Introduction
Genital ulcers are among the most common lesions seen with many causes to consider.
Genital ulcers
Genital ulcers have assumed even more importance in recent years because of HlV -
they can provide an opening for introduction of the virus into the circulation therefore
leading to HIV infection. You should always consider HIV as a possible hidden presence
anytime you are seeing patients with STDs but particularly in patients with genital
ulcers.
Herpes simplex virus (HSV)
Clinical manifestations
HSV often begins as a systemic illness with fever, headache, malaise, myalgias, and
aseptic meningitis. The genital lesions will usually be painful. In untreated cases,
symptoms can last 3-4 weeks in the initial infection. In recurrent episodes, pain and
systemic symptoms are usually much less severe and usually last less than 2 weeks. The
illness tends to be worse in women in most cases.
Ulcer characteristics
A HSV infection usually occurs as grouped ulcers or vesicles on an erythematous base and
are painful and tender in most cases. Atypical appearances are common and a history of
previous similar lesions can often be an aid in diagnosis.
Diagnostic tests
Perform a Tzanck smear of ulcer and obtain viral cultures. Consider empirically
treating the patient.
Treatment
Acyclovir 200 mg orally, 5/day for 10 days. For patients with frequent recurrences
(>6 times/year) consider prescribing suppressive therapy in the form of Acyclovir 200
mg TID or 400 mg BID for 6 months. Consider tailoring the therapy by decreasing the
medication amount to the lowest effective dose.
Syphilis - Etiologic agent: Treponema pallidum
Clinical manifestations
The initial or primary stage of this multistage illness consists of a painless ulcer
(may not even be noticed by the patient) which heals in 2-3 weeks. Approximately 25
percent of patients will develop the secondary stage (weeks to months after the primary
stage) which consists of fever, malaise, rash, and lymphadenopathy. These signs and
symptoms usually resolves spontaneously. About 20 percent of patients will develop the
tertiary stage (years after the primary stage) of this illness and this can take 1 of 3
forms: cardiovascular, neuro, or gummas.
Ulcer characteristics
Syphilitic ulcers are usually single and painless, have a clean base, and are almost
circular with indurated, sharp margins.
Diagnostic testing
This includes darkfield examination (pathology or dermatology can do this).
Serological tests are specific and confirmatory (MHA-TP), and others are non-specific
(VDRL and
RPR).
Treatment
Penicillin allergic patients
For those allergic to penicillin, use Tetracycline 500 mg QID for 15 days for primary
syphilis and 30 days for secondary syphilis.
Chancroid - Etiologic agent: Haemophilus ducreyi
Clinical manifestations
Chancroid usually presents with a painful ulcer and significant inguinal lymphadenitis
and if untreated, may progress to severe tissue damage and scarring. If untreated, the
ulcer can persist for 30 or more days. The lymph nodes often suppurate and require
drainage. All features are less common in women who often have asymptomatic illness.
Ulcer characteristics
They are usually painful and tender with ragged undermined edges, sharply demarcated
and with a necrotic base.
Diagnostic tests
Perform a gram's stain (small GNR, parallel school of fish alignment), a
DFA, or
culture of the material from the ulcer or bubo.
Treatment
Ceftriaxone 250 mg IM x 1 or
Erythromycin 500 mg PO QID x 7 days.
Lymphogranuloma venereum (LGV) - Etiologic
agent: Chlamydia trachomatis (serovariants L1, L2, L3)
Clinical manifestations
LGV usually begins as a small painless ulcer that heals spontaneously. Later, tender
inguinal buboes form (often above and below the inguinal ligament causing the groove sign)
which may suppurate accompanied by fever and malaise. Spontaneous rupture of the buboe
relieves the pain. The lesions heal slowly over months with pronounced tissue and
lymphatic scarring leading to deformity and genital lymphedema (genital elephantiasis).
Urethral and rectal strictures as well as fistulas can be seen.
Ulcer characteristics
These ulcers are usually small painless lesions with variable appearance (papule,
ulcer, or vesicle) and often disappear by the time the patient presents with symptoms.
Primary infection can also present as a urethritis without a local skin lesion.
Diagnostic tests.
LGV serology titers
- should see > 1:64, a 4-fold rise usually is not seen. Also
can see characteristic histopathological changes. Growth of the organism is usually not
practical.
Treatment.
Doxycycline 100 mg PO BID x 21 days or
Erythromycin500 mg PO QID x 21 days. Both
regimens may need to be continued longer if patient is not healing well.
Granuloma Inguinale or Donovanosis - Etiologic agent:
Calymmatobacterium granulomatis
Clinical manifestations
This disease begins as single or multiple small subcutaneous lesions which erode
through the skin. The lesions continue to expand outward with destruction of normal
tissue. They heal slowly over months with scarring and deformity.
Ulcer characteristics
These are sharply demarcated, painless, and friable with a beefy red granulation
tissue appearance. The appearance is similar to cancer in some cases.
Diagnostic tests
Crush preparation examination and histopathology.
Treatment
Doxycycline100 mg PO BID or Septra DS 1 PO BID until all lesions are healed.
General Principles
-
Try to obtain the exact diagnosis.
-
Consider all of the alternatives.
-
Check for other STDs such as nonulcer forming conditions and especially HIV.
-
Refer to a specialist if the patient does not improve in a timely manner.
Prepared by LCDR Mark Anderson, MC, USN, Naval Medical Center San Diego, San
Diego, CA.
Approved for public release; Distribution is unlimited.
