What is the management for a patient with penile ulcers and a positive Venereal Disease Research Laboratory (VDRL) test indicating syphilis?

Management of Penile Ulcers with Positive VDRL

Treat immediately with benzathine penicillin G 2.4 million units intramuscularly as a single dose for early syphilis (primary or secondary stage), which is the most likely diagnosis given the presence of penile ulcers with positive VDRL. 1

Initial Diagnostic Approach

Before or concurrent with treatment, perform the following evaluations:

• Darkfield microscopy or direct fluorescent antibody testing of the ulcer exudate - this is the definitive diagnostic method for early syphilis when lesions are present and should be prioritized 1, 2
• Quantitative nontreponemal test (VDRL or RPR) - document the baseline titer as this will be essential for monitoring treatment response 1, 2
• Treponemal test confirmation (FTA-ABS or TP-PA) - to confirm true syphilis infection versus false-positive VDRL 2, 3
• HIV testing - mandatory for all patients with syphilis, as HIV coinfection affects management and follow-up 1
• Evaluation for other sexually transmitted infections - including HSV culture or antigen testing and consideration of chancroid (Haemophilus ducreyi) if in endemic areas 1

Treatment Algorithm Based on Stage

Primary Syphilis (Most Likely with Penile Ulcer)

• Benzathine penicillin G 2.4 million units IM as a single dose 1, 3, 4
• This covers the typical presentation of a painless penile chancre with positive serology 4

If Neurologic or Ocular Symptoms Present

• Perform lumbar puncture for CSF examination - any patient with neurologic symptoms (headache, vision changes, hearing loss, confusion) or ocular manifestations (uveitis, neuroretinitis) requires CSF evaluation 1
• If neurosyphilis confirmed: Aqueous crystalline penicillin G 18-24 million units per day IV (administered as 3-4 million units every 4 hours) for 10-14 days 1

Penicillin Allergy Considerations

• For non-pregnant patients with early syphilis: Doxycycline 100 mg orally twice daily for 14 days is an acceptable alternative 1, 3
• For pregnant patients or neurosyphilis: Penicillin desensitization is mandatory, as penicillin is the only proven effective treatment 1

Critical Follow-Up Protocol

• Clinical and serologic evaluation at 6 and 12 months post-treatment using quantitative nontreponemal tests (same method, same laboratory) 1, 3
• Treatment success is defined by a fourfold decline in nontreponemal titer (e.g., from 1:32 to 1:8) within 6-12 months 1, 2, 3
• If HIV-positive: More frequent monitoring at 3-month intervals instead of 6-month intervals 1, 3

Common Pitfalls to Avoid

• Do not delay treatment waiting for darkfield results - if clinical suspicion is high and diagnostic capabilities are limited, treat empirically for syphilis 1
• Do not use treponemal test titers to monitor treatment response - these remain positive for life in most patients regardless of cure 1, 2, 3
• Do not compare VDRL and RPR titers directly - use the same test method throughout follow-up 1, 2
• Do not assume treatment failure with persistent low titers - some patients remain "serofast" with stable low titers (typically <1:8) despite adequate treatment 3

Partner Management

• All sexual contacts within the past 90 days (for primary syphilis) should be evaluated clinically and serologically and treated presumptively 1
• Sexual transmission occurs only when mucocutaneous lesions are present, which is uncommon after the first year of infection 1

Special Consideration: Jarisch-Herxheimer Reaction

• Warn patients about possible acute febrile reaction within 24 hours of treatment, characterized by fever, headache, and myalgia 1
• This reaction is common in early syphilis and does not indicate treatment failure 1
• Antipyretics may be recommended, though no proven prevention methods exist 1