Penile Ulcers in Syphilis: Natural Course and Characteristics
Penile ulcers from primary syphilis (chancres) appear once and then spontaneously heal within 3-6 weeks, even without treatment, but the infection progresses to later stages if untreated. 1
Primary Syphilis Ulcer Characteristics
- The primary syphilitic chancre is typically:
- Single, painless, clean-based ulcer
- Appears at the site of inoculation (penile shaft, glans, or foreskin)
- Has indurated (firm) borders
- Develops 10-90 days after exposure
- Heals spontaneously within 3-6 weeks without treatment
- Often accompanied by regional lymphadenopathy
Natural Course of Syphilis Ulcers
- Primary Stage: A single chancre appears and resolves without treatment within 3-6 weeks 1
- Secondary Stage: After the primary chancre heals, the infection becomes systemic with:
- Possible mucocutaneous lesions (not the same as the primary chancre)
- Rash, often involving palms and soles
- Lymphadenopathy
- These manifestations also resolve without treatment 1
- Latent Stage: No visible signs but serologic tests remain positive
- Tertiary Stage: Can develop years later with serious complications affecting multiple organ systems
Important Clinical Considerations
- The primary chancre is self-limited and will heal even without treatment 1
- The disappearance of the ulcer does NOT mean the infection is cured - it has merely progressed to later stages
- New ulcers in the primary stage do not typically recur at the same site
- In secondary syphilis, mucocutaneous lesions may appear but these differ from the primary chancre 1
Diagnostic Approach
- Darkfield examination or direct fluorescent antibody tests of lesion exudate are definitive methods for diagnosing early syphilis 1
- Serologic testing includes:
- Nontreponemal tests (VDRL, RPR) - correlate with disease activity
- Treponemal tests (FTA-ABS, TP-PA) - usually remain positive for life
Treatment
- Recommended treatment for primary syphilis is benzathine penicillin G given intramuscularly as a single dose 1
- Alternative regimen for penicillin-allergic patients is doxycycline 100 mg orally twice daily for 14 days 2
- Treatment cures the infection and prevents progression to later stages
Common Pitfalls and Caveats
- Do not confuse with herpes: Unlike syphilis chancres, herpes lesions are typically painful, multiple, and recurrent
- Do not mistake healing for cure: The spontaneous resolution of the chancre does not indicate cure but progression to secondary syphilis if untreated
- Do not overlook HIV co-infection: Syphilis facilitates HIV transmission and may present atypically in HIV-positive patients 2
- Do not miss partner notification: Essential to prevent reinfection and further transmission 2
Remember that while the primary syphilitic chancre will heal on its own, the infection remains and progresses through its stages if not properly treated with antibiotics.