Lawrence S. Neinstein, M.D., F.A.C.P.
Professor of Pediatrics and Medicine
USC Keck School of Medicine
Executive Director
University Park Health Center
Associate Dean of Student Affairs
   

 

 

Sexuality - Sexually Transmitted Infections - Genital Ulcers (B3)

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GENITAL ULCERS

Another major symptom complex are those teens presenting with a genital ulcer. The major considerations included in the differential in decreasing frequency are:

  • Herpes Simplex
  • Syphilis
  • Chancroid
  • Trauma
  • LGV
  • Granuloma Inguinale

Herpes Simplex

Herpes Simplex is the most common ulcerative lesion in adolescents.

The above picture on the left demonstrates the most common appearance of the early herpetic vesicles while the picture on the right shows lesions several days later when they have broken down into multiple painful shallow ulcers. Herpes simplex virus is the cause of over 90% of vesiculoulcerative lesions of the genitals. It is probably second in STD prevalence after human papilloma virus in the United States . In the United States, about 17% of 20-29 year olds are HSV-2 seropositive.

Transmission : Transmission is through sexual contact, either genital-genital or oral-genital. While viral shedding is highest while genital lesions are present, asymptomatic shedding does occur. This makes it crucial to be as certain as possible of the diagnosis as counseling includes making the adolescent aware of the consequences of asymptomatic shedding.

HSV-1 usually causes herpetic gingivostomatitis but can cause herpes genitalis while HSV-2 commonly causes genital herpes.

Clinical presentation:

Not infrequently a primary episode goes undetected and the first clinical episode is from a prior infection. This is called a "nonprimary first episode". A first clinical episode may also be atypical presenting with either very small lesions or with dysuria, dyspareunia or other vague symptoms. Some helpful clinical information includes the following:

  • Incubation period is usually 1-45 days and averages 6-8 days.
  • The duration from onset of lesions to complete healing is about 3 weeks in a primary episode and often only about a week in recurrent episodes.
  • Symptoms generally start with paresthesias or burning and are followed by 1-2 mm vesicles on an erythematous base as seen above. These vesicles break down into painful ulcers as seen on the right above.
  • The ulcers tend to be multiple and painful but more severe and more commonly bilateral in primary infections.
  • Constitutional symptoms are more frequent and severe in a primary infections.
  • Cervix involvement mainly occurs in primary infections with more nonmucosal involvement in recurrent infections.

Differential Diagnosis:

The main diseases to be considering in the differential diagnosis include syphilis, chancroid, scabies, pediculosis, allergic and contact dermatitis and traumatic lesions. Less common causes include lymphogranuloma venereum and the genital lesions of Behcet's syndrome.

Diagnosis:

The diagnosis is usually based on a combination of the clinical history and examination. Some laboratory tests may be helpful including dark-field examination and syphilis serology and potentially either a viral culture or one of the newer herpes antibody tests. It is critical that one only use one of the newer technology antibody tests.

Treatment:

Treatment guidelines are extensively reviewed in the CDC guidelines of 2002. A few helpful general points include:

  • In general, medications are indicated for the treatment of initial episodes and the management of recurrences in certain individuals.
  • It is helpful to try and use regimens with less dosing per day to encourage compliance when possible. However, these medications are more expensive.
  • None of the medications eliminate latent virus nor do the medications effect the risk, frequency or severity of recurrences when the medication is stopped.
  • Patients with active lesions should abstain from intercourse until the lesions are clearly healed. Since viral shedding can occur in the absence of lesions, it is important to recommend the regular use of condoms to any patient who has had an episode of genital herpes.
  • Significant psychological distress can result from herpes infections. Typical reactions include denial, shock, fear, guilt, feelings of social isolation, and anger at the partner. In addition, anxiety and depression can also occur.

Syphilis

Another significant cause of ulcerative lesions is the primary chancre of syphilis. Syphilis rates have decreased dramatically since the advent of antibiotics although there have been significant outbreaks in many geographic areas in past 30 years.

As seen below a major epidemic occurred in the late 1980s/early 1990s. This was of particular significance in the African-American community.

Primary and secondary syphilis - Rates by race and ethnicity: United states, 1981-2000 and the Healthy People year 2010 objective
click for full-size image

The slides below demonstrate characteristic lesions of primary syphilis. The typical "classic" primary syphilitic chancre (on the left) is a painless, ulcerative lesion with a "punched out" appearance. It often has an indurated hard raised border.

Syphilis is caused by Treponema pallidum, a motile, spiral microorganism that is best visualized by dark-field microscopy. Syphilis is almost exclusively transmitted through either sexual contact or through congenital transmission during pregnancy. The estimated rate of transmission after sexual exposure to a person with a chancre is 30%.

