What is the management of penile ulcers?

Management of Penile Ulcers

The management of penile ulcers requires a systematic diagnostic approach followed by targeted treatment based on the specific etiology, with most cases requiring antimicrobial therapy for herpes, syphilis, or chancroid, which are the most common causes in the United States. 1

Diagnostic Approach

Required Testing

• Serologic test for syphilis (all patients)
• Darkfield examination or direct immunofluorescence for Treponema pallidum
• Culture or antigen test for Herpes Simplex Virus (HSV)
• Culture for Haemophilus ducreyi (in settings where chancroid is prevalent)
• HIV testing (mandatory for patients with syphilis or chancroid, recommended for those with HSV) 1, 2

Clinical Assessment

• Evaluate pain (painful ulcers suggest HSV or chancroid; painless ulcers suggest syphilis)
• Check for lymphadenopathy (suppurative adenopathy suggests chancroid)
• Note number and appearance of ulcers
• Document ulcer location (prepuce, coronal sulcus, frenulum, shaft, or glans) 3

Treatment Algorithm

1. Empiric Treatment

When test results are not immediately available:

• If diagnosis is unclear, treat for the most likely cause based on clinical presentation
• In areas where chancroid is prevalent, consider treatment for both syphilis and chancroid 1

2. Specific Treatments by Etiology

Herpes Simplex Virus (most common in US)

• First episode: Oral acyclovir for 7-10 days
• Recurrent episodes: Oral acyclovir for 5 days
• Alternative medications: Valacyclovir or famciclovir 2, 4

Syphilis

• Intramuscular penicillin G benzathine in a single dose 5

Chancroid (H. ducreyi)

One of the following regimens:

• Azithromycin 1 g orally in a single dose
• Ceftriaxone 250 mg IM in a single dose
• Ciprofloxacin 500 mg orally twice daily for 3 days (contraindicated in pregnant women, lactating women, and persons under 18)
• Erythromycin base 500 mg orally four times daily for 7 days 1, 6

Lymphogranuloma Venereum

• Doxycycline 100mg orally twice daily for 21 days 2, 5

Granuloma Inguinale (Donovanosis)

• Doxycycline 100mg orally twice daily for at least 3 weeks and until all lesions have completely healed 2

Follow-Up Care

Monitoring

• Re-examination 3-7 days after treatment initiation 2
• Signs of treatment failure include:
  • No symptomatic improvement within 3 days
  • No objective improvement within 7 days
  • Worsening symptoms despite therapy
  • Development of new lesions during treatment 2

Wound Care

• Gentle cleansing with sterile saline solution
• Application of plain petrolatum ointment directly to the ulcer
• Cover with non-adherent dressing or petrolatum-impregnated gauze 2

Special Considerations

HIV Co-infection

• May require longer courses of therapy
• Closer monitoring recommended
• HIV-positive patients heal more slowly than HIV-negative patients 2

Treatment Failures

If no improvement after 3-7 days, consider:

• Incorrect diagnosis
• Co-infection with another STD
• HIV infection
• Non-adherence to treatment
• Antimicrobial resistance 2

Partner Management

• Sexual partners should be examined and treated appropriately
• Consider missing co-infections in patients with chancroid 1

Important Caveats

• Up to 25% of patients with genital ulcers have no laboratory-confirmed diagnosis even after complete evaluation 1, 5
• Non-infectious causes should be considered when infectious etiologies are ruled out (trauma, psoriasis, Behçet syndrome, fixed drug eruptions) 5, 7
• Rare causes include Epstein-Barr virus and infectious mononucleosis 7, 8
• Ciprofloxacin is contraindicated for pregnant and lactating women and persons under 18 years 1

By following this systematic approach to diagnosis and treatment, most penile ulcers can be effectively managed, reducing morbidity and preventing transmission of sexually transmitted infections.