Infectious genital ulcers
Infectious genital ulcers are caused chiefly by herpes simplex virus and syphilis in the United States, with chancroid, lymphogranuloma venereum, and granuloma inguinale as less common causes, distinguished by ulcer pain, number, and associated lymphadenopathy, and worked up with an ordered panel of HSV NAAT, syphilis serology or darkfield, and targeted testing since a substantial minority of ulcers have no identified cause and empiric therapy is often required.
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What this article covers
- Overview
A clinical syndrome with several distinct infectious causes, not a single disease: genital ulcers most commonly result from herpes simplex virus (HSV) or Treponema pallidum (syphilis) in the United…
- Epidemiology
HSV is now a leading cause of symptomatic genital ulcer disease in some populations: in young heterosexual women and MSM (men who have sex with men), HSV-1 has become a more common cause than in the past.
- Risk factors
Unprotected sexual contact with an infected partner: the shared root risk factor across all causes.
- Pathophysiology
HSV causes painful vesicles that rapidly ulcerate: primary infection produces multiple painful papules that progress to vesicles, then ulcerate, crust, and heal over 2 to 3 weeks, with lifelong ganglionic latency and periodic reactivation.
- Clinical features
Herpes simplex virus: multiple painful lesions beginning as erythematous papules that progress to vesicles, then ulcers, often with tender inguinal lymphadenopathy and, in primary infection, fever…
- Differential diagnosis
Herpes simplex virus: Herpes simplex virus HSV causes multiple painful vesicles/ulcers with tender lymphadenopathy, confirmed by NAAT rather than type-specific serology.
- Diagnosis
First, no single criteria set diagnoses "genital ulcer disease" as a whole; each cause is confirmed by a pathogen-specific test, applied in the ordered evaluation below: the cause is established by…
- Management
First, treat empirically for the most likely cause based on presentation and local epidemiology while confirmatory tests are pending, then adjust once results return.
- Complications
Increased HIV acquisition and transmission risk: any open genital ulcer disrupts the mucosal barrier and raises both susceptibility to and infectiousness for HIV.
- Prognosis
Excellent with prompt therapy for the bacterial causes: syphilis, chancroid, LGV, and granuloma inguinale respond well to first-line regimens when treated before complications develop.
- Prevention
Consistent condom use lowers but does not eliminate transmission risk, since HSV and syphilis can spread from skin not covered by a condom.
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Related articles
- Syphilis (Treponema pallidum infection)
Syphilis is a sexually transmitted infection with the spirochete Treponema pallidum that progresses through painless chancre (primary), disseminated rash and condyloma lata (secondary), latent, and tertiary stages including neurosyphilis, diagnosed by paired nontreponemal and treponemal serology and treated with a single dose of intramuscular benzathine penicillin G for early disease.
- Herpes simplex virus (HSV) infection
Herpes simplex virus type 1 or 2 establishes lifelong latency in sensory ganglia after mucocutaneous infection, causing painful vesicular-to-ulcerative outbreaks of the mouth or genitals with intermittent asymptomatic shedding; diagnosis is by NAAT of an ulcer swab and treatment is oral nucleoside analogues, escalating to intravenous acyclovir for encephalitis, severe mucocutaneous disease, or disseminated infection in immunosuppressed hosts.
- Chlamydia trachomatis infection
Chlamydia trachomatis is the most commonly reported bacterial sexually transmitted infection in the United States, frequently asymptomatic, and diagnosed by nucleic acid amplification testing of urine or genital/rectal/oropharyngeal swabs. Uncomplicated genital infection is treated with a single dose of azithromycin or a course of doxycycline, complications include pelvic inflammatory disease and epididymitis, and LGV serovars require a 21-day course and are an increasing cause of proctitis.
- Condyloma acuminata (anogenital warts)
Condyloma acuminata are soft, verrucous anogenital warts caused chiefly by human papillomavirus types 6 and 11, diagnosed clinically on inspection, and treated with patient-applied imiquimod or podofilox or provider-administered trichloroacetic acid or cryotherapy, with 9-valent HPV vaccination as the primary prevention.
- Human papillomavirus (HPV) infection
Human papillomavirus is a nonenveloped DNA virus with low-risk types (6, 11) that cause warts and high-risk types (16, 18, and others) that drive cervical, anal, vulvar, penile, and oropharyngeal cancer, prevented by 9-valent vaccination and managed by type-specific screening rather than treatment of the virus itself.
- Pelvic inflammatory disease
Pelvic inflammatory disease is an ascending polymicrobial infection of the upper female genital tract, most often caused by Neisseria gonorrhoeae, Chlamydia trachomatis, or Mycoplasma genitalium, diagnosed clinically on uterine, adnexal, or cervical motion tenderness. Most women are treated as outpatients with a single dose of ceftriaxone plus 14 days of doxycycline, while parenteral cefotetan or cefoxitin plus doxycycline, or clindamycin plus gentamicin, is reserved for hospitalized patients, with tubo-ovarian abscess and infertility among the major complications of delayed treatment.