What is the treatment for a patient with a painless genital ulcer, one sexual partner, no previous Sexually Transmitted Infection (STI), and no lymphadenopathy?

From the Guidelines

The patient with a painless genital ulcer, one sexual partner, no previous Sexually Transmitted Infection (STI), and no lymphadenopathy should be treated for syphilis.

Diagnosis and Treatment

• The diagnosis of genital ulcers should include a serologic test for syphilis and diagnostic evaluation for herpes, as the diagnosis based on medical history and physical examination alone is often inaccurate 1.
• The patient's presentation of a painless genital ulcer is consistent with primary syphilis, which is typically characterized by a single, painless chancre at the site of inoculation.
• Presumptive treatment for primary syphilis is recommended in persons who have new onset genital ulcers and are from communities or groups with high syphilis rates, or if there are doubts about follow-up or adherence to recommendations 1.
• The treatment for syphilis typically involves the administration of benzathine penicillin G 2.4 million units IM as a single dose.

Rationale

• The evidence suggests that a diagnosis based on history and physical examination alone is often inaccurate, and therefore, laboratory tests such as serologic tests for syphilis and diagnostic evaluation for herpes are necessary to guide treatment 1.
• The patient's presentation and lack of previous STI history do not necessarily rule out syphilis, and therefore, presumptive treatment is recommended to prevent further complications and transmission.
• While genital herpes is a possible cause of genital ulcers, the patient's presentation of a painless ulcer is more consistent with syphilis, and therefore, treatment for syphilis is the most appropriate course of action 1.

From the FDA Drug Label

Genital ulcer disease (chancroid)One single 1 gram dose Urethritis and cervicitis due to Chlamydia trachomatis or Neisseria gonorrhoeae. Genital ulcer disease in men due to Haemophilus ducreyi (chancroid).

The treatment for a patient with a painless genital ulcer, one sexual partner, no previous Sexually Transmitted Infection (STI), and no lymphadenopathy is Azithromycin 1 gram single dose for chancroid, but the cause of the ulcer is not specified. Key considerations:

• The patient should have a serologic test for syphilis and appropriate cultures for gonorrhea performed at the time of diagnosis.
• Appropriate antimicrobial therapy and follow-up tests for these diseases should be initiated if infection is confirmed.
• Azithromycin should not be relied upon to treat syphilis. 2

From the Research

Treatment Options for Genital Ulcers

The treatment for a patient with a painless genital ulcer, one sexual partner, no previous Sexually Transmitted Infection (STI), and no lymphadenopathy depends on the underlying cause of the ulcer.

• The most common causes of genital ulcers in the United States are herpes simplex virus infection and syphilis 3.
• Other infectious causes include chancroid, lymphogranuloma venereum, granuloma inguinale (donovanosis), secondary bacterial infections, and fungi 3, 4.
• Noninfectious etiologies, including sexual trauma, psoriasis, Behçet syndrome, and fixed drug eruptions, can also lead to genital ulcers 3, 4.

Diagnostic Tests

The following tests should be considered in all patients with genital ulcers:

• Serologic tests for syphilis and darkfield microscopy or direct fluorescent antibody testing for Treponema pallidum 3.
• Culture or polymerase chain reaction test for herpes simplex virus 3.
• Culture for Haemophilus ducreyi in settings with a high prevalence of chancroid 3.

Treatment Modalities

Treatment options for genital ulcers include:

• Oral acyclovir for 7-10 days for the first episode of herpes simplex virus infection 3, 5.
• One dose of intramuscular penicillin G benzathine for genital ulcers caused by primary syphilis 3, 5.
• A single dose of intramuscular ceftriaxone or oral azithromycin for chancroid 3, 5.
• 21 days of oral doxycycline for lymphogranuloma venereum and donovanosis 3.