Genital ulcer

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A genital ulcer is an open sore located on the genital area, which includes the vulva, penis, perianal region, or anus. Genital ulcers are most commonly caused by infectious agents (fungal infections, secondary bacterial infections, or sexually transmitted infections such as genital herpes, syphilis or chancroid). However, this is not always the case, as a genital ulcer may have noninfectious causes as well. [1]

Contents

Overview

A genital ulcer may be located on the vulva, penis, perianal region, or anus. Globally, the incidence of genital ulcers is estimated to be approximately 20 million cases annually. [2] The most likely cause of a genital ulcer varies depending on the characteristics of a population and location. The most common cause of genital ulcers in the United States is herpes simplex infections, with syphilis the second most common cause, and chancroid the third. [3] These common causes of genital ulcer disease (HSV-1, HSV-2 and treponema pallidum) can all be efficiently transmitted through oral sex. [1]

Important signs associated with genital ulcers that may assist in the diagnosis of the cause of the genital ulcer may include the presence of tender or non-tender enlarged lymph nodes in the groin area, a painful or non-painful genital ulcer, or the presence of vesicular lesions, which are small, painful, elevated blisters.[ citation needed ]

The most common causes of a genital ulcer include infectious agents, with sexually transmitted infections being the most common, but which can also include fungal infections and secondary bacterial infections. [2] While infectious agents are the most common cause, a genital ulcer may also be the result of non-infectious causes such as Behcet's syndrome, lupus, or psoriasis. [4]

Since it is difficult to determine a cause of a genital ulcer from history, examination, and population characteristics alone, further testing is often needed. The most common diagnostic tools used are targeted towards the most common etiologies of genital ulcers: syphilis (syphilis serology, PCR testing, or dark-field examination), herpes simplex virus (PCR, culture, or type specific HSV antibodies), and haemophilus ducreyi (culture on special media currently not widely available in most hospital systems) if the individual is in a known endemic region. [3] Further diagnostic tools such as a biopsy or culture are often utilized if ulcers appear unusual or do not respond as expected to therapy. [1]

Since genital ulcers are often infectious in origin, there is an increased risk of acquiring HIV in a HIV negative patient through viral introduction through the open sore [5] [6] Conversely, there is an increased risk of HIV transmission through increased shedding of viral HIV in the presence of a genital ulcer in a patient with a history of HIV. [6] [5] Available studies did not give enough evidence that treatment of genital ulcer reduce the sexual infection of HIV. However, genital ulcer need to be treated regardless of HIV infection probability of the treatment. [7] The CDC recommends testing for HIV in any individual presenting for a genital ulcer who does not already have a history of HIV. [3]

Infectious sexually transmitted causes

Risk factors for sexually transmitted genital ulcers are similar to the risk factors for most sexually transmitted infections which include multiple sex partners, alcohol, illicit drug use, homelessness, poverty, inmates, men who have sex with men, sexually active teenagers, sexual contact without contraceptive use, and unstable housing. [8] The most common cause of genital ulcers in the North America and Western Europe are the result of HSV or syphilis infections, while the most common cause in other parts of the world is chancroid. [9] [4] Most sexually active adolescents with genital ulcers have a herpes simplex virus infection, more commonly type 2. [4] Meanwhile, according to 2017 CDC reports, syphilis is more common in men who have sex with men populations although rates of syphilis have been rising in heterosexual men and women in the United States. [10] Following syphilis and genital herpes infections, a chancroid is the third most common cause but tends to occur in focused outbreaks over time. [4] While rates of H. ducreyi infection seem to be declining according to a 2017 report, it is possible this may be due to lack of testing since H. ducreyi requires a very specialized culture medium which is not commonly available. [3] [10] Less common causes include lymphogranuloma venereum, which is more common in men who have sex with men, and granuloma inguinale, which is more common in tropical regions globally. rather than in the United States. [4]

