STI-related Genital Ulcer

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Cause

  • Herpes simplex
  • Treponema pallidum (syphilis)
  • Haemophilus ducreyi (chancroid)
  • Calymmatobacterium granulomatis (granuloma inguinale)

Symptoms

  • Genital ulcer (painful or painless)
  • Urethral discharge
  • Inguinal swelling (lymphadenopathy)

Signs

  • Inguinal lymphadenopathy 
  • Herpes simplex
    • Multiple, recurrent vesicular lesions (Herpes simplex)
  • Syphilitic ulcers
    • Often single, painless and indurated lesions with a clear base and well-defined edges
    • Occasionally multiple, painful, non-indurated or have a purulent base
    • Discrete, firm, painless, inguinal lymphadenopathy a week after the primary lesion
    • Primary ulcer usually heals within six weeks, usually without leaving a scar.
  • Chancroid
    • Painful with undermined ragged edges
    • The base is covered with a purulent exudate and easily bleeds to touch
    • Several ulcers may coalesce to form serpiginous lesions
    • Lymphadenopathy is usually unilateral and may become fluctuant
  • Granuloma inguinale
    • Begins with a small papule that progresses into an enlarging granulomatous ulcer with trauma
    • Edges are well defined
    • Healing is not spontaneous and is accompanied by extensive scarring

Investigations

  • VDRL (if available)
  • TPHA (if available)

TreatmentTreatment Objectives

  • To treat small ulcers and vesicles, especially if recurrent for Herpes simplex
  • To direct initial management of all ulcers at herpes simplex, syphilis and chancroid concurrently

Non-pharmacological Treatment

Keep lesions dry and clean

Pharmacological Treatment

Evidence Rating: [C]

For Herpes simplex

  • Aciclovir, oral, 200 mg 4-6 hourly for 7-10 days (5 doses daily)

Or

  • Aciclovir, oral, 400 mg 8 hourly for 7-10 days

For individuals with herpes and HIV co-infection

  • Aciclovir, oral, 400 mg 8 hourly for 7-10 days 

Or

  • Aciclovir, oral, 800 mg 12 hourly for 7-10 days

Episodic therapy for recurrent episodes 

  • Aciclovir, oral, 400 mg 8 hourly for 5 days 

Or

  • Aciclovir, oral, 800 mg 12 hourly for 5 days

Or

  • Aciclovir, oral, 800 mg 8 hourly for 2 days

Suppressive therapy in HIV infected individuals 

  • Aciclovir, oral, 400-800 mg 8-12 hourly for 2-6 years

For Syphilis

  • Benzathine Penicillin G, IM, 1.2 MU in each buttock (total dose 2.4 MU) stat

Or 

  • Procaine Penicillin Aqueous, IM (by deep injection), 1.2 MU daily for 10 days

For persons allergic to penicillin

  • Doxycycline, oral, 100 mg 12 hourly for 14 days

Or

  • Tetracycline, oral, 500 mg 6 hourly for 14 days

For pregnant women allergic to penicillin

  • Erythromycin, oral, 500 mg 6 hourly for 14 days

Or

  • Azithromycin, oral, 500 mg daily for 10 days

For Chancroid

  • Ceftriaxone, IM, 250 mg stat.

Or

  • Azithromycin, oral, 1 g stat.

Or

  • Ciprofloxacin, oral, 500 mg 12 hourly for 3 days

Or

  • Erythromycin, oral, 500 mg 6 hourly for 7 days