What is the workup for a painful penile ulcer in a gay man with a new partner and no discharge?

From the Guidelines

The workup for a painful penile ulcer in a gay man with a new partner should include testing for several sexually transmitted infections (STIs), with a focus on herpes simplex virus (HSV), syphilis, and HIV, given the high prevalence of these infections in this population 1. Initial evaluation should involve a thorough physical examination and comprehensive STI panel including:

• Serologic tests for syphilis (RPR/VDRL with confirmatory treponemal test)
• HIV testing
• Hepatitis B and C testing Direct sampling of the ulcer for HSV PCR testing is essential, as genital herpes is a common cause of painful genital ulcers 1. Additionally, nucleic acid amplification tests (NAATs) for gonorrhea and chlamydia from urethral, rectal, and pharyngeal sites should be performed based on sexual practices. Lymphogranuloma venereum (LGV) and chancroid testing may be considered in certain geographic regions. While awaiting results, empiric treatment with acyclovir 400mg orally three times daily for 7-10 days may be initiated if herpes is suspected based on clinical presentation 1. The absence of discharge suggests against urethritis, but comprehensive testing remains important as co-infections are common. Patient counseling should include abstinence from sexual activity until treatment is completed and partners are notified. The evaluation should occur promptly as early diagnosis improves treatment outcomes and prevents transmission to others.

From the Research

Workup for Painful Penile Ulceration

The workup for a painful penile ulcer in a gay man with a new partner and no discharge involves considering various infectious and noninfectious causes.

• The differential diagnosis includes:
  • Herpes simplex virus (HSV) infection 2, 3, 4
  • Syphilis 5, 2, 3, 4
  • Lymphogranuloma venereum (LGV) 5, 2, 3
  • Chancroid 2, 3, 4
  • Traumatic ulceration 6
  • Other noninfectious causes such as inflammatory or malignant conditions 2

Diagnostic Approach

• A thorough medical history and physical examination are essential in evaluating the patient 3, 4
• Laboratory tests, including polymerase chain reaction (PCR) and antibody tests, can help identify the underlying cause of the ulcer 3
• The clinical presentation of genital ulcers can be variable, and the classic signs and symptoms of each disease may not always be present 4
• A high index of suspicion for HSV-2 infection is necessary, given its high prevalence in men with genital ulcers 3

Considerations in Gay Men

• Gay men may be at higher risk for certain infections, such as LGV and syphilis 5, 3
• The presence of other sexually transmitted infections (STIs) should be considered, and patients should be screened for STIs such as gonorrhea, chlamydia, and HIV 5, 3
• The use of empirical treatment for gonorrhea and chlamydia in patients with ulcers and dysuria but without urethral discharge should be cautious, given the high prevalence of HSV-2 infection in this population 3