Genital Ulcers

Author: Michelle Lin, MD
Updated: 5/4/2012

Genital Ulcers

  • Leading causes in the US: HSV types 1 and 2 (most common) > syphilis > chancroid
  • Note: 10% of chancroid are coinfected with syphilis or HSV

Differential diagnosis of genital ulcers

Infectious (more common) Non-infectious (less common)
Genital herpes simple virus (HSV) Behcet syndrome
Syphilis Fixed drug eruption
Chancroid Psoriasis
Lymphogranuloma venereum Sexual trauma
Granuloma inguinale (donovanosis) Wegener granulomatosis
Fungal infection (eg. candida)
Secondary bacterial infection

National Coalition of STD Director Fact Sheets From “The Practitioner’s Handbook for the Management of STDs” (4th ed, 2007):

Primary HSV Recurrent HSV Syphilis Chancroid LGV
Primary lesion Vesicle, papule,ulcers, typically bilateral Grouped vesicles, papules, ulcers, typically unilateral Ulcer, papule Ulcer, papule Papule, pustule, ulcer
Border Erythematous,"punched out" Erythematous,"punched out" Sharply demarcated Violaceous, undermined Variable
Depth Superficial Superficial Superficial Excavated Superficial
Base Red and smooth Red and smooth Red and smooth Yellow to gray exudate Variable
Secretion Serous Serous Serous Purulent to hemorrhagic Variable
Number of Lesions Bilateral, multiple, extensive lesion may coalesce Usually unilateral; labia, penis, scrotum, buttocks, perianal Vulva, penis, anal perianal, oral Penis, vulva Urethra, cervix, rectum
Induration None None Firm Rare, usually soft None
Pain Common Common, less severe Rare Often Variable
Itching Common Common Rare Rare Rare
Lymph Nodes Tender, firm, bilateral inguinal adenopathy Lymphadenopathy, uncommon, unilateral Nontender, firm, enlarged Tender, enlarged, may suppurate Inguinal and femoral lymphadenopathy: tender, may suppurate
Incubation Period 2-14 days Recurrence within 6-9 months of primary infection 10-90 days 1-14 days 3-21 days
Time Course 21 days 7-10 days 2-3 weeks 2-3 weeks 1-2 weeks
Diagnostic Test Viral culture Viral culture is most sensitive, especially once vesicles rupture and ulcerate. If lesions are granulating, HSV cultures may be negative and HSV serology is useful to confirm etiology. Darkfield microscopy, FTA-ABS, VDRL, RPR and DFA-TP Culture of Haemophilus ducreyi; Gram stain of pus aspirate from lymph node Isolation of Chlamydia trachomatis from urethra, cervix, rectum or lymph node aspirate; complement fixation serology ≥ 1/64


  • Roett MA, Mayor MT, Uduhiri KA. Diagnosis and management of genital ulcers. Am Fam Physician. 2012 Feb 1;85(3):254-62. [PubMed]