Genital Ulcers Table

Canadian Guidelines on Sexually Transmitted Infections - Genital Ulcer Disease

Herpes simplex virus (HSV)

Clinical

- multiple vesicular lesions that rupture, become painful shallow ulcers

- constitutional symptoms/lymphadenopathy

- atypical presentation includes: fissures, furuncles, patchy erythema, linear ulcerations or excoriations. Also consider HSV if lesions on lower abdomen, buttocks or thighs.

- Increased incidence of HSV-1 genital ulcers.

Diagnosis

- Ulcer scraping/vesicular lesion for Herpes PCR. Unroof vesicle, rotate sterile Dacron/rayon swab firmly in base of lesion. Sample more than 1 lesion. Insert swab in viral transport medium.

Syphilis

Clinical

- typically single painless well demarcated ulcer (chancre) with clean base/indurated border

- may be multiple/painful (up to 30% co-infected with HSV)

Diagnosis

- Serology (nontreponemal and treponemal tests) ± syphilis PCR (where available).

Chancroid

Clinical

- nonindurated, painful with serpiginous border, friable base covered with necrotic/purulent exudate

- tender, suppurative unilateral inguinal lymphadenopathy

- extremely rare in Canada - no reported cases in Alberta in the last 20 years

Diagnosis

- only test for chancroid if syphilis and HSV negative and epidemiologic exposure (i.e. appropriate travel history or contact with a traveler).

- Gram stain of lesion - Gram negative slender rod/ coccobacilli in "school of fish" pattern.

- H. ducreyi culture or PCR - consult microbiologist.

Lymphogranuloma venereum (LGV)

Clinical

- small shallow painless genital/rectal papule or ulcer

- no induration

- unilateral tender inguinal/femoral lymphadenopathy

- rectal bleeding/pain/discharge

- ulcerative proctitis

- extremely rare in Canada - no reported cases in Alberta in the last 20 years

Diagnosis

- only test for LGV if syphilis and HSV negative and epidemiologic exposure (i.e. appropriate travel history or contact with a traveler).

- NAAT for Chlamydia

- Positive Chlamydia NAAT can be sent for typing for LGV serovars L1, L2, L3 - consult microbiologist.

Granuloma inguinale (donovanosis)

Clinical

- persistent painless beefy red (highly vascular) papules/ulcers; may be hypertrophic/necrotic/sclerotic

- +/- subcutaneous granulomas

- no lymphadenopathy

- extremely rare in Canada - no reported cases in Alberta in the last 20 years

Diagnosis

- only test for donovanosis if syphilis and HSV negative and epidemiologic exposure (i.e. appropriate travel history or contact with a traveler).

- Intracytoplasmic Donovan bodies on Wright stain or positive Giemsa stain

- Biopsy of lesion

- Consult microbiologist

Behcet's syndrome

Clinical

- recurrent aphthous ulcers (> 3 per year) in association with recurrent genital ulcers +/- eye lesions (uveitis)/cutaneous lesions (erythema nodosum)

Diagnosis

- Rheumatoid factor/antinuclear antibody testing

- Biopsy demonstrating diffuse arteritis/venulitis.

- Consult rheumatologist

Drug eruptions

Clinical

- Ulcers resolve with discontinuation of drug (NSAIDS, antimalarials, ACE inhibitors, B-blockers, lithium, salicylates, corticosteroids)

Diagnosis

- Careful drug history

- Symptoms resolve when offending agent discontinued.