or within the first few months of life present with
clinical lesions similar to those seen in secondary syphilis.
Late congenital syphilis refers to cases of
untreated congenital syphilis of more than 2 years duration.
Classic manifestations of this chronic infection include interstitial keratitis of the eyes, saber shins, saddle nose, Hutchinson’s incisors, mulberry molars, eighth nerve deafness, gummas and neurosyphilis.
A historically famous pattern of congenital syphilis is called Hutchinson triad and consists of:
- Interstitial keratitis
- Hutchinson’s teeth
- Eighth nerve deafness
The treatment for syphilis is ———–, with ———– utilized in patients allergic to the primary choice.
penicillin
tetracycline
HUMAN PAPILLOMAVIRUS INFECTION Human papillomavirus (HPV) is the cause of a number of
epithelial proliferations in the genital tract, including condyloma acuminatum, some precancerous lesions and some carcinomas.
HUMAN PAPILLOMAVIRUS INFECTION
Condyloma acuminatum is usually associated with
HPV types 6 or 11 and typically arises on moist mucocutaneous surfaces. They present as benign papillary nodules, and frequently appear in clusters.
HUMAN PAPILLOMAVIRUS INFECTION Other types of HPV (16, 18, 31, 33, 45, 52, and 58) are found more frequently in
epithelial neoplasia, including cervical and oropharyngeal cancer.
HUMAN PAPILLOMAVIRUS INFECTION
Condylomata sometime occur
singly but more often in multiple sites. The penis and around the anus are the common sites in men, while the vulva is the most frequent site in females. Occasional lesions are seen intraorally and it is not uncommon to develop synchronous lesions.
HUMAN PAPILLOMAVIRUS INFECTION
Genital HPV can be transmitted to
neonates during vaginal delivery and may result in life-threatening papillomas of the upper respiratory tract.
HUMAN PAPILLOMAVIRUS INFECTION
Neonate upper respiratory papillomas:
These lesions are treated with
surgery, laser ablation, cryotherapy, or topical imiquimod.
Malignant transformation of ——— can occur but is uncommon.
condyloma acuminatum
GONORRHEA:
Gonorrhea is a frequent sexually transmitted disease caused by
Neisseria gonorrhoeae, a gram-negative diplococcus.
GONORRHEA
An estimated ——— cases occur annually in the U.S., and this is complicated by the emergence of strains which are resistant to multiple antibiotics.
800K cases
GONORRHEA Humans are the ———-, and spread requires direct contact with the mucosa of an infected person.
only natural reservoir
GONORRHEA
Sites of entry include the
urethra, oropharynx, eyes and the anorectum.
GONORRHEA
The diplococcus evokes a
neutrophilic inflammatory reaction which produces copious amounts of pus.
GONORRHEA
two to seven days after exposure, symptomatic males exhibit
dysuria, urinary frequency and mucopurulent exudation from the urethra; the main symptoms in females are dysuria, lower pelvic pain and vaginal discharge.
GONORRHEA:
—–of the females and —- of the males are asymptomatic.
80%
40%
These asymptomatic individuals are the major reservoir of infection.
GONORRHEA:
If untreated, it spreads up the genital tract and may produce
sterility in both sexes.
GONORRHEA
In males, ascending infection results in
acute prostatitis, epididymitis or orchitis.
GONORRHEA
Ascending infection involving the uterus, fallopian tubes, and ovaries results in
acute salpingitis.
GONORRHEA
Following the acute infection, granulation tissue and fibrosis results in
permanent deformities, giving rise to pelvic inflammatory disease.
GONORRHEA
Mothers may produce
blindness in infants from gonococcal contamination at birth - gonococcal ophthalmia neonatorum; this is presently rare because of a prophylactic antibiotic placed in the eyes of all newborns.
GONORRHEA:
Culture of the organism from discharges has been the
primary diagnostic test.
GONORRHEA
Treatment for gonorrhea in the past was
penicillin, but resistance has become a problem.
NONGONOCOCCAL URETHRITIS AND CERVICITIS
Nongonococcal urethritis and cervicitis are the most common forms of
sexually transmitted disease which must be reported to CDC.
