In Reply

Unfortunately, space limitations made it impossible to discuss all important sexually transmitted diseases (1). These also include lymphogranuloma venereum, which is caused by Chlamydia trachomatis serovar CTL1–3. This disease is endemic to tropical and subtropical countries, and in Europe, it affects especially HIV-infected men who have sex with men (MSM). It is diagnosed by nucleic acid amplification techniques (NAAT), and a positive result should be followed by serovar differentiation. Patients are treated with doxycycline (100 mg orally twice daily for 21 days) or, alternatively, with azithromycin (1.5 g p.o. on days 1, 8, and 15). Azithromycin resistance has also been described. Swab controls (using NAAT) are therefore carried out at six weeks after therapy. Partner treatment should always be carried out (2).

Chancroid (or ulcus molle), which is rare in Europe, is caused by Haemophylus ducreyi. It is characterized by an ulcer that is usually painful, which provides an important differential diagnosis to the commonly painless ulcus durum. Diagnosis can be made only using special culture media or by employing NAAT, which however usually depends on in-house PCRs rather than routinely available equipment. In clinical practice, diagnosing a painful ulcer with regional lymphadenopathy is a diagnosis of exclusion, with a lack of proof of T. pallidum and/or herpes. Treatment consists of a single dose of azithromycin (1.5 g p.o.). Concomitant HIV infection frequently leads to treatment failure (2).

Caused by Klebsiella, granuloma inguinale is a rare, mildly contagious ulcer that results from a chronic granulomatous infectious disease of the genital and perigenital regions. Without treatment, it continuously propagates and may abscess. It is treated with cotrimoxazole (960 mg p.o. twice daily for 21 days) (2).

In regard to treatment of human papilloma virus diseases, it should be noted that only imiquimod, podophyllotoxin and the purified dry extract from green teas leaves with the active substance epigallocatechin gallate are mentioned in the current CDC treatment guideline from 2015 (3). In the AWMF guideline, 5-fluorouracil is also recommended for treating extensive multifocal, anal intraepithelial neoplasia, if this cannot be resolved primarily by ablative treatment (4).

The comment from Reinhard Laszig, that Ureaplasma urealyticum and Mycoplasma genitalium are also important causative pathogens in urethritis, is correct. This is accounted for in the new guidelines (3, 5). Further, therapy proposals exist for these, as mentioned in the publication (1).