DiseaseInfectious causeClinical signsDiagnostic testsTreatment
Genital herpes infection Herpes simplex virus type 1 or type 2Multiple painful vesicular lesions that can rupture to form shallow ulcers. Often will have painless lymph node enlargement. [3] Cell culture and PCR, HSV specific antibodiesAntivirals
Syphilis Treponema pallidum Single painless ulcer with well marked borders (chancre) during the primary syphilis infection stage that often goes unnoticed until the disease progresses to secondary and tertiary stage of symptoms. May be associated with mild painful lymph node enlargement. [2] [3] serology, PCR, dark field microscope examinationAntibiotics
Chancroid Haemophilus ducreyi Single painful ulcer with drainage of pus and a friable base. Often associated with painful regional lymph node enlargement that can develop into bullae. [3] Special culture medium for haemophilusAntibiotics
Lymphogranuloma venereum Chlamydia trachomatis serovars L1, L2, or L3Often presents as a unilateral painful regional lymph node enlargement. While there is sometimes a genital ulcer, it often resolves prior to medical evaluation or goes undetected since the ulcer is often small and painless. This is a systemic disease that can mimic many other inflammatory diseases. [3] Serology, PCR, culture, biopsyAntibiotics
Granuloma inguinale Klebsiella granulomatis Beefy red painless ulcers with rare regional lymph node enlargement which progressively worsens over time. [2] Difficult to culture so requires tissue biopsy to identify organismAntibiotics

Non-infectious causes

Genital ulcers are not strictly a sign of a sexually transmitted illness, although non-infectious sources are significantly more infrequent in comparison. The most common non-infectious sources of genital ulcers are first Behcet's disease, and second drug reaction. [2]

Behcet's syndrome is a chronic systemic vasculitis infection that is defined by recurrent oral and genital aphthous ulcers but can also affect many other organ systems, such as the eyes, ears, nervous system, heart, lungs, joints, and intestines. [11] Behcet's syndrome commonly presents in the 30-40 age range [11] and is more common in the Middle East and Asia. [12] There is a familial component to Behcet's syndrome since it has associations with the HLA-B51 gene. [11]

Causes of drug induced genital ulcers take the form of Stevens–Johnson syndrome, toxic epidermal necrolysis, erythema multiforme, and fixed drug eruptions in response to a diverse list of medications. [11] Stevens–Johnson syndrome and toxic epidermal necrolysis are more likely than erythema multiforme to have genital manifestations although all present with a toxic appearing patient. [11] A fixed drug eruption in comparison does not present as a toxic appearing patient but rather single or multiple erythematous patches that vary in size and shape which eventually turn dark brown in color and become itchy. [11] The defining characteristic is that these drug eruptions appear in the same location each time the offending medication is used, and will resolve on their own. [11]

Other potential causes of non-infectious genital ulcers are diverse, but can include sexual trauma, Lipschutz ulcers, inflammatory bowel diseases such as Crohn's disease, lichen planus, lichen sclerosis, and immunobullous disease such as pemphigous vulgaris, since bullous pemphigoid is less likely to occur on the genitals. [11] Cancers of the vulva and penis, with the most common subtype being squamous cell carcinoma, can also present as genital ulcers, but leukemias such as chronic lymphocytic leukemia and acute promyelotic leukemia have also been identified. [11]

Infectious non-sexually transmitted causes

Even lesser common etiologies of genital ulcers include fungal infection, secondary bacterial infections, and parasitic infections. [11] [4]

Fungal infections are rare causes of genital ulcers, but candida albicans infection is typically the most common source, and is more prevalent in patients with a history of diabetes mellitus, chronic steroid use, or other immunodeficiencies. [11] There have also been rare case reports of paracoccidioidomycosis, zygomycosis and histoplasmosis infections causing genital ulcers. [11]

Parasitic infections such as amoebiasis and leishmaniasis can present in cutaneous form in the genital regions. This can be confused with a sexually transmitted infection or sepsis due to their tendency to present with additional systemic symptoms. [11]

Genital tuberculosis can also present as a genital ulcer, either in the form of cutaneous tuberculosis from a systemic infection, or a primary tuberculosis chancre at the site of inoculation via direct genital contact with infected sputum. [11] Cutaneous tuberculosis typically presents initially as red or yellow nodules that eventually break down to form soft, painful, and roughly circular ulcers, which as a rule are covered in a pseudomembrane. [11] Primary tuberculosis chancre, on the other hand, often presents as a painless ulcer with well defined edges that appears rather nonspecific. [11]

Related Research Articles

<span class="mw-page-title-main">Chancroid</span> Sexually transmitted bacterial infection in humans

Chancroid is a bacterial sexually transmitted infection characterized by painful sores on the genitalia. Chancroid is known to spread from one individual to another solely through sexual contact. However, there have been reports of accidental infection through the hand.

<span class="mw-page-title-main">Haemophilus ducreyi</span> Species of gram-negative, pathogenic bacterium

Haemophilus ducreyi are fastidious gram-negative coccobacilli bacteria.

This is a list of AIDS-related topics, many of which were originally taken from the public domain U.S. Department of Health Glossary of HIV/AIDS-Related Terms, 4th Edition.

