Ano-genital ulcers can be caused by a wide variety of infectious and non-infectious conditions.
|Ulcers||Herpes simplex viruses (HSV) 1 and 2 are the most common causes. Ulcers are generally painful and commence as vesicles. Inguinal nodes often tender.
Syphilis causes relatively less painful ulcers, more likely if sexual exposure to men who have sex with men (MSM), remote Aboriginal populations and outside Australia. Lesions often indurated and may have non-tender lymphadenopathy. Lesions can be painful if super-infected by other microbes.
Rarer infectious causes include donovanosis, lymphogranuloma venereum (LGV) and chancroid. Non-infectious causes include fixed drug eruptions, aphthous ulcers, trauma, carcinoma and Crohn’s disease.
Swab of base of ulcer or de-roofed vesicle
Swab of base of ulcer
Serology. If clinical suspicion of syphilis, refer to the syphilis guideline.
|Donovanosis||Dry swab or punch biopsy of lesions.||Histology has low to moderate sensitivity but highly specific; requires experienced histopathologist as classic Donovan bodies may be sparse.
NAAT is highly sensitive and specific but NAAT only available in research laboratories.
|Lymphogranuloma venereum (LGV)||Swab from ulcer||NAAT (chlamydia)|
|Chancroid||If chancroid suspected, seek specialist advice.|
|NAAT – Nucleic Acid Amplification Test|
|Principal Treatment Options|
Aciclovir 400mg PO, TDS for 5 days
Episodic therapy: Famciclovir 1g PO, BD for 1 day
Suppressive therapy: Famciclovir 250mg PO, BD for 6 months.
|Syphilis #||Benzathine penicillin 1.8g IMI, stat.||Procaine penicillin 1.5g IMI, daily for 10 days.|
|Donovanosis||Azithromycin 500mg PO, daily for 7 days
Azithromycin 1g PO, once weekly for at least 4 weeks, until complete resolution of lesions.
|Doxycycline 100mg PO, BD for a minimum of 4 weeks, until complete resolution of lesions.|
|Lymphogranuloma venereum (LGV)||Doxycycline 100mg PO, BD for 21 days.||Alternative regimens are not recommended due to lack of efficacy data. If alternative regimen required, seek specialist advice.|
|Chancroid||Azithromycin 1g PO, stat
Ceftriaxone 500mg in 2mL of 1% lignocaine IMI, stat
Ciprofloxacin 500mg PO, BD for 3 days.
|Alternative regimens are not recommended.|
*Limited evidence comparing other antiviral agents (aciclovir and famciclovir) with valaciclovir indicate that they are therapeutically equivalent for treating herpes. The ability for the patient to adhere to the recommended dosing frequency should be considered when selecting the appropriate treatment. Initial episodes of herpes may require a longer duration of treatment.
#Seek specialist advice for all patients who are pregnant, hypersensitive to penicillin or who are HIV positive.
Other immediate management
- If a specific STI is considered likely refer to the disease specific guideline for information on advice to patient of any requirement to abstain from sexual contact.
- When diagnosis is in doubt consider recommending abstinence until results of diagnostic tests are available, especially where significant behavioural risk factors are present.
- Contact tracing.
- Contact tracing is a high priority for syphilis, donovanosis, lymphogranuloma venereum (LGV) and chancroid and should be performed in all patients with confirmed infection.
- If the contact of syphilis is confirmed (i.e. the named contact names the index case) then treatment should be offered even if the serology is negative.
- Contact tracing for herpes is not recommended.
See Australasian Contract Tracing Manual for more information.
- Confirm patient adherence with treatment and assess for symptom resolution.
- Confirm contact tracing procedures have been undertaken or offer more contact tracing support.
- Provide further sexual health education and prevention counselling.
Consider alternative diagnoses, biopsy or referral for any lesions not responding as expected to treatment.
For test of cure (TOC) and retesting advice see:
100% of patients complaining of a genital ulcer have a genital examination.