Genital Ulcer

Aka: Genital Ulcer

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II. Definitions

  1. Genital Ulcer
    1. Open soft-tissue lesions on the vagina, penis, perineal and anorectal surface

III. Risk Factors

  1. See Sexually Transmitted Disease
  2. Uncircumcised male
  3. Current or former Prison Inmates
  4. Low income urban setting (esp. women)
  5. Sex workers
  6. IV Drug Abuse
  7. Multiple sexual partners

IV. Causes: Mnemonic - CHISEL

  1. Chancroid (painful)
  2. Herpes Genitalis (painful)
  3. Inguinale (Granuloma Inguinale)
  4. Syphilis
  5. Eruption secondary to drugs (Fixed Drug Eruption)
  6. Lymphogranuloma venereum

V. Causes: Young Sexually Active Patients in the United States

  1. Most Common
    1. Genital Herpes (60-70% of Genital Ulcers, may be HSV 1 or 2)
  2. Less common
    1. Syphilis (10-20% of Genital Ulcers)
    2. Chancroid (Haemophilus ducreyi)
    3. Fixed Drug Eruption
  3. Rare
    1. Lymphogranuloma venereum (Chlamydia trachomatis L1, L2 and L3)
    2. Granuloma Inguinale (Donovanosis, Klebsiella granulomatis)
    3. Bacterial Infection
    4. Fungal infection
    5. Behcet's Disease

VI. Causes: Sexually Transmitted Disease Genital Ulcers

  1. Painful
    1. Genital Herpes (Herpes Genitalis)
      1. Grouped vessicles or small ulcers, serous discharge
      2. 60-70% of U.S. Genital Ulcers (rare in 3rd world)
    2. Chancroid
      1. Open sore with gray, yellow ulcer base
      2. 50-70% in third world (rare in U.S.)
  2. Non-Painful
    1. Granuloma Inguinale (Donovanosis)
    2. Lymphogranuloma venereum
    3. Primary Syphilis (Early)
      1. 10-20% of Genital Ulcers

VII. Causes: Non-Sexually Transmitted Disease Genital Ulcers

  1. Fixed Drug Eruption
    1. Pruritic lesion or burning pain
  2. Fungal infection (e.g. Candida infection)
  3. Scabies
  4. Pyoderma
  5. Genital Trauma
  6. Psoriasis
  7. Lipschutz Ulcer
  8. Granulomatosis with Polyangiitis (previously known as Wegener's Granulomatosis)
  9. Excoriations
  10. Fixed Drug Eruption
  11. Behcet's Disease
  12. Mononucleosis

VIII. History

  1. Sexual History
    1. Possible Sexually Transmitted Disease exposure
      1. Unprotected sex
    2. Men who have Sex with Men
      1. Lymphogranuloma venereum
      2. Syphilis
    3. Symptoms
      1. Urethral discharge
      2. Dysuria
      3. Regional Lymphadenopathy
      4. Genital or perianal ulcers
      5. Proctitis
  2. Medications recently started or changed
    1. Fixed Drug Eruption
    2. NSAIDs
    3. Antimalarials
    4. ACE Inhibitors
    5. Beta Blockers
    6. Lithium
    7. Salicylates
    8. Corticosteroids
    9. Antiretroviral Therapy initiation (if coinfected with HIV and HSV-2)
  3. Medical History
    1. Behcet Syndrome
      1. Frequent Aphthous Ulcers or known HLA-B51/B5 carrier
      2. More common in Middle East, Asia and Japan
    2. Psoriasis
      1. Increases risk of Genital Ulcers after medication or Trauma exposure