Clinical manifestations:

  • Primary syphilis: After an incubation period of 9-90 days (average 21 days), the primary lesions appears similar to the pictures above. Most lesions are on the external genitalia and in comparison to herpes are usually single (although multiple lesions can occur). Regional lymphadenopathy can occur and healing of the chancre usually occurs within 3 to 6 weeks. The lesions sometimes are less obvious as seen on the lesion on the frenulum of the penis (lesion on the right above).
  • Secondary syphilis: Approximately 6-8 weeks (maximum is 6 months) after exposure and 4 to 10 weeks after the onset of the chancre, the manifestations of secondary syphilis appear. The organism can still be found in the lesions during this stage and in body fluids. The signs and symptoms of secondary syphilis usually resolve after several weeks or months. The classic sign of secondary syphilis is the skin rash seen below:

Secondary syphilis

Secondary Syphilis Rash
click for full-size image

This kind of rash affects about 90% of individuals with secondary syphilis. The rash aside from the trunk and extremities has a predilection for palms and soles as seen in the typical rash below from a teen who presented with fatigue, adenopathy, pharyngitis and was thought to have scarlet fever.

Secondary syphilis -

Palmar rash

Palmar Rash
click for full-size image

These lesions may be scaly and hyperkeratotic. The skin lesions of secondary syphilis may also involve mucous membranes. It is important to remember that almost any type of rash can occur with secondary syphilis. One type, condylomata lata, can look very similar to condylomata accuminata. Below is an example of condylomata lata lesions.

Condylomata lata lesions
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Other manifestations of secondary syphilis include general or regional lymphadenopathy (70%), hepatosplenomegaly, fatigue, pharyngitis, headaches, nasal discharge, arthralgias, myalgias, weight loss, fever, alopecia, iritis and glomerulonephritis.

  • Latent syphilis: After resolution of secondary syphilis the period during the first year of infection is called the early latent period. The late latent period extends from after the first year of infection until the signs of tertiary syphilis appear. Latent syphilis is characterized by the absence of clinical signs and symptoms, positive serology and negative spinal fluid serology.
  • Neurosyphilis can occur in up to 20% of patients who are untreated but is uncommon in adolescents. Most cases are asymptomatic
  • Late or tertiary syphilis: May occur 2 to 10 years after initial exposure in untreated individuals and can include cardiovascular involvement and gummas.

Diagnosis

Syphilis screening can be an important element of routine health care for sexually experienced adolescents. However, routine screening depends on the incidence in the population and the risk profile of the adolescent. Diagnosis in a teen with symptoms can include a dark-field examination of a primary ulcer and serologic testing including nontreponemal antibody tests such as the VDRL and RPR and specific treponemal antibody tests such as the FTA-ABS and the microhemagglutination test (MHA-TP)

In general, nontreponemal tests are used for screening (RPR) and to follow treatment success (quantitative VDRL). The treponemal specific tests are to confirm a positive screening test (rule out a false positive screening test). The treponemal tests may remain positive after treatment and titers do not correspond to disease activity.

At the time of appearance of a primary chancre about 25% of individuals will have a positive serologic tests. The positivity rate rises rapidly to 50% by 2 weeks after appearance of a chancre to 75% after three weeks and about 100% by 4 weeks. Almost 20-40% of positive serologic screening tests are false positives related to medications, collagen vascular diseases, drug abuse, other acute infections, Hashimoto's thyroiditis, sarcoidosis, lymphoma and HIV infections.

Treatment

Treatment is complicated and based on the stage of the disease. Guidelines are clearly outlined in the 2002 CDC STD treatment guidelines. In general, penicillin is the optimal antibiotic for syphilis treatment and the only proven therapy for neurosyphilis, congenital syphilis, and syphilis during pregnancy. Persons exposed to an individual with primary, secondary, or early latent syphilis within the preceding 90 days should be treated presumptively. There have been reports among HIV positive individuals of higher rates of neurological complications and treatment failures. HIV-positive patients with syphilis require careful evaluation for late and unusual manifestations of syphilis, including CSF evaluation. These individuals require careful follow-up after therapy.

Chancroid

Another STD in the differential of ulcerative lesions but far less common is chancroid.

Chancroid
click for full-size image

Chancroid is caused by Haemophilus ducreyi and most commonly found in developing countries with the highest prevalence in southern, central, and eastern Africa . The typical lesion (seen above) appears after a 3 day to 2 week incubation period. The characteristic ulcer is painful, soft, friable, nonindurated with ragged undermined scalloped margins, a foul-smelling yellow-gray exudative covering and surrounding erythema. Several of these lesions may be present in a patient. Within 1 to 23 weeks, painful inguinal lymphadenitis develops in 30-60% of patients. In 25% of patients this progresses into a suppurative bubo seen below.

Suppurative Bubo
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Some characteristic differences in the ulcerative lesions:

  • Syphilis: The ulcers are nonpainful, with indurated borders.
  • Herpes: The lesions start as vesicles, are usually painful, more superficial, more numerous, and surrounded by a narrower zone of erythema. Adenopathy is usually bilateral.

Diagnosis:

The diagnosis involves the clinical appearance and direct smear or cultures from an ulcer or aspiration from an infected lymph node. The organism appears as a "school of fish" as seen below

Chancroid Organism
click for full-size image

Treatment guidelines are outlined in the CDC guidelines but include either a zithromycin, ceftriaxone, ciprofloxacin, or erythromycin.

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Copyright (©) 2004-2013 Lawrence S. Neinstein, University of Southern California . All rights reserved. Republication or redistribution of the text, table, graphs and photos is expressly prohibited. The University of Southern California shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon.