Genital Ulcers

DDx

Sexual (most common)

• HSV1/2 (95% of genital ulcers)
  • Painful vesicles on erythematous base
• Chancroid (Haemophilis ducreyi)
  • Painful, single or multiple necrotizing ulcers
• Syphilis (Treponema pallidum)
  • Painless papule evolving to chancre, indurated with serous exudates
  • Most cases single ulcer with smooth margin/base
• Lymphogranuloma venereum (Chlamydia trachomatis)
  • Painless papule which may ulcerate, followed weeks later by tender lymphadenopathy ("buboes")
    • MSM characterized by proctocolitis
• Granuloma inguinale / Donovanosis (Klebsiella granulomatis)
  • Painless progressive enlarging ulcer(s), beefy red, friable, with rolled margins
• Primary HIV
  • Painful ulcer (can also be oral, esophageal, anal), fever, flu-like illness

Non-Sexual

• Infectious
  • Bacterial (Staph, Strep, Pseudomonas, Mycoplasma, Salmonella, Lyme)
  • Viral (EBV, CMV, HZV, Influenza, Parvovirus, Paramyxovirus, Mumps)
  • Fungal (candida)
  • Parasitic (Toxoplasma, scabies)
• Malignancy (SCC)
• Drug / Fixed drug eruption
  • NSAIDs
  • Imiquimod
  • Hydroxyurea
  • Hydralazine

History

• Sexual history
  • Exposure last 90 days
  • Sites of contact
  • Travel
  • History of STIs
  • Drugs/alcohol/high-risk behaviours
• Painful (HSV, chancroid)
• Painless (syphilis, LGV, granuloma inguinale)
• Urinary symptoms (concomitant urethritis)
• Constitutional symptoms
• Recurrent episodes (HSV, Behçet syndrome, drug)

Physical Exam

• Oral, rectal
• Genital/urethral exam
• Hepatomegaly
• Lymphadenopathy
  • Tender (HSV, chancroid, LGV)
  • Non-tender (late primary syphilis)
  • Significant inguinal, cervical, axillary (HIV)

Investigations

• STI screen (HIV, Syphilis, Gono/chlam)
• HSV PCR (or viral culture, or direct fluorescent antibody)

Treatment

• Avoid sexual intercourse
• Consistent barrier contraception for prevention
• Consider empiric treatment for HSV
  • May consider empiric treatment for other genital ulcer diseases in certain cases (eg. poor follow-up) after consulting with specialist
• Consider early referral/follow-up in atypical, immunosuppressed, travel, systemic disease
• Treat partners except for HSV

Specific Treatment

• HSV
  • Acyclovir 400mg PO TID x 7-10d
• Chancroid
  • Azithromycin 1g PO x1 or Ceftriaxone 250mg IM x1
• Syphilis
  • Pen G 2.4 million units IM
  • Re-test for syphilis
• LGV
  • Doxycycline 100mg PO BID x 21d
• Granuloma inguinale
  • Azithromycin 1g PO weekly or 500mg PO daily until lesions have healed (minimum 3 weeks)