Genital Ulcers In Men & Women (With Or Without Buboes)

The commonest cause of genital ulcers in both men and women is genital herpes simplex virus type 2 (HSV2) infection. Syphilis and chancroid also cause genital ulcers but the prevalence of chancroid is low in Zimbabwe. Clinical differentiation between the causes of genital ulcers is inaccurate except if the patient gives a clear history of recurrent attacks of vesicular lesions that may crust and heal spontaneously or if the clinical appearance of the lesions are those of superficial ulcers, when the diagnosis of genital herpes may be suspected. It should be noted that syphilis may remain undetected in the body for long periods of time and clinical manifestations may only occur when long term complications develop. Syphilis should be ruled out in all patients presenting with genital ulcers. lmmunosuppressed persons with HIV infection frequently develop attacks of genital herpes that produce lesions which tend to persist and require treatment with antiviral medicines, such as acyclovir. Hence it is important to bear in mind all these three diagnoses whenever managing persons with genital ulcers syndromically.

Treatment of genital ulcers:

Advice on local hygiene such as washing the ulcer twice a day with salt water (1 teaspoon salt to 1 litre water) and give the following:

	Medicine	Adult dose	Frequency	Duration
	benzathine penicillin im	2.4MU (1.44gm)	once only
and	ciprofloxacin po	500mg	twice a day	3 days
and	acyclovir po	400mg	three times a day	5 days
Or	acyclovir po	800mg	twice a day	5 days

If treating Primary Genital Herpes**

	Medicine	Adult dose	Frequency	Duration
	acyclovir po	400mg	three times a day	10 days
Or	acyclovir po	200mg	5 times a day	10 days

In case of penicillin allergy, use doxycycline 100mg twice a day for 20 days

CAUTION IN PREGNANCY: see chapter on Obstetric and Gynaecological Conditions. Ciprofloxacin should not be used during pregnancy or in lactating mothers. In pregnant women genital ulcers are best treated with erythromycin 500mg four times a day for 7 days or Azithromycin 1g single dose or ceftriaxone 250mg IM single dose. Women who are penicillin allergic should be treated with erythromycin 500mg four times a day for 14 days or 30 days depending on stage of syphilis (less than 2yrs or more than 2yrs)

**Note: In an individual with primary genital herpes ulcers, the lesions tend to be more severe (usually accompanied by systemic illness such as fever, headaches, myalgia), with eruptions lasting up to 3 weeks. For this reason, primary genital herpes is treated for 10 days, and not for 5 days as with recurrent genital herpes.