Ano-genital Ulcers
Overview
Ano-genital ulcers can be caused by a wide variety of infectious and non-infectious conditions.
Possible causes
• STIs: Herpes simplex viruses (HSV), syphilis, lymphogranuloma venereum (LGV), donovanosis, chancroid
• Other conditions: Fixed drug eruptions, aphthous ulcers, trauma, carcinoma, Crohn’s disease.
Clinical presentation
| Symptoms | Comments/Considerations |
|---|---|
| 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. |
Diagnosis
| Infection | Site/Specimen | Test |
|---|---|---|
| Herpes |
Swab of base of ulcer or de-roofed vesicle |
NAAT |
| Syphilis |
Swab of base of ulcer Blood |
NAAT 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 | ||
Specimen collection
Urethral swabs for microscopy should be collected when the patient has not urinated for at least 1 hour and only if the patient has frank urethral discharge. Squeeze the urethra to express the discharge and collect on urethral swab. It is not necessary to insert the swab into the urethra. Vaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient.Clinician collected for NAAT/culture/microscopy
Rectal swabs should be collected by inserting a sterile swab 2-4cms into the anal canal and moving the swab gently side to side for 10-20 seconds.
Pharyngeal swabs should be collected from the tonsils and oropharynx.
High vaginal swab of vaginal discharge smeared onto a glass slide, air dried and sent for microscopy. Swab inserted into transport medium for culture.Self-collection of samples for NAAT testing
Management
| Principal Treatment Options | ||
|---|---|---|
| Infection | Recommended | Alternative |
| Herpes* |
Initial episode: |
Initial episode: Aciclovir 400mg PO, TDS for 5 days Recurrence: 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 OR 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 OR Ceftriaxone 500mg in 2mL of 1% lignocaine IMI, stat OR Ciprofloxacin 500mg PO, BD for 3 days. |
Alternative regimens are not recommended. |
Treatment advice
*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
- 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.
Follow up
- 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:
Auditable outcomes
100% of patients complaining of a genital ulcer have a genital examination.