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Infectious Diseases and Microbiology: Genital Lesions and Ulcers
Basics
Description
Genital lesions involve the reproductive organs and can result from a range of infectious and noninfectious conditions.
Epidemiology
Genital ulcers are the most frequent sexually transmitted cause of genital lesions. In North America and Europe, the leading sexually transmitted causes of genital ulcer disease are herpes simplex and syphilis. In the United States, a substantial proportion of people aged 14–49 have HSV-2 infection, and HSV-1 accounts for a significant minority of genital herpes cases. Chancroid is more common in Africa, Asia, and Latin America but can occur in sporadic U.S. outbreaks. Lymphogranuloma venereum is uncommon in industrialized countries, though outbreaks have been reported among men who have sex with men.
Risk Factors
About half of exposed sexual partners may acquire genital warts (HPV) after contact with an infected partner. Sexual transmission of syphilis can be high, with rates reported up to roughly one-third per exposure.
General Prevention
Risk reduction includes abstinence, consistent condom use, limiting partners, safer-sex practices, and HPV vaccination. Two HPV vaccines are available for females aged 9–26 that protect against HPV 6 and 11 (responsible for most genital warts) and HPV 16 and 18 (responsible for a large proportion of cervical cancers): the quadrivalent vaccine (Gardasil) and the bivalent vaccine (Cervarix). Quadrivalent vaccination in males aged 9–26 can reduce genital warts.
Etiology
Infectious Ulcers
Common causes include genital herpes, syphilis due to Treponema pallidum, chancroid due to Haemophilus ducreyi, lymphogranuloma venereum from Chlamydia trachomatis serovars L1–L3, donovanosis (granuloma inguinale) from Klebsiella granulomatis, and less commonly tuberculosis or tularemia. Additional reported etiologies include candidiasis, histoplasmosis, amebiasis, gonorrhea, and trichomoniasis. Acute or primary HIV infection can present with genital ulcers, and a notable minority of ulcer cases involve more than one pathogen.
Noninfectious Ulcers
Noninfectious causes include trauma, fixed drug eruption, malignancy, systemic lupus erythematosus, and Behçet disease.
Other Lesion Patterns
Papules may be due to candidiasis, molluscum contagiosum, scabies, syphilis, or condylomata acuminata from HPV, with types 6 and 11 most common and types 16, 18, 31, 33, and 35 linked to cervical dysplasia. Vesicles or bullae suggest herpes, impetigo, or scabies. Diffuse erythema may occur with candidiasis, erysipelas often after trauma or surgery, contact dermatitis, drug eruption, psoriasis, or trauma. Other patterns include benign cysts, nodules from hidradenitis or furunculosis, and crusted lesions from herpes or scabies
.
Commonly Associated Conditions
HIV and other sexually transmitted infections commonly coexist with genital lesions.
Diagnosis
History
Key points include time of onset, associated symptoms, immunodeficiency, prior sexually transmitted infections, prior similar lesions, and travel. Typical incubation periods vary by cause, including herpes within days but sometimes up to weeks, genital warts usually weeks to months, syphilis typically weeks but up to months, chancroid usually within a week but variable, donovanosis over weeks, molluscum potentially months, and ectoparasites such as pubic lice or scabies often after several weeks. Lesions appearing within hours of exposure suggest trauma, chemical irritation, or hypersensitivity. Itching is common early in herpes and with scabies or pubic lice, and mild pruritus can occur in secondary syphilis.
Physical Examination
Define lesion morphology and distribution, determine whether disease is localized or generalized, assess tenderness, lymphadenopathy, and any urethral or vaginal discharge, and examine buccal mucosa and perianal skin; pelvic examination or prostate assessment is often needed. Early herpes often begins as clustered vesicles on an erythematous base, may show umbilication, is typically very painful, and is often ulcerated by presentation. Pain is typical of herpes, chancroid, and tularemia, whereas donovanosis ulcers are usually painless. Ulcer base and borders can help narrow the differential: Behçet ulcers may be yellow and necrotic, chancroid bases are often necrotic, donovanosis can appear beefy red with hypertrophy, and syphilitic and herpetic ulcers may have cleaner bases; chancroid ulcers are classically nonindurated with irregular erythematous edges, syphilitic ulcers are indurated, and herpetic ulcers often have erythematous borders. Primary syphilis more often produces a solitary lesion, while chancroid often causes multiple ulcers of varying size. Behçet disease can cause recurrent, multiple genital ulcers involving scrotum or vulva and may be accompanied by recurrent oral ulcers and skin or eye disease, which may not occur simultaneously. Linear burrows suggest scabies, and reddish specks may reflect crab louse excreta. Urethral discharge suggests gonorrhea or reactive arthritis. In adults with genital lesions, inguinal lymphadenopathy supports consideration of chancroid, LGV, syphilis, herpes, lymphoma, or tuberculosis. LGV ulcers may be unnoticed and heal spontaneously, followed weeks later by painful inguinal lymphadenopathy and systemic symptoms, and untreated disease can progress to elephantiasis-like genital distortion. Lymphadenopathy tends to be unilateral in chancroid and LGV and more often bilateral in genital herpes. Painful perianal ulcers or mucosal ulcers seen on anoscopy should be treated presumptively for HSV and LGV. Molluscum contagiosum causes mildly contagious umbilicated papules up to about 1 cm, and advanced HIV may cause widespread or large lesions. Tuberculous genital lesions may appear as chronic minimally painful red, firm, nodular sores. Clinical appearance alone is often insufficient for diagnosis.