NONGONOCOCCAL URETHRITIS AND CERVICITIS
This infection mimics ——- in males and is mostly —– in females, although occasionally it does produce cervicitis and/or urethritis.
gonococcal urethritis
asymptomatic
NONGONOCOCCAL URETHRITIS AND CERVICITIS
Most cases appear related to
Chlamydia trachomatis, but a number of other organisms also have been implicated as a possible cause in some cases.
NONGONOCOCCAL URETHRITIS AND CERVICITIS
The infection is usually
milder with fewer complications than gonorrhea but does produce suppuration within the infected area.
NONGONOCOCCAL URETHRITIS AND CERVICITIS
Males develop
urethritis which may spread into the epididymes;
NONGONOCOCCAL URETHRITIS AND CERVICITIS
females develop
urethritis and/or cervicitis which may spread into the oviducts and even produce pelvic inflammatory disease.
NONGONOCOCCAL URETHRITIS AND CERVICITIS
Infants born of infected mothers may develop
conjunctivitis or neonatal pneumonia.
NONGONOCOCCAL URETHRITIS AND CERVICITIS
The infection often is recognized by its
persistence following penicillin treatment for gonorrhea (“postgonococcal urethritis”).
NONGONOCOCCAL URETHRITIS AND CERVICITIS
Positive identification of C. trachomatis by culture is not
available routinely.
NONGONOCOCCAL URETHRITIS AND CERVICITIS
The diagnosis is made by
exclusion of gonorrhea by smear and culture and possibly with detection of bacteria by molecular techniques.
NONGONOCOCCAL URETHRITIS AND CERVICITIS
Best approach is to treat all patients with
gonorrhea-like symptoms with a regimen which is effective against both gonorrhea and chlamydia.
NONGONOCOCCAL URETHRITIS AND CERVICITIS
=——— is the treatment of choice.
Ceftriaxone combined with doxycycline
NONGONOCOCCAL URETHRITIS AND CERVICITIS
Reactive arthritis (Reiter Syndrome) is a significant manifestation of
chlamydial infection. This is an immune-mediated process that develops in response to genitourinary or gastrointestinal infections and predominates in patients who are HLA-B27 positive.
reactive arthritis:
It typically presents as a combination of
urethritis/cervicitis, arthritis, conjunctivitis, and mucocutaneous lesions.
GENITAL HERPES SIMPLEX:
Genital herpes simplex (herpes genitalis) is a common STD that affects an estimated 50 million individuals in the U.S. and occurs from infection by herpes simplex virus. Most are caused by
HSV Type II, with a small percentage related to Type I.
GENITAL HERPES SIMPLEX
Spread is possible when the virus comes in contact with a
mucosal surface or broken skin.
GENITAL HERPES SIMPLEX
HSV actively shed during periods of
clinically visible lesions.
GENITAL HERPES SIMPLEX
The clinical manifestations vary considerably, depending on whether the infection is
primary or recurrent.
GENITAL HERPES SIMPLEX
Primary infections may be
asymptomatic; the remainder develop painful focal lesions with dysuria, fever, lymphadenopathy, headache and malaise.
GENITAL HERPES SIMPLEX
The glans penis or surrounding areas in men and the cervix in women are the
usual sites. Involvement of the vagina, vulva and labia may also be seen.
GENITAL HERPES SIMPLEX
The lesions are small vesicles that quickly
ulcerate;
GENITAL HERPES SIMPLEX
the diagnosis is made via a
smear or biopsy which will reveal the cytopathologic effects of the virus in epithelial cells (ballooning degeneration of epithelial cells with large, multinucleate “Tzanck cells”).
GENITAL HERPES SIMPLEX
Without treatment, the clinical manifestations of primary herpes may last
3-6 weeks.
GENITAL HERPES SIMPLEX
Recurrent herpes presents with
periodic vesiculo-erosive lesions that heal in 7-10 days.
GENITAL HERPES SIMPLEX
More than 80% of the patients with HSV Type II genital herpes have
one or more recurrences yearly for several years.
GENITAL HERPES SIMPLEX
Herpes is a significant clinical problem since it can spread to others and may produce
infections in newborns that often are fatal (neonatal herpes).
GENITAL HERPES SIMPLEX
Such infection of the newborn occurs in about
half of infants delivered vaginally of mothers suffering from either primary or recurrent genital infection.
GENITAL HERPES SIMPLEX
Approximately 60% of affected infants
die of the infection.
