Genital Ulcer

1. See Also
   1. Sexually Transmitted Disease
2. Causes: Young sexually active patients in the United States
   1. Most Common
      1. Genital Herpes (60-70% of Genital Ulcers)
      2. Syphilis (10-20% of Genital Ulcers)
   2. Less common
      1. Chancroid
      2. Fixed Drug Eruption
   3. Rare
      1. Lymphogranuloma venereum
      2. Granuloma Inguinale (Donovanosis)
      3. Bacterial infection
      4. Fungal infection
      5. Behcet's Disease
3. 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
4. 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
5. 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. Wegener granulomatosis
   8. Excoriations
   9. Fixed Drug Eruption
   10. Behcet's Disease
6. History
   1. Sexual History
      1. Possible Sexually Transmitted Disease exposure
      2. Men who have sex with men
         1. Lymphogranuloma venereum
         2. Syphilis
   2. Medications recently started or changed
      1. Fixed Drug Eruption
   3. Medical History
      1. Behcet Syndrome
         1. Frequent Aphthous Ulcers or known HLA-B51/B5 carrier
      2. Psoriasis
         1. Increases risk of Genital Ulcers after medication or trauma exposure
7. Signs
   1. Genital Herpes
      1. Vessicle
         1. Multiple vesicular lesions on foreskin, labia, vagina or anus
      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
      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 (Aphthous Ulcer) and Genital Ulcers
         2. Genital Ulcers scar in more than half of cases
8. 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 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. Gonorrhea Test (Gonorrhea PCR)
      4. Hepatitis B Surface Antigen
9. 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. 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
10. Resources
    1. CDC - Genital Ulcers
       1. http://www.cdc.gov/std/treatment/2010/genital-ulcers.htm
11. References
    1. Gomes (2007) Braz J Infect Dis 11(2):254-60.
    2. Roett (2012) Am Fam Physician 85(3): 254-62