Diagnostic Tests and Interpretation
Laboratory Studies
All patients with genital, anal, or perianal ulcers should receive syphilis serology with dark-field examination when available, HSV testing by culture or PCR or type-specific serology, and HIV testing. If suspicion and culture capacity exist, obtain H. ducreyi culture for chancroid. Donovanosis can be supported by identifying intracellular Donovan bodies on Giemsa or Wright stain from lesion scrapings or biopsy, with biopsy favored when malignancy is possible. Chancroid culture can be sensitive but is limited by availability of selective media; a probable diagnosis relies on painful ulcers typical of chancroid with negative testing for syphilis and HSV. LGV diagnosis is supported by serology or by isolating C. trachomatis with confirmation of L1–L3 serovars. Molluscum can be confirmed by histology and electron microscopy. Chancres may be missed by patients, and early syphilis serology can be falsely negative; when diagnosis is uncertain or cancer is possible, biopsy is indicated.
Treatment
Medications
Chancroid can be treated with single-dose azithromycin 1 g orally or ceftriaxone 250 mg intramuscularly. Condylomata acuminata have no single best therapy; options include imiquimod 5% cream three times weekly for up to 16 weeks or podofilox 0.5% solution or gel twice daily for three days followed by one day off, repeated in cycles. Donovanosis can be treated for more than three weeks with trimethoprim-sulfamethoxazole, tetracycline, or doxycycline. Genital herpes is treated with acyclovir, famciclovir, or valacyclovir for 7–10 days, with intravenous acyclovir for severe disease. Tuberculous genital lesions require systemic antituberculosis therapy. LGV is treated with doxycycline 100 mg twice daily for 21 days. Molluscum contagiosum can be managed with lesion destruction via desiccation, cryotherapy, or curettage.
Complementary and Alternative Therapies
Alternative chancroid regimens include erythromycin for seven days or ciprofloxacin for three days. Wart management can include cryosurgery, excision, electrosurgery, or laser therapy. Donovanosis alternatives include prolonged ciprofloxacin, erythromycin, or chloramphenicol. LGV can also be treated with erythromycin four times daily for 21 days.
Ongoing Care and Follow-Up
Patients should be encouraged to have sexual partners evaluated and treated. HIV testing should be performed at diagnosis and repeated with syphilis serology about three months later if initially negative. Consider cervical cytology screening for patients evaluated for sexually transmitted infections who have not had a Pap smear within the past year, and counsel patients with HPV on the need for ongoing screening.
Pediatric Considerations
Sexually transmitted genital lesions in a child require evaluation for sexual abuse.
Complications
Untreated primary syphilis can disseminate and progress to secondary disease within weeks. Chancroid, genital herpes, and syphilis increase susceptibility to HIV transmission.
Basics
Description
Genital lesions involve the reproductive organs and can result from a range of infectious and noninfectious conditions.
Epidemiology
Genital ulcers are the most frequent sexually transmitted cause of genital lesions. In North America and Europe, the leading sexually transmitted causes of genital ulcer disease are herpes simplex and syphilis. In the United States, a substantial proportion of people aged 14–49 have HSV-2 infection, and HSV-1 accounts for a significant minority of genital herpes cases. Chancroid is more common in Africa, Asia, and Latin America but can occur in sporadic U.S. outbreaks. Lymphogranuloma venereum is uncommon in industrialized countries, though outbreaks have been reported among men who have sex with men.
Risk Factors
About half of exposed sexual partners may acquire genital warts (HPV) after contact with an infected partner. Sexual transmission of syphilis can be high, with rates reported up to roughly one-third per exposure.
