Genital ulcers
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"genital ulcer" AND diagnosis
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CDC genital ulcer disease STI treatment guidelines 2021 syphilis herpes chancroid
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https://www.cdc.gov/mmwr/volumes/70/rr/rr7004a1.htm
Genital ulcers are breaks in the skin or mucosa of the vulva, vagina, penis, scrotum, anus, or perianal area. They may be sexually transmitted, but not always.
Common causes
| Pattern | More likely cause |
|---|---|
| Painful clusters of blisters that become shallow ulcers, often recurrent | Genital herpes, HSV-1 or HSV-2 |
| Single painless, firm/indurated ulcer with a clean base | Primary syphilis |
| Deep, painful ulcer with ragged or undermined edges, sometimes tender swollen groin nodes | Chancroid, Haemophilus ducreyi |
| Small transient ulcer followed by painful groin lymph nodes or proctitis | Lymphogranuloma venereum, LGV |
| Slowly enlarging, painless, beefy-red ulcer that bleeds easily | Donovanosis, rare in many regions |
| Recurrent oral and genital ulcers, sometimes eye or joint symptoms | Behçet disease |
| Other non-STI causes | Trauma, aphthous ulcers, fixed drug eruption, inflammatory disease, or cancer |
HSV and syphilis cause most genital ulcers in many high-income settings. Appearance can guide the differential, but examination alone is often inaccurate. Berek & Novak’s Gynecology, p. 821-822.
What evaluation is needed
Anyone with a new genital, anal, or perianal ulcer should be assessed promptly. Typical tests include:
- Swab of the lesion for HSV-1/HSV-2 PCR/NAAT
- Syphilis blood tests, usually both a nontreponemal test such as RPR/VDRL and a treponemal test
- HIV test
- Testing for chancroid where it is locally prevalent
- Pregnancy test when relevant
- Biopsy or specialist referral if ulcers are atypical, persistent, or do not improve
The CDC ulcer-disease guidance advises testing all patients with genital ulcers and treating suspected infectious syphilis or a first herpes episode without waiting for results when clinical suspicion is high.
Until seen
- Avoid oral, vaginal, and anal sexual contact until evaluated and lesions are healed.
- Do not apply steroid, antibiotic, or “wart-remover” creams unless prescribed.
- Avoid touching lesions, wash hands if contact occurs, and do not share sex toys.
- Tell recent sexual partners if an STI is diagnosed so they can be tested and treated.
Seek same-day care if this is a first episode, you are pregnant, have fever, severe pain, difficulty passing urine, rapidly spreading sores, eye symptoms, or immunosuppression. Genital ulcers can raise the likelihood of acquiring or transmitting HIV. Harrison’s Principles of Internal Medicine, p. 1150.
If you mean that you currently have an ulcer, please arrange an in-person sexual-health or clinician visit as soon as possible, ideally while the lesion is still present for swab testing.
Treatment of chancroiid
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chancroid treatment
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CDC Chancroid STI Treatment Guidelines recommended regimens azithromycin ceftriaxone ciprofloxacin erythromycin
Chancroid is treated with one of the following antibiotic regimens, prescribed after clinical assessment and testing for other causes of genital ulcers:
- Azithromycin 1 g orally once, or
- Ceftriaxone 250 mg intramuscularly once, or
- Ciprofloxacin 500 mg orally twice daily for 3 days, or
- Erythromycin base 500 mg orally three times daily for 7 days.
These are the CDC recommended regimens. Ciprofloxacin should not be used during pregnancy or breastfeeding.
Additional management
- Test for syphilis, herpes simplex virus, and HIV, since co-infections or an alternative diagnosis are possible.
- Avoid sexual contact until ulcers have completely healed.
- Recent sex partners should be examined and treated, even if asymptomatic, if sexual contact occurred during the 10 days before symptom onset.
- Reassess in 3 to 7 days. Symptoms should improve in about 3 days and ulcers objectively improve within 7 days. Large ulcers can take more than 2 weeks to heal.
- Tender fluctuant groin lymph nodes or buboes may need needle aspiration or drainage by a clinician.
- People with HIV may heal more slowly and have a higher risk of treatment failure, so need close follow-up.
Do not self-treat a genital ulcer based solely on appearance. Chancroid is uncommon in many countries, and herpes or syphilis are more frequent causes.
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