GENITAL ULCER DISEASE

Genital Ulcer Disease (GUD)

Objectives:

1. Discuss the epidemiology and etiology of GUD.

2. Describe the clinical manifestations according to the etiologic agent involved.

3. Choose the appropriate diagnostic evaluation.

4. Select the appropriate treatment.

5. Discuss the follow-up of patients and the management of sexual partners.

6. List potential complications.

Genital ulcer disease

Definition:

Ulcerative, erosive, pustular or vesicular lesions on the genitalia with or without lymphadenopathy

Etiology

A. STD-related etiologies and organisms:

1. Genital herpes: Herpes Simplex Virus Type 1 and Type 2

2. Primary syphilis: Treponema pallidum var. pallidum

3. Chancroid: Haemophilus ducreyi

4. Lymphogranuloma venereum (LGV): Chlamydia trachomatis serovars L1-L3

5. Granuloma inguinale (Donovanosis): Calymmatobacterium granulomatis

Etiology cont’dB. Non STD-related etiologies:

1. Non-STD infectious causes of GUD: Candidiasis/balanitis, scabies, common skin infections (e.g. Staph).

2. Non-infectious causes of GUD: aphthous ulcers, Behcet’s syndrome, fixed drug eruption, Reiter’s syndrome, trauma/abrasions.

Etilogy cont’d

C. No etiology is found in 20% to 30-50% of GUD cases

- related to the sensitivity of the laboratory tests

. affected by self-medication, . duration of lesion , . technology of the test

EPIDEMIOLOGY

Incidence• In developed countries (In the USA and Europe)

• The most frequent cause of GUD is Herpes (62 %), followed by syphilis (13 % ) then by chancroid (12-20 %) . LGV very rare Donovanosis is almost never encountered in USA • GUD may comprise ~5% STD visits in USA

• Estimated number of GUD (herpes + syphilis +chancroid ) is 1/50th combined number of reported cases of gonorrhea and Chlamydia

Epidemiology cont’d

2. In developing world:

• The most frequent cause of GUD is Chancroid followed by syphilis, then by genital herpes

• There are reports (studies) indicating that HSV is increasing, being the leading cause of GUD

• Granuloma Inguinale – endemic in India, Papua New Guinea, central Australia, Southern Africa and Brazil. • In sub-Saharan Africa and Asia GUD can account for 20%- 70% STD clinic visits.

DIAGNOSTIC APPROACH

Patient history:

1. Lesion history: - prodrome,

- initial presentation (especially presence of vesicles, recurrence) - duration of lesions

- presence of pain & other symptoms

- use of systemic or topical remedies

- any history of similar symptoms in the past

- partners with similar symptoms

2. Medical history: HIV status, skin conditions, drug allergies, medication

3. Sexual history:

Gender of partners

Number of partners (New, etc)

Commercial sex exposure

Partners with signs and symptoms

Partners with known HSV or recent syphilis diagnosis

Physical Examination

1. General examination: • Thorough examination of the oral cavity, skin of torso, palms and soles and neurological examination, including cranial nerves2. exam of the groins Lymph nodes: note and location of enlarged lymph nodes size tenderness presence of bubo 3. Genital exam: exam genital and perianal area for: a. ulcerative lesion: - exam for - appearance, - distribution, - size, - number, - induration, - depth - tenderness b. other lesions

Clinical features - Clinical presentation may overlap or be atypical. - Co infections may occur in up to 10% cases.

Characteristics of GUD associated with the different etiologic agents:

Typical presentation:

1. Genital Herpes: Type of lesions: Duration L/nodes Vesicles, then ulcer 17-20 days firm, Number- multiple & clustered (primary ) tender bilateral few ulcers (recurrent) 5-10 days Borders- erythematous Base- red, smooth, w/o indurations Depth- Superficial Painful

2.Primary syphilis

Type of lesions duration l/nodes

Enlarged,Papule, then ulcer 1—6 wks Bilateral Number- usually single, mobile rarely multiple lesions, firm discrete Borders- demarcated, rolled non-tender

Base-indurated, red, smooth, clean

Depth- Superficial Painless.

3. Chancroid incubation 3-10 days

Types of lesion Duration L/nodes Papules, Pustules, then ulcer 2 -3 weeks or more enlarged, Number- usually one, tender multiple lesions matted Borders- ragged, undermined Base- Soft with purulent exudates suppurative, Depth- Deep unilateral Painful

LGV Incubation -3-30 days

Types of lesion Duration (1-2 wks) Lymph nodes Often presenting symptoms.

rarely presents as GUD multiple enlarged matted, tender may suppurate “Groove sign” –(30-40% ) Papules, then ulcer Number usually one Borders- variable Base- w/o indurations Depth- Superficial Painless

Donovanosis incubation not precisely known (few days-months)

Types of lesion Lymph nodes Firm, papules or Subc. Nodules L/nodes are not involved then, ulcer Swelling in the groin Number- usually single, multiple resembling bubo- suppurative

Borders- variable pseudobubo Base- fleshy, beef-red granulomatous ( this is subcut granuloma) breaks to form un ulcerNon-indurated, bleeds profusely on touch

Non-tender

Genital UlcerEvaluation

Diagnosis based on medical history and physical examination often inaccurate

Serologic test for syphilis

Culture/antigen test for herpes simplex

Haemophilus ducreyi culture in settings where chancroid is

prevalent

Biopsy may be useful

Treatment

Genital Herpes

First Clinical Episode

Acyclovir 400 mg tidor

Famciclovir 250 mg tid or

Valacyclovir 1000 mg bid

Duration of Therapy 7-10 days

Genital Herpes Episodic Therapy

Acyclovir 400 mg three times daily x 5 daysor

Acyclovir 800 mg twice daily x 5 daysor

Famciclovir 125 mg twice daily x 5 daysor

Valacyclovir 500 mg twice daily x 3-5 daysor

Valacyclovir 1 gm orally daily x 5 days

Syphilis

Primary, Secondary, Early Latent

Recommended regimen Benzathine Penicillin G, 2.4 million units IM

Penicillin Allergy* Doxycycline 100 mg twice daily x 14 days

or Ceftriaxone 1 gm IM/IV daily x 8-10 days (limited studies)

or Azithromycin 2 gm single oral dose (preliminary data)

*Use in HIV-infection has not been studied

ChancroidAzithromycin 1 gm orally

orCeftriaxone 250 mg IM in a single dose

orCiprofloxacin 500 mg twice daily x 3 days

orErythromycin base 500 mg tid x 7 days

Lymphogranuloma Venereum

Recommended regimen

Doxycycline 100 mg twice daily for 21 days

Alternative regimen

Erythromycin base 500 mg four times daily for 21 days

Granuloma Inguinale

Doxycycline 100 mg twice dailyor

Trimethoprim-sulfamethoxazole 800 mg/160 mg twice daily

Minimum treatment duration three weeks

Granuloma Inguinale

Ciprofloxacin 750 mg twice daily or

Erythromycin base 500 mg four times daily or

Azithromycin 1 gm orally weekly

Minimum treatment duration three weeks

Alternative regimens