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)

  • Genital herpes simple virus (HSV)
  • Syphilis
  • Chancroid
  • Lymphogranuloma venereum
  • Granuloma inguinale (donovanosis)
  • Fungal infection (eg. candida)
  • Secondary bacterial infection

Non-infectious (less common)

  • Behcet syndrome
  • Fixed drug eruption
  • Psoriasis
  • Sexual trauma
  • Wegener granulomatosis

Primary HSV

  • Primary Lesion: Vesicle, papule,ulcers, typically bilateral
  • Border: Erythematous,"punched out"
  • Depth: Superficial
  • Base: Red and smooth
  • Secretion: Serous
  • Number of Lesions: Bilateral, multiple, extensive lesion may coalesce
  • Induration: None
  • Pain: Common
  • Itching: Common
  • Lymph Nodes: Tender, firm, bilateral inguinal adenopathy
  • Incubation Period: 2-14 days
  • Time Course: 21 days
  • Diagnostic Test: Viral culture

Recurrent HSV

  • Primary Lesion: Grouped vesicles, papules, ulcers, typically unilateral
  • Border: Erythematous,"punched out"
  • Depth: Superficial
  • Base: Red and smooth
  • Secretion: Serous
  • Number of Lesions: Usually unilateral; labia, penis, scrotum, buttocks, perianal
  • Induration: None
  • Pain: Common, less severe
  • Itching: Common
  • Lymph Nodes: Lymphadenopathy, uncommon, unilateral
  • Incubation Period: Recurrence within 6-9 months of primary infection
  • Time Course: 7-10 days
  • Diagnostic Test: 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.

Syphilis

  • Primary Lesion: Ulcer, papule
  • Border: Sharply demarcated
  • Depth: Superficial
  • Base: Red and smooth
  • Secretion: Serous
  • Number of Lesions: Vulva, penis, anal perianal, oral
  • Induration: Firm
  • Pain: Rare
  • Itching: Rare
  • Lymph Nodes: Nontender, firm, enlarged
  • Incubation Period: 10-90 days
  • Time Course: 2-3 weeks
  • Diagnostic Test: Darkfield microscopy, FTA-ABS, VDRL, RPR and DFA-TP

Chancroid

  • Primary Lesion: Ulcer, papule
  • Border: Violaceous, undermined
  • Depth: Excavated
  • Base: Yellow to gray exudate
  • Secretion: Purulent to hemorrhagic
  • Number of Lesions: Penis, vulva
  • Induration: Rare, usually soft
  • Pain: Often
  • Itching: Rare
  • Lymph Nodes: Tender, enlarged, may suppurate
  • Incubation Period: 1-14 days
  • Time Course: 2-3 weeks
  • Diagnostic Test: Culture of Haemophilus ducreyi; Gram stain of pus aspirate from lymph node

LGV

  • Primary Lesion: Papule, pustule, ulcer
  • Border: Variable
  • Depth: Superficial
  • Base: Variable
  • Secretion: Variable
  • Number of Lesions: Urethra, cervix, rectum
  • Induration: None
  • Pain: Variable
  • Itching: Rare
  • Lymph Nodes: Inguinal and femoral lymphadenopathy: tender, may suppurate
  • Incubation Period: 3-21 days
  • Time Course: 1-2 weeks
  • Diagnostic Test: Isolation of Chlamydia trachomatis from urethra, cervix, rectum or lymph node aspirate; complement fixation serology ≥ 1/64

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

References

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