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, chancroid, and lymphogranuloma venereum (LGV), as these are the most common causes of genital ulcers in this population, as noted in the 1993 CDC guidelines 1. The initial evaluation should involve a comprehensive sexual history and physical examination, followed by specific tests for these infections.

• Testing should include:
  • HSV PCR or viral culture from the ulcer
  • Serologic testing for syphilis (RPR/VDRL and treponemal-specific tests)
  • HIV testing
• Additional tests may include nucleic acid amplification tests (NAATs) for gonorrhea and chlamydia from the ulcer and other relevant sites (urethra, rectum, pharynx), as outlined in the 2018 guide to utilization of the microbiology laboratory for diagnosis of infectious diseases 1. While awaiting results, empiric treatment may be considered based on the clinical presentation, as recommended in the 1998 HIV prevention guidelines 1.
• For suspected herpes, valacyclovir 1g orally twice daily for 7-10 days is recommended.
• For suspected syphilis, benzathine penicillin G 2.4 million units IM as a single dose is the standard treatment. The patient should abstain from sexual activity until healing is complete and should be counseled about safer sex practices, including condom use.
• Partners should be notified and tested as well, to prevent further transmission of infection. Early diagnosis and treatment are crucial to prevent complications and further transmission of infection, highlighting the importance of prompt and thorough evaluation and management of painful penile ulcers in high-risk populations.

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