Genital ulcers are among the most common lesions seen with many causes to consider.

• Herpes simplex.

• Syphilis.

• Chancroid.

• Lymphogranuloma venereum.

• Granuloma inguinale (Donovanosis).

Genital ulcers have assumed even more importance in recent years because of HlV - they can provide an opening for introduction of the virus into the circulation therefore leading to HIV infection. You should always consider HIV as a possible hidden presence anytime you are seeing patients with STDs but particularly in patients with genital ulcers.

Herpes simplex virus (HSV)

Clinical manifestations
HSV often begins as a systemic illness with fever, headache, malaise, myalgias, and aseptic meningitis. The genital lesions will usually be painful. In untreated cases, symptoms can last 3-4 weeks in the initial infection. In recurrent episodes, pain and systemic symptoms are usually much less severe and usually last less than 2 weeks. The illness tends to be worse in women in most cases.

Ulcer characteristics
A HSV infection usually occurs as grouped ulcers or vesicles on an erythematous base and are painful and tender in most cases. Atypical appearances are common and a history of previous similar lesions can often be an aid in diagnosis.

Diagnostic tests
Perform a Tzanck smear of ulcer and obtain viral cultures. Consider empirically treating the patient.

Treatment
Acyclovir 200 mg orally, 5/day for 10 days. For patients with frequent recurrences (>6 times/year) consider prescribing suppressive therapy in the form of Acyclovir 200 mg TID or 400 mg BID for 6 months. Consider tailoring the therapy by decreasing the medication amount to the lowest effective dose.

Clinical manifestations
The initial or primary stage of this multistage illness consists of a painless ulcer (may not even be noticed by the patient) which heals in 2-3 weeks. Approximately 25 percent of patients will develop the secondary stage (weeks to months after the primary stage) which consists of fever, malaise, rash, and lymphadenopathy. These signs and symptoms usually resolves spontaneously. About 20 percent of patients will develop the tertiary stage (years after the primary stage) of this illness and this can take 1 of 3 forms: cardiovascular, neuro, or gummas.

Ulcer characteristics
Syphilitic ulcers are usually single and painless, have a clean base, and are almost circular with indurated, sharp margins.

Diagnostic testing
This includes darkfield examination (pathology or dermatology can do this). Serological tests are specific and confirmatory (MHA-TP), and others are non-specific (VDRL and RPR).

• Primary: Benzathine penicillin G 2.4 million units IM x 1.

• Secondary: Same as for primary or procaine penicillin G 2.4 million units every day for 10 days.

• Tertiary: Hospitalize for high dose IV penicillin administration.

• Latent: Benzathine penicillin G, 2.4 million units IM every week x 3 (perform an LP to rule out neurosyphilis).

Penicillin allergic patients
For those allergic to penicillin, use Tetracycline 500 mg QID for 15 days for primary syphilis and 30 days for secondary syphilis.

Clinical manifestations
Chancroid usually presents with a painful ulcer and significant inguinal lymphadenitis and if untreated, may progress to severe tissue damage and scarring. If untreated, the ulcer can persist for 30 or more days. The lymph nodes often suppurate and require drainage. All features are less common in women who often have asymptomatic illness.

Ulcer characteristics
They are usually painful and tender with ragged undermined edges, sharply demarcated and with a necrotic base.

Diagnostic tests
Perform a gram's stain (small GNR, parallel school of fish alignment), a DFA, or culture of the material from the ulcer or bubo.

Treatment
Ceftriaxone 250 mg IM x 1 or Erythromycin 500 mg PO QID x 7 days.