Genital Ulcers

Outline Herpes Simplex Syphilis Chancroid Lymphogranuloma Veneruem Donovanosis

1. Herpes Simplex Relatively common ulcerative problem Herpes Simplex Type 2 STD Recurrent, incurable Starts with a Rash  Blister  Pus formation  Healing

Diagnosis PCR (most accurate and sensitive) Serologic tests Western Blot Assay (most sensitive for recurrent and subclinical)

Treatment No cure Primary episode Recurrent episodes Valacycolvir 1000 mg 2x a day for 7-10 days Recurrent episodes Valacyclovir 1000 mg Daily or 500 mg 2x daily for 5 days Daily Suppressive Therapy Valacyclovir 500 mg daily (≤8 recurrences/year) or 1000 mg/day or 250 mg bid ( 9 recurrences/year)

2. Syphilis Treponema Pallidum (Spirochete) Screening tests: VDRL RPR Confirmatory: FTA-ABS Screening (non-specific) FTA-ABS (false positives)

Stages Primary Secondary Tertiary PAINLESS papule Systemic (hematogenous spread) Tertiary Involvement of CNS, CVS, musculoskeletal

Treatment Early (Primary, secondary and early latent syphilis of less than 1 year’s duration) Parenteral Penicillin Benzathine Penicillin G 2.4 million units, single dose Alternative (Penicillin allergic non-pregnant patients) Doxycycline 100 mg orally 2x/day for 2 weeks or Tetracycline 500 mg 4x daily for 2 weeks Late Latent Syphilis (more than 1 year’s duration, gummas and cardiovascular syphilis) Benzathine Penicillin G 2.4 million units IM for 4 doses at 1-week intervals Neurosyphilis Aqueous crystalline Penicillin G, 3-4 million units IV ever 4 hours, for 20-14 days or Procaine Penicillin 2.4 million units IM daily for 10-14 days plus Probenecid (adjuvant substance which allows penicillin to stay longer) 500 mg p.o. 4x daily for 10-14 days

3. Chancroid Hemophilus ducreyi Soft chancre

Diagnosis Always painful ulcer Manifests with the deepest scarring The ulcers have a dirty, gray, necrotic, foul-smelling exudate, and there is an absence of induration at the base

Treatment Azithromycin 1 g orally, single dose or Ceftriaxone 250 mg IM, single dose or Ciprofloxacin (Quinolone) 500 mg orally for 4 days

4. Lymphogranuloma Venereum (LGV) A chronic infection of lymphatic tissue produced by Chlamydia trochomatis 3 Phases: Shallow, painless ulcer of the vestibule or labia Painful inguinal and peri-rectal adenopathy Bubos “Groove sign” – Double genito-crural fold You have lymph that coalesces then forms pus and in-folding of crural folds

Treatment Doxycycline 2x daily for 21 days or Azithromycin 1 gm orally once a week for 3 weeks or Ciprofloxacin 750 mg orally 2x daily for 3 weeks or Erythromycin 500 mg 4x daily for 21 days

5. Donovanosis AKA: Granuloma Inguinale Calymmatobacterium granulomatis Close non-sexual contact Asymptomatic nodule Beefy-red ulcer with fresh granulation tissue Ulcers are painless unless secondarily infected asymptomatic nodule. The skin over the nodule ulcerates, and the characteristic lesion is a beefy-red ulcer with fresh granulation tissue. The area around the lesions is highly vascular, thus the ulcers bleed easily when touched. Usually there are multiple nodules and, subsequently, multiple ulcers of the vulva. Adjacent areas of ulceration grow and coalesce and, if untreated, will eventually destroy the normal vulvar architecture. The ulcers are painless unless secondarily infected. Adenopathy is not a prominent feature unless there is a superimposed infection.

Treatment Doxycycline 100 mg orally 2x daily for 3 weeks Azithromycine 1 gm per week for 3 weeks Ciprofloxacin 750 mg orally 2x a day for 3 weeks Erythromycin base 500 mg or TMP-SMz double strength 2x daily for 3 weeks Similar with LGV