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STD: Genital Ulcers
COL Naomi Aronson, MC, USAIntroduction: Genital ulcers have a wide variety of sexually transmitted causes. Chancroid, caused by
Hemophilus ducreyi, has been associated with an increased risk for HIV transmission and may co-exist with
other causes of genital ulcer (such as herpes infection). The incubation period is 3-7 days. Granuloma
inguinale (caused by gram-negative Calymmatobacterium granulomatis) causes beefy red granulomas that
progress slowly but can cover the genitalia and heal slowly with scarring. Patients can spread lesions to
other areas through autoinoculation. Incubation period is 1-12 weeks. Lymphogranuloma venereum (LGV),
caused by variants of Chlamydia trachomatis, starts as a painless vesicle or nodule that then ulcerates and
heals. Days to weeks later, regional lymph nodes become inflamed and tender. Suppuration, scarring,
systemic infection, chronic elephantiasis and rectal strictures have been seen in untreated infection. Caused
by Treponema pallidum, syphilis is known as the “great imitator”. Left untreated, up to 1/3 of patients will
develop tertiary syphilis (CNS infection, aortic aneurysm, gummas of the skin, bone and visceral organs).
Syphilis is curable in all stages but treatment may yield a Jarisch-Herxheimer reaction with fever, rigors and
intensification of the lesions 2-24 hours after initiating treatment. Incubation period of primary stage syphilis
is 10 days to 3 months. Herpes is caused by Herpes simplex (HSV) type 1 and 2, both of which can
cause genital ulcers. HSV 1 is usually milder and often associated with oral sores, “fever blister” (see Color
Plates Picture 10), keratoconjunctivitis and encephalitis. HSV 2 causes a more severe initial episode (fever,
exudative pharyngitis, toxic appearance, multiple genital lesions), and then recurs as a localized cluster of
vesicles that ulcerate painfully. HSV2 is associated with aseptic meningitis and radiculitis. Vaginal delivery in
pregnant women with active genital infection poses a high risk to her newborn (disseminated HSV and death).
The incubation period for HSV is 2-12 days after exposure.
Geographic Associations: Herpes simplex virus and syphilis are worldwide. Chancroid is especially seen in
Africa and Asia and is the most frequent cause of genital ulcer in the tropics. LGV is most prevalent in tropical
and sub-tropical countries. Granuloma inguinale is most often associated with exposure in India, Australia,
South Pacific, Brazil and South Africa.
Subjective: Symptoms
Painless ulcer: Syphilis, LGV, granuloma inguinale (Donovanosis)
Painful ulcer: Herpes simplex, chancroid, phagedenic ulcer (an otherwise painless ulcer secondarily infected
with bacteria)
Constitutional: Acute (1-3 days): Fever (in LGV and 1st episode HSV)
Specific: Acute (1-3 days): Generally starts as papule that ulcerates, HSV: Paresthesias can precede
outbreak, syphilis: rash including palms and soles Chronic (>1 month): LGV may be very chronic, HSV
often recurs
Focused History: Have you had this symptom before? (HSV is often recurrent in same area) Is the sore
painful? (see differential diagnosis) Did the sore start out as a painless ulcer then become more painful?
(possible phagedenic ulcer) How long has the genital sore been present? (HSV usually resolves in ten days,
syphilis in 3-6 weeks; others can be less likely to resolve without specific therapy.)
Objective: Signs
Inspection
HSV: Acute (1-3 days): Vesicles in clusters, 1st time may have fever Sub acute (3-10 days): Shallow
painful ulcer (often multiple) Chronic (>1 month): In AIDS patients- huge non-healing ulcers
Chancroid: Acute (1-3 days): Papules Sub acute (3-10 days): Painful, shaggy edged, deep ulcers;
suppurative regional adenopathy Chronic (>1 month): Phimosis
Granuloma Inguinale: Acute (1-3 days): Bright red, painless, satiny-surface, raised plaque, often in folds
between scrotum or labia and thighs Sub acute (3-10 days): The border of the ulcer shows rolled edge
LGV: Acute (1-3 days): Painless vesicle or nodule that ulcerates and heals; may have fever Sub acute (3-10
days): Groove sign (lymph node adheres above and below inguinal ligament) Chronic (>1 month): Chronic
elephantiasis of genitals, rectal strictures, rectal fistula