Genital Ulcers (Case 49)

Published on 24/06/2015 by admin

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Last modified 24/06/2015

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Genital Ulcers (Case 49)

Patricia D. Brown MD

Case: A 26-year-old man presents to an urgent-care center with a complaint of painful lesions on the penis that appeared 3 days earlier. The patient states that before the appearance of these lesions he had a sensation of “burning and tingling” near the end of his penis; he then noticed several “red bumps and little blisters” that opened and became painful. He has been sexually active with several female partners over the past year (vaginal sex and receptive oral sex), and he admits that he has been inconsistent with the use of condoms. He has no knowledge of any sexually transmitted disease (STD) diagnosis in his previous or current sexual partners. On further questioning, he recalls that he may have experienced several similar episodes of burning and tingling in the same region in the past but never noticed any similar lesions. He is otherwise healthy and denies any prior history of STDs. He believes that he was tested for HIV infection 3 years ago during a visit to his primary-care physician for a routine physical examination. His physical examination is remarkable only for the genital exam, which reveals a cluster of five small, shallow ulcers, each on an erythematous base; there is shotty nontender inguinal adenopathy. The patient is very concerned about the possibility of an STD and also requests testing for HIV.

Differential Diagnosis

Herpes simplex virus (HSV) infection




Speaking Intelligently

The differential diagnosis of genital ulcers includes both infectious and noninfectious etiologies. Ulcers may occur as part of a systemic disease. Among the infectious etiologies, STDs are most common, although infections that are not transmitted sexually can rarely cause genital ulcers. The differential diagnosis can be generated based on the history and clinical characteristics of the lesion and then narrowed on the basis of selected diagnostic testing. It is important to emphasize that a patient diagnosed with an STD is at increased risk for other STDs, including HIV, and to offer screening for these diseases.


Clinical Thinking

• When evaluating a patient with genital ulcers, prioritize the differential diagnosis based on the patient’s history, including a careful review of the sexual history and any travel history, the presence of any systemic symptoms, and the symptoms associated specifically with the genital lesions, including the temporal progression of symptoms and the evolution of the lesions.

• Perform a thorough general physical examination, including inspection of the oral mucosa, skin, and anus, and evaluate for adenopathy. Carefully describe the location and appearance of the ulcer(s).

• Although a presumptive diagnosis can usually be made on clinical grounds, selected diagnostic testing is usually necessary to confirm the diagnosis, although treatment may have to be initiated on the basis of the clinical diagnosis.

• Advise the patient about partner notification, provide counseling regarding future risk reduction, and inform the patient regarding the need for disease reporting.


• A prior history of recurrent genital ulcers is suggestive of HSV infection.

• The sexual history should include type of sexual activity, since trauma (including sexual assault) can be the etiology of genital ulceration.

• Note any associated systemic symptoms such as fever, arthralgias, oral lesions, or skin lesions.

• Obtain a travel history as well as information regarding symptoms in sexual partners.

• Ulcers secondary to HSV are typically painful; a prodrome of itching, burning, or tingling often occurs, and some patients may complain only of these symptoms despite the presence of ulcers. Ulcers secondary to chancroid are also painful.

• The ulcer associated with primary syphilis (chancre) and lymphogranuloma venereum (LGV) is usually painless.

• Noninfectious causes of genital ulcers include ulcers associated with autoimmune diseases such as Behçet syndrome and inflammatory bowel disease, and aphthous ulcers related to HIV infection; these ulcers are typically painful.

Physical Examination

• Carefully examine the oral mucosa, the skin, and all lymph node groups.

• Carefully note the appearance of the genital ulcer, as the ulcer appearance will provide important clues regarding the etiology of the lesion.

• Note if there is a single ulcer or multiple ulcers.

• In a female, even if lesions are present on the external genitalia, perform a pelvic examination to look for additional lesions.

Tests for Consideration

Although a preliminary diagnosis can be made based on history and physical examination, it is important to utilize diagnostic testing to confirm the etiology of genital ulcers.

• Patients should have serologic testing for syphilis (important to screen for a concomitant STD even if an alternative etiology of the ulcer is confirmed).


Culture or antigen-detection testing should be done to rule out HSV.


• In some settings, such as STD clinics, dark field examination for Treponema pallidum is available.


• Testing for Haemophilus ducreyi (chancroid) and LGV should be limited to certain epidemiologic settings (discussed in the Chancroid Clinical Entity).


• Although type-specific serologic tests for HSV subtypes 1 and 2 are available, serologic testing is not of value in the diagnosis of genital ulcer disease during the acute presentation.


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Herpes Simplex Virus