What are the causes of penile ulcers and their treatment options?

From the Guidelines

Penile ulcers are most effectively managed by treating the underlying cause, with the most common causes being sexually transmitted infections (STIs) such as syphilis, genital herpes, chancroid, and lymphogranuloma venereum, and non-STI causes including Behçet's disease, trauma, fixed drug eruptions, and rarely, penile cancer. The treatment approach should prioritize the patient's quality of life, morbidity, and mortality, with a focus on promptly suppressing inflammatory exacerbations and preventing irreversible organ damage, as highlighted in the 2018 update of the EULAR recommendations for the management of Behçet's syndrome 1. For STIs, treatment guidelines from the Centers for Disease Control and Prevention (CDC) recommend specific antibiotic regimens, such as a single intramuscular injection of benzathine penicillin G 2.4 million units for syphilis, antiviral medications like acyclovir or valacyclovir for genital herpes, and azithromycin or ceftriaxone for chancroid 1. Key considerations in managing penile ulcers include:

• Proper diagnosis through physical examination, STI testing, and sometimes biopsy
• Keeping the area clean and avoiding sexual contact while lesions are present, as advised by the CDC 1
• Using pain relievers to manage symptoms while awaiting diagnosis
• Prompt medical attention to address potential complications, especially for causes like penile cancer that require urgent treatment
• Individualized treatment based on the patient's specific condition, age, gender, and preferences, as emphasized in the EULAR recommendations for Behçet's syndrome 1. In cases of Behçet's disease, vigorous treatment is required to prevent scarring and obliterative complications, particularly when there is chronic oral and genital ulceration, and immunosuppressives may be necessary to rapidly suppress inflammation and prevent relapses 1. Overall, a multidisciplinary approach and individualized treatment plan are essential for optimal care and improving patient outcomes.

From the FDA Drug Label

Genital Herpes Initial Episode: VALTREX is indicated for treatment of the initial episode of genital herpes in immunocompetent adults. Genital ulcer disease in men due to Haemophilus ducreyi (chancroid).

The causes of penile ulcer include genital herpes and chancroid. The treatment for penile ulcer includes:

• Valacyclovir (PO) for the treatment of the initial episode of genital herpes in immunocompetent adults 2
• Azithromycin (PO) for the treatment of genital ulcer disease in men due to Haemophilus ducreyi (chancroid) 3

From the Research

Causes of Penile Ulcer

• Herpes simplex virus infection and syphilis are the most common causes of genital ulcers, including penile ulcers, in the United States 4, 5
• Other infectious causes include chancroid, lymphogranuloma venereum, granuloma inguinale (donovanosis), secondary bacterial infections, and fungi 4, 6, 7, 8
• Noninfectious etiologies, including sexual trauma, psoriasis, Behçet syndrome, and fixed drug eruptions, can also lead to penile ulcers 4, 5, 8

Treatment of Penile Ulcer

• The first episode of herpes simplex virus infection is usually treated with seven to 10 days of oral acyclovir (five days for recurrent episodes) 4
• Famciclovir and valacyclovir are alternative therapies for herpes simplex virus infection 4
• One dose of intramuscular penicillin G benzathine is recommended to treat penile ulcers caused by primary syphilis 4
• Treatment options for chancroid include a single dose of intramuscular ceftriaxone or oral azithromycin, ciprofloxacin, or erythromycin 4, 6
• Lymphogranuloma venereum and donovanosis are treated with 21 days of oral doxycycline 4
• Treatment of noninfectious causes of penile ulcers varies by etiology, and ranges from topical wound care for ulcers caused by sexual trauma to consideration of subcutaneous pegylated interferon alfa-2a for ulcers caused by Behçet syndrome 4