IX. Signs

  1. Genital Herpes
    1. Vessicle
      1. Multiple vesicular lesions on foreskin, labia, vagina or anus
      2. Onset after prodromal Paresthesias
    2. Ulcer
      1. Painful shallow ulcers result when vessicles rupture
    3. Lymph
      1. Accompanied by lymhadenopathy with primary (first) infection
  2. Syphilis
    1. Chancre (ulcer in Primary Syphilis)
      1. Single, painless, well-demarcated ulcer
      2. Clean base
      3. Indurated border
      4. Distribution in anogenital region (may also affect oropharynx)
    2. Gumma (lesion in Tertiary Syphilis)
      1. Diffusely distributed soft ulcerative lesions, with firm necotic center
    3. Lymph
      1. Mildly tender inguinal lyphadenopathy (Secondary Syphilis)
  3. Chancroid
    1. Ulcer
      1. Painful, non-indurated ulcer
      2. Localized to prepuce and frenulum in men, vulva or Cervix in women, and at perineum
      3. Serpiginous border
      4. Friable base
    2. Lymph
      1. Painful, unilateral, inguinal Lymphadenitis (50% of cases)
    3. Buboes
      1. Develops from swollen Lymph Nodes
      2. May rupture if become fluctuant
  4. Lymphogranuloma venereum
    1. Papule
      1. Small, shallow, painless genital or rectal Papule
    2. Ulcer
      1. Papules may ulcerate within first month of incubation
    3. Lymph
      1. Tender inguinal or femoral Lymphadenopathy
      2. Lymphatic obstruction may occur with risk of genital elephantiasis
  5. Granuloma Inguinale (Donovanosis)
    1. Papule or ulcer
      1. Persistent, painful, beefy-Red Papules or ulcers onset 2-3 months after exposure
      2. Necrosis or sclerosis may occur
  6. Behcet Sydrome
    1. Ulcer
      1. Recurrent oral (round Aphthous Ulcers <10 mm) and Genital Ulcers
      2. Genital Ulcers scar in more than half of cases

X. Labs

  1. Herpes Simplex Virus Testing
    1. HSV PCR from ulcer scraping or vessicle aspirate (preferred obver HSV culture)
    2. HSV Serology (type specific)
  2. Chancroid testing (if high Incidence in community)
    1. Outside the U.S., PCR testing may be available, which is much more sensitive than culture
    2. Haemophilus ducreyi Gram Stain and culture
      1. May be treated empirically despite negative testing
      2. Indicated in painful ulcers, Regional Lymphadenopathy and other tests negative
  3. Syphilis Testing
    1. Chancre testing with dark field microscopy or direct fluorescent Antibody
    2. VDRL or RPR with reflex to confirmatory testing
  4. Lymphogranuloma venereum
    1. Test Genital swab or bubo aspirate for Chlamydia trachomatis types L1, L2, L3 (culture, PCR, direct immunofluorescence)
  5. Other testing (Sexually Transmitted Diseases that do not cause Genital Ulcers)
    1. Offer testing for other Sexually Transmitted Disease despite not being causes for Genital Ulcers
    2. HIV Test
    3. Chlamydia Test (Chlamydia PCR)
    4. Gonorrhea Test (Gonorrhea PCR)
    5. Hepatitis B Surface Antigen
    6. Trichomonal Vaginitis (women)

XI. Management

  1. General
    1. Cause may not be indentified on lab testing in more than 25% of cases
    2. Treatment may be empiric based on history and examination
    3. Sexual partners should be tested for Sexually Transmitted Disease
    4. Abstain from sexual activity until ulcers have healed and treatment is completed
      1. HIV Transmission is at much higher risk when Genital Ulcers are present
  2. Initial empiric management (start before lab results back)
    1. Genital Herpes treatment (start early to prevent HSV transmission, HIV Transmission and speed healing)
    2. Withdraw medications suspected as cause of possible Fixed Drug Eruption (diagnosis of exclusion)
    3. Consider empiric Syphilis management while awaiting results in high risk patients (e.g. Men who have Sex with Men)
  3. Cause Specific Management
    1. Genital Herpes
    2. Primary Syphilis
    3. Chancroid
    4. Lymphogranuloma venereum (Donovanosis)
    5. Behcet Syndrome
  4. Ulcer Treatment
    1. Keep ulcers clean and bandaged
    2. Sitz baths may be soothing
    3. Various antimicrobials (e.g. silvadene) have been used but are without evidence to support
    4. Consider cool compress with Burow Solution

XII. Prevention

  1. Limit number of sexual partners
  2. Consistent Condom use
  3. Regular Sexually Transmitted Infection Screening

XIII. Resources

  1. CDC - Genital Ulcers
    1. http://www.cdc.gov/std/treatment/2010/genital-ulcers.htm

XIV. References

  1. Gomes (2007) Braz J Infect Dis 11(2):254-60. [PubMed]
  2. Roett (2012) Am Fam Physician 85(3): 254-62 [PubMed]
  3. Roett (2020) Am Fam Physician 101(6): 355-61 [PubMed]

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