Primary Syphilis Evaluation

A 28 year old assigned male at birth presents with the chief complaint of a "new problem in my private parts” He states he feels well otherwise. Which of the following would be most consistent with the clinical presentation of primary syphilis?

A. A three day history of purulent penile discharge with dysuria.

B. A one week history of a painless genital ulcer on the penile shaft.

C. A 5 day history of painful vesicular lesions over the penile glands, with some lesions now crusting over.

D. A one week history of N void dysuria without penile discharge.

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Transcript

Voiceover: Welcome to NP certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying the pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Doctor Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question, so you can better understand 

how to arrive at the correct test answer. 

So, if you're ready, let's jump right in. 

Margaret Fitzgerald: A 28-year-old assigned male at birth presents with the chief complaint of a “new problem in my private parts.” He states he feels well, otherwise. Which of the following would be most consistent with the clinical presentation of primary syphilis? 

A: Three-day history of purulent penile discharge with dysuria. 

B: A 1-week history of a painless genital ulcer on the penile shaft. 

C: A 5-day history of painful vesicular lesions over the penile glans, with some lesions now crusting over. 

D: A week history of dysuria without penile discharge. 

The correct answer is B: A 1-week history of painless genital ulcer on the penile shaft. Where should you begin with a question 

like this? 

First, figure out what kind of a question this is. Given that we're being asked for the clinical presentation of disease, this is actually an assessment slash diagnosis question. 

The reason I say it's not a firm diagnosis question is you're actually gathering information because clearly we have been given very little info about this patient. 

And then we're being asked to apply what we would expect for the classic presentation of disease. 

And as always, keep in mind, on the NP board, you're going to be presented with the classic presentation of disease and not thrown 

some curve ball of atypical presentation. 

And you'll tend to be given just enough information to make the clinical decision, but not a lot of extra. 

I look at this and I want to know about efforts to minimize the acquisition of STIs, whether there's a new partner involved or a partner who has a new partner. 

I think you know what I mean by all of this. I want to know more about this patient’s fever, other constitutional signs or symptoms. 

But nope, we just have to go with what we're given and get rid of two dangerous, dangerous words that can creep into your brain during the boards. 

Yes, but yes. But I can't answer this question unless I know this, this and this. Yes, in real life you need more information. For the boards, they’re forcing you to think of what is the most likely clinical scenario. 

So as with other podcasts, let's start with some background information. 

Syphilis is caused by the bacteria by he name of Treponema pallidum. Syphilis is a complex multi-organ disease. 

And it is bacterial in origin. Sexual contact is the usual route of transmission. 

Syphilis is divided into four stages: primary, secondary, latent, and tertiary. 

Each stage occurs within a time period after acquisition of the causative organism. Primary syphilis occurs about 3 to 90 days after initial exposure with a chancre as its chief manifestation. 

What is a chancre? It's a firm, round, painless, ulcer with a clean base 

and integrated margins accompanied by localized lymphadenopathy. 

Given that the lesion is painless and resolves without treatment in about 3 weeks, many patients do not seek care. The location of the chancre correlates with the site of infection acquisition. 

As a result, more than 90% of chancres are in the anal genital region 

and the remaining are usually oral lesions. 

This stage, as I said, lasts about 3 weeks, then the chancre resolves, 

but the causative organism for the condition remains in circulation. 

Usually, the person with primary syphilis feels well, but suffice to say, feeling well or not, this is a serious bacterial infection that has potential long-term consequences without treatment. 

Plus, the person with syphilis remains able to transmit the organism 

to another via sexual contact. 

At the same time, the disease is readily treated with select 

anti-microbial therapy. Confirmation of the diagnosis is needed with laboratory testing that have an alphabet soup of names, places such as RT-PCR and VDRL. 

Those two are usually used as screening tests plus confirmatory tests 

such as the EIA, FTA-ABS, and TPPA. 

I'll cover the treatment of syphilis in another podcast, as well as the clinical presentation of secondary syphilis. 

By the way, secondary syphilis is the stage where the risk for contagion 

is the greatest. As this is background information, let's tackle the question again. 

A 28-year-old assigned male at birth presents with the chief complaint of a "new problem in my private parts.” He states he feels otherwise. 

Well, which of the following would be most consistent with the clinical presentation of primary syphilis? 

A 3-day history of purulent penile discharge with dysuria. This is not correct, but what could it represent? 

This could either be Neisseria gonorrheae, which is an STI that is most likely to give a male penile discharge. 

Usually there is also a dysuria that goes along with Neisseria gonorrheae. 

But keep in mind Chlamydia trachomatis can present with penile discharge as well. Although usually not as purulent and not in as high 

a volume as we see with Neisseria gonorrheae. 

One of the reasons a infection has a colloquial name of the drip is because of the penile discharge. 

So this could be what's being described here with the purulent 

penile discharge and the dysuria. 

Could be chlamydia. Could be gonorrhea. 

And just remember, these are infections typically limited to the GU tract and not a systemic infection. 

So such as syphilis is this is one reason why when we see one STI, we often test for multiple STIs because the overlap in how things can present is quite common. 

Suffice to say that many people, regardless of birth, sex assignment, with either a Neisseria gonorrheae or Chlamydia trachomatis infection are asymptomatic. 

B: A 1-week history of painless genital 

ulcer on the penile shaft. This is, of course, the correct answer. 

And this would represent primary syphilis. C: A 5-day history of painful vesicular lesions on the penile glans, with some of the earliest lesions 

now forming a crust. This is the clinical presentation 

of genital herpes, also known as herpes simplex type two, also known as HSV-2 or HH-2. 

One key differentiation between the lesion of syphilis in the lesions seen with genital herpes is pain. Herpes lesions are quite painful, 

and oftentimes, particularly if a syphilitic lesion is a chancre 

or is in the anal region, the patient doesn't even know it's there, 

except they'll report, like, I felt something funny down there 

when I washed myself, you know, because you're not typically able 

to easily see the anal region. 

And then being aware of something a little different down there. 

Genital herpes, however, is characterized by painful, ulcerated lesions and that one of the big differentials here. 

Now HHV-2 is usually characterized as a below the belt form of herpes. So usually that's the bug that causes a genital herpes. 

But HSV-1 the cold sore virus can also infect the genital region. But HSV-2 usually does not infect the oral region. 

C: A 1-week history of dysuria without penile discharge. This is a fairly vague piece of history, but you know, you always have to just deal with what you're given on the NP board. 

Could be UTI. Although UTIs are pretty uncommon in men of this age. It could also be Chlamydia trachomatis just because quite often, regardless of birth sex assignment, chlamydia presents with in-void burning but without urgency. And that's how one thing that you should think of is almost without fail. 

There'll be urinary urgency with a UTI, with a cystitis. But there will be a urethra, right? Sometimes gonorrhea can present that way 

as well. 

And obviously further testing is required to figure out what's going on. 

Key takeaway, as with all disease, is knowing how these conditions present clinically is key to safe practice. In particular, considering STIs often tend to come in clusters when a person presents with one STI get comprehensive testing for Neisseria gonorrheae and Chlamydia trachomatis, syphilis, HIV and other STIs should be performed at the same time. 

Voiceover: Thank you for listening to NP certification Q&A presented by Fitzgerald Health Education Associates. 

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