GENITAL ULCER DISEASE

Genital ulcer syndrome is one of the commonest syndromes that affect men and women. Single or multiple ulcers can be present.

Causes

Multiple organisms can cause genital sores, commonly:

  • Treponema pallidum bacteria: syphilis
  • Herpes simplex virus: genital herpes
  • Haemophilus ducreyi: Chancroid
  • Donovania granulomatis: Granuloma inguinale
  • Chlamydia strains: lymphogranuloma venerium (LGV)

Clinical features

Mixed infections are common

  • Primary syphilis: the ulcer is at first painless and may be between or on the labia or on the penis
  • Secondary syphilis: multiple, painless ulcers on the penis or vulva
  • Genital Herpes: small, multiple, usually painful blisters, vesicles, or ulcers. Often recurrent
  • Granuloma inguinale: an irregular ulcer which increases in size and may cover a large area
  • Chancroid: multiple, large, irregular ulcers with enlarged painful suppurating lymph nodes

Differential diagnosis

  • Cancer of the penis in elderly men
  • Cancer of the vulva in women >50 years

Investigations

  • Swab: for microscopy
  • Blood: for VDRL/TPR

Management

Multiple painful blisters or vesicles: likely herpes

  • Aciclovir 400 mg every 5 hours for 7 days
  • If RPR positive add Benzathine penicillin 2.4 MU IM single dose (half in each buttock)
  • If lesions persist, repeat acyclovir for 7 days

All other cases

  • Ciprofloxacin 500 mg every 12 hours for 3 days plus Benzathine penicillin 2.4 MU IM single dose (half into each buttock)
  • In penicillin allergy, give Erythromycin 500 mg every 6 hours for 14 days

If ulcer persists >10 days and partner was treated

  • Add Erythromicin 500 mg every 6 hours for 7 days

If ulcer still persists

  • Refer for specialist management

Note

  • Negative RPR does not exclude early syphilis
  • Genital ulcers may appear with enlarged and fluctuating inguinal lymph nodes (buboes). Do not incise buboes