Vulvitis is inflammation of the vulva, the external female mammalian genitalia that include the labia majora, labia minora, clitoris, and introitus. It may co-occur as vulvovaginitis with vaginitis, inflammation of the vagina, and may have infectious or non-infectious causes. The warm and moist conditions of the vulva make it easily affected. Vulvitis is prone to occur in any female especially those who have certain sensitivities, infections, allergies, or diseases that make them likely to have vulvitis. Postmenopausal women and prepubescent girls are more prone to be affected by it, as compared to women in their menstruation period. It is so because they have low estrogen levels which makes their vulvar tissue thin and dry. Women having diabetes are also prone to be affected by vulvitis due to the high sugar content in their cells, increasing their vulnerability. Vulvitis is not a disease, it is just an inflammation caused by an infection, allergy or injury. Vulvitis may also be symptom of any sexually transmitted disease or a fungal infection.

The CDC Classification System for HIV Infection is the medical classification system used by the United States Centers for Disease Control and Prevention (CDC) to classify HIV disease and infection. The system is used to allow the government to handle epidemic statistics and define who receives US government assistance.

<span class="mw-page-title-main">Vertically transmitted infection</span> Infection caused by pathogens that use mother-to-children transmission

A vertically transmitted infection is an infection caused by pathogenic bacteria or viruses that use mother-to-child transmission, that is, transmission directly from the mother to an embryo, fetus, or baby during pregnancy or childbirth. It can occur when the mother has a pre-existing disease or becomes infected during pregnancy. Nutritional deficiencies may exacerbate the risks of perinatal infections. Vertical transmission is important for the mathematical modelling of infectious diseases, especially for diseases of animals with large litter sizes, as it causes a wave of new infectious individuals.

<span class="mw-page-title-main">Herpetic gingivostomatitis</span> Medical condition

Gingivostomatitis is a combination of gingivitis and stomatitis, or an inflammation of the oral mucosa and gingiva. Herpetic gingivostomatitis is often the initial presentation during the first ("primary") herpes simplex infection. It is of greater severity than herpes labialis which is often the subsequent presentations. Primary herpetic gingivostomatitis is the most common viral infection of the mouth.

<span class="mw-page-title-main">Genital herpes</span> Infection by herpes simplex viruses of the genitals

Genital herpes is a herpes infection of the genitals caused by the herpes simplex virus (HSV). Most people either have no or mild symptoms and thus do not know they are infected. When symptoms do occur, they typically include small blisters that break open to form painful ulcers. Flu-like symptoms, such as fever, aching, or swollen lymph nodes, may also occur. Onset is typically around 4 days after exposure with symptoms lasting up to 4 weeks. Once infected further outbreaks may occur but are generally milder.

Venereology is a branch of medicine that is concerned with the study and treatment of sexually transmitted diseases (STDs). The name derives from Roman goddess Venus, associated with love, beauty and fertility. A physician specializing in venereology is called a venereologist. In many areas of the world, the specialty is usually combined with dermatology.

Herpes gladiatorum is one of the most infectious of herpes-caused diseases, and is transmissible by skin-to-skin contact. The disease was first described in the 1960s in the New England Journal of Medicine. It is caused by contagious infection with human herpes simplex virus type 1 (HSV-1), which more commonly causes oral herpes. Another strain, HSV-2 usually causes genital herpes, although the strains are very similar and either can cause herpes in any location.

<span class="mw-page-title-main">Condom effectiveness</span>

Condom effectiveness is how effective condoms are at preventing STDs and pregnancy. Correctly using male condoms and other barriers like female condoms and dental dams, every time, can reduce the risk of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) and viral hepatitis. They can also provide protection against other diseases that may be transmitted through sex like Zika and Ebola. Using male or female condoms correctly, every time, can also help prevent pregnancy.

A vaginal disease is a pathological condition that affects part or all of the vagina.

The central nervous system (CNS) controls most of the functions of the body and mind. It comprises the brain, spinal cord and the nerve fibers that branch off to all parts of the body. The CNS viral diseases are caused by viruses that attack the CNS. Existing and emerging viral CNS infections are major sources of human morbidity and mortality.

<span class="mw-page-title-main">Sexually transmitted infection</span> Infection transmitted through human sexual behavior

A sexually transmitted infection (STI), also referred to as a sexually transmitted disease (STD) and the older term venereal disease (VD), is an infection that is spread by sexual activity, especially vaginal intercourse, anal sex, oral sex, or sometimes manual sex. STIs often do not initially cause symptoms, which results in a risk of passing the infection on to others. Symptoms and signs of STIs may include vaginal discharge, penile discharge, ulcers on or around the genitals, and pelvic pain. Some STIs can cause infertility.

