GENITAL ULCERS

JALI GARZA
HOW TO APPROACH?

Almost all genital ulcers caused by sexually transmitted diseases. Which one is the cause?

Important points:
Get a thorough sexual history!!
Painful or painless?
Multiple ulcers or one single ulcer?
Has this ever happened before?
Associated lymphadenopathy?
History of travel or sexual encounter with someone who has recently traveled?
Co-infection with another STD?
HERPES SIMPLEX
Most common cause in the US.

Can be caused by HSV-1 or HSV-2, recurrences less common with HSV-1.

Usually painful with lymphadenopathy common. 1 or more lesions.

Infection is lifelong and incurable.

Mother acquiring herpes for first time at the end of pregnancy is the greatest risk to baby.

Diagnostic testing:
Isolation of HSV in cell culture and PCR
Viral culture isolates should be typed to determine HSV 1 or 2
Treatment:
acyclovir (400 mg three times daily), famciclovir (250 mg three times daily) and 
valacyclovir (1000 mg twice daily) for 7-10 days
SYPHILIS
Second most common cause in US

Primary syphilis: Single, painless ulcer

Will go away on its own without treatment, but syphilis can progress.

Diagnostic testing:
Nontreponemal testing is commonly used for serologic screening for syphilis. Venereal Disease
Research Laboratory (VDRL), Rapid Plasma Reagin (RPR). These must be confirmed with
Specific treponemal test (FTA-ABS).
Directly through visualization of spirochetes by darkfield microscopy or direct
immunofluorescence.
Treatment:
IM Benzathine Penicillin
LESS COMMON CAUSES: CHANCROID, LGV, GI
Chancroid: Painful genital ulcer and tender suppurative inguinal adenopathy
Commonly associated with HIV co-infx
Clinical diagnosis with negative syphilis and Herpes testing
Treatment: azithromycin (1 gram PO) or ceftriaxone (250 mg IM)

LGV: Vesicle or ulcer with inguinal or femoral lymphadenopathy

Africa, India, parts of Southeast Asia, and the Caribbean
Positive test for Chlamydia trachomatis after clinical suspicion.
Treat with Doxy

Granuloma Inguinale: Painless, raised, red lesions that bleed easily.

Klebsiella causative agent.
India, Papua New Guinea, the Caribbean, South America, and Australia
Donovan bodies diagnostic
NON-INFECTIOUS CAUSES

Fixed drug reactions (antibiotics, antiepileptics, nonsteroidal anti-

inflammatory agents, sildenafil, and phenothiazines)
Behçet’s disease (Genital ulcers, apthous ulcers, uveitis)
Neoplasms (squamous cell carcinoma)
Trauma (sexual abuse, burns)