- Genital Ulcer
- Open soft-tissue lesions on the vagina, penis, perineal and anorectal surface
- See Sexually Transmitted Disease
- Uncircumcised male
- Current or former Prison Inmates
- Low income urban setting (esp. women)
- Sex workers
-
IV Drug Abuse
- Multiple sexual partners
- Causes
-
Young Sexually Active Patients in the United States
- Painful
- Genital Herpes (Herpes Genitalis)
- Grouped vessicles or small ulcers, serous discharge
- 60-70% of U.S. Genital Ulcers (rare in 3rd world)
- Chancroid
- Open sore with gray, yellow ulcer base
- 50-70% in third world (rare in U.S.)
- Non-Painful
- Granuloma Inguinale (Donovanosis)
- Lymphogranuloma venereum
- Primary Syphilis (Early)
- 10-20% of Genital Ulcers
-
Sexual History
- Possible Sexually Transmitted Disease exposure
- Unprotected sex
-
Men who have Sex with Men
-
Lymphogranuloma venereum
-
Syphilis
- Symptoms
- Urethral discharge
- Dysuria
- Regional Lymphadenopathy
- Genital or perianal ulcers
- Proctitis
- Medications recently started or changed
- Fixed Drug Eruption
- NSAIDs
- Antimalarials
- ACE Inhibitors
- Beta Blockers
- Lithium
- Salicylates
- Corticosteroids
- Antiretroviral Therapy initiation (if coinfected with HIV and HSV-2)
- Medical History
- Behcet Syndrome
- Frequent Aphthous Ulcers or known HLA-B51/B5 carrier
- More common in Middle East, Asia and Japan
- Psoriasis
- Increases risk of Genital Ulcers after medication or Trauma exposure
-
Genital Herpes
- Vessicle
- Multiple vesicular lesions on foreskin, labia, vagina or anus
- Onset after prodromal Paresthesias
- Ulcer
- Painful shallow ulcers result when vessicles rupture
-
Lymph
- Accompanied by lymhadenopathy with primary (first) infection
-
Syphilis
-
Chancre (ulcer in Primary Syphilis)
- Single, painless, well-demarcated ulcer
- Clean base
- Indurated border
- Distribution in anogenital region (may also affect oropharynx)
-
Gumma (lesion in Tertiary Syphilis)
- Diffusely distributed soft ulcerative lesions, with firm necotic center
-
Lymph
- Mildly tender inguinal lyphadenopathy (Secondary Syphilis)
-
Chancroid
- Ulcer
- Painful, non-indurated ulcer
- Localized to prepuce and frenulum in men, vulva or Cervix in women, and at perineum
- Serpiginous border
- Friable base
-
Lymph
- Painful, unilateral, inguinal Lymphadenitis (50% of cases)
-
Buboes
- Develops from swollen Lymph Nodes
- May rupture if become fluctuant
-
Lymphogranuloma venereum
-
Papule
- Small, shallow, painless genital or rectal Papule
- Ulcer
- Papules may ulcerate within first month of incubation
-
Lymph
- Tender inguinal or femoral Lymphadenopathy
-
Lymphatic obstruction may occur with risk of genital elephantiasis
-
Granuloma Inguinale (Donovanosis)
- Papule or ulcer
- Persistent, painful, beefy-Red Papules or ulcers onset 2-3 months after exposure
- Necrosis or sclerosis may occur
- Behcet Sydrome
- Ulcer
- Recurrent oral (round Aphthous Ulcers <10 mm) and Genital Ulcers
- Genital Ulcers scar in more than half of cases
-
Herpes Simplex Virus Testing
-
HSV PCR from ulcer scraping or vessicle aspirate (preferred obver HSV culture)
- HSV Serology (type specific)
-
Chancroid testing (if high Incidence in community)
- Outside the U.S., PCR testing may be available, which is much more sensitive than culture
- Haemophilus ducreyi Gram Stain and culture
- May be treated empirically despite negative testing
- Indicated in painful ulcers, Regional Lymphadenopathy and other tests negative
-
Syphilis Testing
-
Chancre testing with dark field microscopy or direct fluorescent Antibody
-
VDRL or RPR with reflex to confirmatory testing
-
Lymphogranuloma venereum
- Test Genital swab or bubo aspirate for Chlamydia trachomatis types L1, L2, L3 (culture, PCR, direct immunofluorescence)
- Other testing (Sexually Transmitted Diseases that do not cause Genital Ulcers)
- Offer testing for other Sexually Transmitted Disease despite not being causes for Genital Ulcers
- HIV Test
- Chlamydia Test (Chlamydia PCR)
- Gonorrhea Test (Gonorrhea PCR)
- Hepatitis B Surface Antigen
- Trichomonal Vaginitis (women)
-
General
- Cause may not be indentified on lab testing in more than 25% of cases
- Treatment may be empiric based on history and examination
- Sexual partners should be tested for Sexually Transmitted Disease
- Abstain from sexual activity until ulcers have healed and treatment is completed
- HIV Transmission is at much higher risk when Genital Ulcers are present
- Initial empiric management (start before lab results back)
- Genital Herpes treatment (start early to prevent HSV transmission, HIV Transmission and speed healing)
- Withdraw medications suspected as cause of possible Fixed Drug Eruption (diagnosis of exclusion)
- Consider empiric Syphilis management while awaiting results in high risk patients (e.g. Men who have Sex with Men)
- Cause Specific Management
- Genital Herpes
- Primary Syphilis
- Chancroid
- Lymphogranuloma venereum (Donovanosis)
- Behcet Syndrome
- Ulcer Treatment
- Keep ulcers clean and bandaged
- Sitz baths may be soothing
- Various antimicrobials (e.g. silvadene) have been used but are without evidence to support
- Consider cool compress with Burow Solution
- Limit number of sexual partners
- Consistent Condom use
- Regular Sexually Transmitted Infection Screening
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