<span class="mw-page-title-main">Herpes</span> Viral disease caused by herpes simplex viruses

Herpes simplex, often known simply as herpes, is a viral infection caused by the herpes simplex virus. Herpes infections are categorized by the area of the body that is infected. The two major types of herpes are oral herpes and genital herpes, though other forms also exist.

Neonatal herpes simplex, or simply neonatal herpes, is a herpes infection in a newborn baby caused by the herpes simplex virus (HSV), mostly as a result of vertical transmission of the HSV from an affected mother to her baby. Types include skin, eye, and mouth herpes (SEM), disseminated herpes (DIS), and central nervous system herpes (CNS). Depending on the type, symptoms vary from a fever to small blisters, irritability, low body temperature, lethargy, breathing difficulty, and a large abdomen due to ascites or large liver. There may be red streaming eyes or no symptoms.

<span class="mw-page-title-main">Cold sore</span> Herpes simplex virus infection of the lip

A cold sore is a type of herpes infection caused by the herpes simplex virus that affects primarily the lip. Symptoms typically include a burning pain followed by small blisters or sores. The first attack may also be accompanied by fever, sore throat, and enlarged lymph nodes. The rash usually heals within ten days, but the virus remains dormant in the trigeminal ganglion. The virus may periodically reactivate to create another outbreak of sores in the mouth or lip.

The epidemiology of herpes simplex is of substantial epidemiologic and public health interest. Worldwide, the rate of infection with herpes simplex virus—counting both HSV-1 and HSV-2—is around 90%. Although many people infected with HSV develop labial or genital lesions, the majority are either undiagnosed or display no physical symptoms—individuals with no symptoms are described as asymptomatic or as having subclinical herpes.

References

  1. 1 2 3 Roett, MA (15 March 2020). "Genital Ulcers: Differential Diagnosis and Management". American Family Physician. 101 (6): 355–361. ISSN   0002-838X. PMID   32163252.
  2. 1 2 3 4 5 ROETT, Michelle (1 February 2012). "Diagnosis and Management of Genital Ulcers". American Family Physician. 85 (3): 254–262. PMID   22335265.
  3. 1 2 3 4 5 6 7 8 "2015 STD Treatment Guidelines". Centers for Disease Control and Prevention. Retrieved 10 July 2020.
  4. 1 2 3 4 5 6 Roett, M. A. (15 March 2020). "Genital Ulcers: Differential Diagnosis and Management". American Family Physician. 101 (6): 355–361. PMID   32163252.
  5. 1 2 Powers KA, Poole C, Pettifor AE, et al.: Rethinking the heterosexual infectivity of HIV-1: a systematic review and meta-analysis.Lancet Infect Dis 2008; 8: pp. 553-563.
  6. 1 2 Bruisten SM, Cairo I, Fennema H, et al.: Diagnosing genital ulcer disease in a clinic for sexually transmitted diseases in Amsterdam, the Netherlands.J Clin Microbiol 2001; 39: pp. 601-605.
  7. ↑ Mutua, Florence M; M'Imunya, James Machoki; Wiysonge, Charles Shey (15 August 2012). "Genital ulcer disease treatment for reducing sexual acquisition of HIV". Cochrane Database of Systematic Reviews (8): CD007933. doi:10.1002/14651858.cd007933.pub2. ISSN   1465-1858. PMID   22895969.
  8. ↑ Kelly JD, Cohen J, Grimes B, et al.: High rates of herpes simplex virus type 2 infection in homeless women: informing public health strategies. Womens Health (Larchmt) 2016; 25: pp. 840-845.
  9. ↑ Mroczkowski TF, Martin DH. Genital ulcer disease. Dermatol Clin. 1994;12(4):753-764.
  10. 1 2 Centers for Disease Control and Prevention : Sexually transmitted disease surveillance. https://www.cdc.gov/std/stats17/2017-STD-Surveillance-Report_CDC-clearance-9.10.18.pdf
  11. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Sehgal VN, Pandhi D, Khurana A. Nonspecific genital ulcers. Clin Dermatol. 2014;32(2):259-274. doi : 10.1016/j.clindermatol.2013.08.024
  12. ↑ "Behcet's Disease". National Institute of Health. Retrieved 14 July 2020.
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