Differential Diagnosis of Genital Ulcers

Ulcer
STDs Ulcers
Organism Description Management
Genital ulcer :
• Button-like papule that develops into a Not Allergic to penicillin:
Syphilis (Chancre) Treponema Pallidum painless erosion and then ulcerates with
Penicillin G Benzathine
raised border & scanty serous exudate. (Single dose of 2.4 milion units , IM )
IP : 9-90
90 days Surface may be crusted.
- Site: genital (95%) & extragenital (5%) In Allergy to Penicillin :
- Shape: rounded or oval , regular & well-defined.
defined. Doxycycline
- Surface: dull red, clean , oozing (scanty serous exud.) (100 mg, PO , twice a day / for 2 W. )
- Edge: sloping
- Base: indurated.
- Palpation: firm
- Number :
- single ( common ) ;
- few multiple, or kissing lesions ( less commonly)
- Pain: Painless (unless superinfected with S.aureus)

Regional LNs :
Regional lymphadenopathy appears within 7 days.
Nodes are :
- Discrete,
- Firm, rubbery,
- Non-tender,
- Unilateral (more commonly).

Genital ulcer :
• Tender papule with erythematous halo that Azithromycin
Chancroid Hemophilus Ducreyi evolves to pustule erosion, ulcer. ( 1 g , PO , single dose )
(Soft Chancre) Ceftriaxone
IP : 4-7
7 days - Site: genital & extragenital. ( 250 mg , IM , single dose )
- Shape: oval , well-defined. Ciprofloxacin
- Surface: Floor: covered with gray to yellow exudate. ( 500 mg, PO , twice for 3 D )
- Edge: Undermined.
- Base: It is friable with granulation tissue (not indurated)
- Margin: surrounded by erythematous halo.
- Palpation: Soft
- Number:
- Multiple (common), merging to form large
or giant ulcers (>2 cm) with serpiginous shape.
- Singular.
- Pain: Painful.
Regional LNs : The genital ulcer is followed by :
Painful inguinal lymphadenitis appears 7–21
21 days
after primary lesion :
- matted
- Firm at first
- Tender
- Unilateral (more commonly)
- Adherent to the overlying skin which is red,
hot , edematous & tender.

Genital ulcer :
- Painless, granulating , progressive, ulcerative Trimethoprim-
Granuloma inguinale Calymmatobacterium
lesions of the genital & perianal areas.
granulomatis Sulfamethoxazole
- Highly vascular (i.e., a beefy red appearance)
appearanc ( one double-strength tablet twice)
and bleed easily on contact.
IP : 2-6
6 weeks
- Spreads by : Doxycycline
(100 mg, PO , twice a day)
• direct extension or
• autoinoculation of approximated skin surfaces
BOTH for 3 weeks
Regional LNs :
- No regional lymphadenopathy.
- Large subcutaneous nodule may mimic a
lymph node, i.e., pseudobubo .
 Genital ulcer :
Transient primary genital ulcer: Recommended :
Lymphogranuloma Invasive chlamydia
- Small , painless, papule/or vesicle which Azithromycin
Venerum Trachomatis breaks into non-indurated ulcer ( 1 g , PO , single dose )
( Serotype: L1 , L2 , L3 )
- Single , or grouped small ulcers (herpetiform) Doxycycline
- Heals within few days (100 mg, PO , twice/ for 7 days)
IP :
1ry stage: 3- 12 days In heterosexual Males Alternative :
- Cordlike lymphangitis of dorsal penis may follow. Erythromycin base
2ry stage: 10 – 30 days - Lymphangial abscess (bubonulus) may rupture, resulting in
( 500 mg PO four Ames/ for 7 days )
sinuses and fistulas of urethra and deforming scars of
penis.
Females Cervicitis, perimetritis, salpingitis may occur.
Receptive Anal Intercourse (Women or men) :
Primary anal rectal infection:
hemorrhagic proctitis + with regional lymphadenitis

Regional LNs : The genital ulcer is followed by :

Inguinal Syndrome ( Inguinal lymphadenitis ) :
Painful inguinal lymphadenopathy appearing 2–6 W.
after presumed exposure.
• Initially, nodes are discrete,
• BUT with progressive periadenitis results in:
in
a matted mass of nodes which become
fluctuant & suppurative.
• “Groove” sign: Extensive enlargement of inguinal
nodes above & below the inguinal ligament (nonspecific)
• Overlying skin becomes :
Fixed – inflamed – thin - eventually develops
multiple draining fistulas.
- Usually unilateral
- Palpable iliac/femoral nodes often present on
same side.

Transmission :
• Usually skin-to-skin contact.
Genital Herpes HSV- 2 , >= 90% of cases • Transmission occurs during times of Oral Acyclovir
HSV-1
1, 10% of cases asymptomatic HSV shedding (70%) (400 mg, three times/ for 7–10 days)
( Herpes Progentalis )
• Transmission in discordant couples (one partner
IP : 2-20 days infected, the other not) (10%).
Symptoms :
Primary GH
• Asymptomatic ( Most common )
• Symptomatic: constitutional symptoms fever,
headache, malaise, myalgia (occurs only in 1ry)
• Depending on location, pain, itching, dysuria,
lumbar radiculitis, vaginal or urethral discharge
are common symptoms.
• Deep pelvic pain associated with pelvic
lymphadenopathy.
Recurrent GH
• Common symptoms: itching, burning, fissure,
redness, irritation prior to eruption of vesicles.
• Dysuria, sciatica, rectal discomfort.

Genital Ulcer :
Burning sensation precedes appearance of :
Initially, an erythematous plaque is noted ,followed
,fo
soon by grouped vesicles may evolve to pustules,
pustules
as the overlying epidermis sloughs ,they become
eroded Erosions may enlarge to ulcerations;
ulcerations

They heal in 2–4 weeks,( but followed by recurrence)

- Often with postinflammatory hypo- or
hyperpigmentation,
- uncommonly with scarring.

Regional LNs :
Inguinal/femoral lymphadenopathy :
- nodes enlarged,
- firm, nonfluctuant,
- tender;
- usually unilateral.
 Non-STDs Ulcers
- The ulcer appear immediately after the trauma
Traumatic ulcer
- Soft , tender

Fixed drug eruption - Recurrent, superficial , soft erosion with

h surrounding violacious margin
- Lymph nodes are not enlarged

Scabies - The causative organism is sarcoptes scabii, which could be demonstrated in scrapings the lesion
- Itching , which is more severe at night
- Other lesions of scabies present in characteristic sites

- History of pyogenic abscess preceding the ulcer

Pyogenic ulcer
- Soft , purulent floor

- Old age patient

Malignant ulcer
- Everted edges, hard, friable and bleed easily

- Recurrent, multiple , superficial , tender ulcers on the scrotum or genitals

Behcet's ulcer
- The ulcer is accompanied by :
• Apthous ulcers in mouth and
• Iritis.