Genital ulcers may be painful or painless and frequently are accompanied by inguinal lymphadenopathy (a break in the continuity of the skin or mucosa of the genitalia). They increase a patient’s susceptibility to HIV infection.

CAUSES

• Syphilis
• Chancroid
• Lymphogranuloma venereum
• Herpes simplex
• Granuloma inguinale

SYMPTOMS AND SIGNS

• Classical herpes lesions can be recognized by their appearance, which is a painful cluster of vesicles. These vesicles later break down into superficial ulcers in crops. The patient often gives a history of past episodes of similar lesions

• Ulcers due to chancroid are painful and have undermined ragged edges. The base is covered with a dirty purulent exudate and easily bleeds on touch

• Painless, indurated lesions with regular edges are most often due to syphillis

• A red beefy looking ulcer with an offensive discharge may be granuloma inguinale

However, because genital ulcers often do not correspond to classic descriptions, in the syndromic management, initial management should be directed at both syphilis and chancroid.

TREATMENT

If lesions are typical of herpes, then treat accordingly i.e. keep dry and clean and give analgesics if needed.

SYPHILIS

• Benzathine Penicillin, IM, 2.4 million units in 2 divided doses during one clinic visit; give one injection in each buttock.

or

• Aqueous Procaine Benzylpenicillin (Procaine Penicillin), deep IM, 1.2 million units daily, for 10 days

For persons allergic to penicillin use:

• Doxycycline, oral, 100 mg 12 hourly for 15 days.or
Tetracycline, oral, 500 mg 6 hourly for 15 days or
Erythromycin, oral, 500 mg 6 hourly for 15 days

plus

CHANCROID

• Ciprofloxacin, oral, 500mg 2 times daily for 3 days

or

Ceftriaxone, IM, 250mg stat or
Erythromycin, oral, 500mg 6 hourly for 7 days

If the ulcer is improved after treatment, but not healed, repeat the treatment.

REFER

If the ulcer is no better or worse after treatment, refer to a facility with microbiology support to exclude other causes

Genital ulcers may be managed via the flow chart below

GENITAL ULCER DISEASE FLOW CHART

HEALTH EDUCATION

Management of STIs is not complete without patient education and counselling.

Necessary education to each STI patient includes the following:

1. Notification of partner(s) (Contact tracing)

• Tell the patient that the ailment they have was aquired through sex
• Tell the patient to inform his/her sexual partners in the last 3 months so that they may also be treated.

2. Compliance

• Tell the patient how to take the medicine

• Tell the patient to refrain from sex until all symptoms are gone and treatment of patients and their partners have been completed

• Tell the patient to return to the clinic if treatment fails

• The patient should avoid self medication and traditional remedies

3. Condom use

• Provide condoms and show how to use them

4. Risk reduction education

• Explain the risks and possible complications of the various STIs
• Counsel patients to reduce the number of sexual partners they have
• Counsel patients to avoid sex with persons who have multiple sexual partners

Remember that the patient with one STI may have another infection such as HIV.