What are the principal diseases causing genital ulcers, their risk factors, clinical manifestations, diagnosis, treatment, and follow-up?

From the Guidelines

Las úlceras genitales son causadas principalmente por infecciones de transmisión sexual, incluyendo el virus del herpes simple (HSV), la sífilis, el chancroide, la linfogranuloma venéreo (LGV) y el granuloma inguinale. Los principales factores de riesgo incluyen el sexo sin protección, múltiples parejas sexuales, antecedentes de infecciones de transmisión sexual y estado inmunocomprometido. Las manifestaciones clínicas varían según el patógeno:

• HSV: presenta con vesículas dolorosas y agrupadas que se rompen en úlceras
• Sífilis: causa úlceras induradas y sin dolor (cáncre)
• Chancroide: produce úlceras dolorosas y blandas con bordes irregulares
• LGV: comienza con una pequeña pápula indolora que se ulceriza y progresa a linfadenopatía
• Granuloma inguinale: se presenta como úlceras rojas y sin dolor que sangran con facilidad. El diagnóstico implica evaluación clínica, pruebas serológicas, PCR, cultivo y microscopía. El tratamiento depende del agente causante:
• HSV: se trata con aciclovir 400mg oral tres veces al día durante 7-10 días (primer episodio) o 5 días (recurrente) 1
• Sífilis: requiere benzatina penicilina G 2,4 millones de unidades IM como dosis única para la sífilis primaria
• Chancroide: responde a azitromicina 1g oral como dosis única o ceftriaxona 250mg IM como dosis única
• LGV: requiere doxiciclina 100mg oral dos veces al día durante 21 días
• Granuloma inguinale: se trata con doxiciclina 100mg oral dos veces al día durante al menos 3 semanas. El seguimiento incluye evaluación clínica, pruebas serológicas para sífilis a los 3,6 y 12 meses, notificación y tratamiento de parejas, y prueba de VIH debido al aumento del riesgo de transmisión con úlceras genitales. Es importante tener en cuenta que la mayoría de las infecciones por HSV son transmitidas por personas que no saben que están infectadas o son asintomáticas cuando se produce la transmisión, por lo que el diagnóstico y el tratamiento oportunos son cruciales para prevenir la propagación de la infección 1.

From the FDA Drug Label

1 INDICATIONS AND USAGE 1.1 Adult Patients Genital Herpes Initial Episode: VALTREX is indicated for treatment of the initial episode of genital herpes in immunocompetent adults.

Genital ulcer disease in men due to Haemophilus ducreyi (chancroid). Due to the small number of women included in clinical trials, the efficacy of azithromycin in the treatment of chancroid in women has not been established

The principal diseases in genital ulcers are:

• Genital Herpes: caused by the herpes simplex virus (HSV), treated with valacyclovir 2
• Chancroid: caused by Haemophilus ducreyi, treated with azithromycin 3

Risk factors for genital ulcers include:

• Sexual transmission: genital herpes and chancroid can be transmitted through sexual contact
• Immunocompromised status: individuals with weakened immune systems are more susceptible to genital herpes and other infections

Clinical manifestations of genital ulcers include:

• Painful ulcers or sores: on the genitals, anus, or thighs
• Itching or burning: in the genital area
• Swollen lymph nodes: in the groin area

Diagnosis of genital ulcers is typically made through:

• Physical examination: visual inspection of the ulcers
• Laboratory tests: such as viral culture or PCR to confirm the presence of HSV or other pathogens

Treatment of genital ulcers depends on the underlying cause:

• Antiviral medication: such as valacyclovir for genital herpes 2
• Antibiotics: such as azithromycin for chancroid 3

Follow-up care for genital ulcers includes:

• Monitoring for symptoms: to ensure the infection is resolving
• Prevention of transmission: through safe sex practices and avoidance of contact with the ulcers
• Screening for other STIs: to detect and treat any co-infections 2 3

From the Research

Principal Diseases in Genital Ulcers

• Herpes simplex virus infection and syphilis are the most common causes of genital ulcers in the United States 4
• Other infectious causes include chancroid, lymphogranuloma venereum, granuloma inguinale (donovanosis), secondary bacterial infections, and fungi 4
• Noninfectious etiologies, including sexual trauma, psoriasis, Behçet syndrome, and fixed drug eruptions, can also lead to genital ulcers 4

Risk Factors

• High prevalence of HIV infection (73%) was found in patients with genital ulcers, but there was no difference between HIV-positive and HIV-negative patients in the clinical presentation and etiology of genital ulcer disease 5

Clinical Manifestations

• Genital ulcers may present with unique features that can help clinicians identify the etiology and start treatment in a timely manner 6
• The clinical presentation of infectious and noninfectious genital ulcers can vary depending on the etiology 6

Diagnosis

• Initial treatment of genital ulcers is generally based on clinical presentation, but the following tests should be considered in all patients: serologic tests for syphilis and darkfield microscopy or direct fluorescent antibody testing for Treponema pallidum, culture or polymerase chain reaction test for herpes simplex virus, and culture for Haemophilus ducreyi in settings with a high prevalence of chancroid 4
• A syndromic approach can be used to diagnose and manage genital ulcers, especially in situations where no laboratory support is available 5
• The diagnostic accuracy of syndromic management for genital ulcer disease has been evaluated, and the results show that algorithms requiring a clinical diagnosis to determine and treat the aetiology of GUD have poor sensitivities for syphilis and herpes simplex virus 7

Treatment

• The first episode of herpes simplex virus infection is usually treated with seven to 10 days of oral acyclovir (five days for recurrent episodes) 4
• Famciclovir and valacyclovir are alternative therapies for herpes simplex virus infection 4
• One dose of intramuscular penicillin G benzathine is recommended to treat genital ulcers caused by primary syphilis 4
• Treatment options for chancroid include a single dose of intramuscular ceftriaxone or oral azithromycin, ciprofloxacin, or erythromycin 4, 8
• Lymphogranuloma venereum and donovanosis are treated with 21 days of oral doxycycline 4

Follow-up

• No specific follow-up recommendations are provided in the studies, but it is likely that patients with genital ulcers will require follow-up care to monitor the effectiveness of treatment and to manage any potential complications 4, 5, 6, 7, 8