General Prevention
Risk reduction includes abstinence, consistent condom use, limiting partners, safer-sex practices, and HPV vaccination. Two HPV vaccines are available for females aged 9–26 that protect against HPV 6 and 11 (responsible for most genital warts) and HPV 16 and 18 (responsible for a large proportion of cervical cancers): the quadrivalent vaccine (Gardasil) and the bivalent vaccine (Cervarix). Quadrivalent vaccination in males aged 9–26 can reduce genital warts.
Etiology
Infectious Ulcers
Common causes include genital herpes, syphilis due to Treponema pallidum, chancroid due to Haemophilus ducreyi, lymphogranuloma venereum from Chlamydia trachomatis serovars L1–L3, donovanosis (granuloma inguinale) from Klebsiella granulomatis, and less commonly tuberculosis or tularemia. Additional reported etiologies include candidiasis, histoplasmosis, amebiasis, gonorrhea, and trichomoniasis. Acute or primary HIV infection can present with genital ulcers, and a notable minority of ulcer cases involve more than one pathogen.
Noninfectious Ulcers
Noninfectious causes include trauma, fixed drug eruption, malignancy, systemic lupus erythematosus, and Behçet disease.
Other Lesion Patterns
Papules may be due to candidiasis, molluscum contagiosum, scabies, syphilis, or condylomata acuminata from HPV, with types 6 and 11 most common and types 16, 18, 31, 33, and 35 linked to cervical dysplasia. Vesicles or bullae suggest herpes, impetigo, or scabies. Diffuse erythema may occur with candidiasis, erysipelas often after trauma or surgery, contact dermatitis, drug eruption, psoriasis, or trauma. Other patterns include benign cysts, nodules from hidradenitis or furunculosis, and crusted lesions from herpes or scabies
.
Commonly Associated Conditions
HIV and other sexually transmitted infections commonly coexist with genital lesions.
Diagnosis
History
Key points include time of onset, associated symptoms, immunodeficiency, prior sexually transmitted infections, prior similar lesions, and travel. Typical incubation periods vary by cause, including herpes within days but sometimes up to weeks, genital warts usually weeks to months, syphilis typically weeks but up to months, chancroid usually within a week but variable, donovanosis over weeks, molluscum potentially months, and ectoparasites such as pubic lice or scabies often after several weeks. Lesions appearing within hours of exposure suggest trauma, chemical irritation, or hypersensitivity. Itching is common early in herpes and with scabies or pubic lice, and mild pruritus can occur in secondary syphilis.
Physical Examination
Define lesion morphology and distribution, determine whether disease is localized or generalized, assess tenderness, lymphadenopathy, and any urethral or vaginal discharge, and examine buccal mucosa and perianal skin; pelvic examination or prostate assessment is often needed. Early herpes often begins as clustered vesicles on an erythematous base, may show umbilication, is typically very painful, and is often ulcerated by presentation. Pain is typical of herpes, chancroid, and tularemia, whereas donovanosis ulcers are usually painless. Ulcer base and borders can help narrow the differential: Behçet ulcers may be yellow and necrotic, chancroid bases are often necrotic, donovanosis can appear beefy red with hypertrophy, and syphilitic and herpetic ulcers may have cleaner bases; chancroid ulcers are classically nonindurated with irregular erythematous edges, syphilitic ulcers are indurated, and herpetic ulcers often have erythematous borders. Primary syphilis more often produces a solitary lesion, while chancroid often causes multiple ulcers of varying size. Behçet disease can cause recurrent, multiple genital ulcers involving scrotum or vulva and may be accompanied by recurrent oral ulcers and skin or eye disease, which may not occur simultaneously. Linear burrows suggest scabies, and reddish specks may reflect crab louse excreta. Urethral discharge suggests gonorrhea or reactive arthritis. In adults with genital lesions, inguinal lymphadenopathy supports consideration of chancroid, LGV, syphilis, herpes, lymphoma, or tuberculosis. LGV ulcers may be unnoticed and heal spontaneously, followed weeks later by painful inguinal lymphadenopathy and systemic symptoms, and untreated disease can progress to elephantiasis-like genital distortion. Lymphadenopathy tends to be unilateral in chancroid and LGV and more often bilateral in genital herpes. Painful perianal ulcers or mucosal ulcers seen on anoscopy should be treated presumptively for HSV and LGV. Molluscum contagiosum causes mildly contagious umbilicated papules up to about 1 cm, and advanced HIV may cause widespread or large lesions. Tuberculous genital lesions may appear as chronic minimally painful red, firm, nodular sores. Clinical appearance alone is often insufficient for diagnosis.
Diagnostic Tests and Interpretation
Laboratory Studies
All patients with genital, anal, or perianal ulcers should receive syphilis serology with dark-field examination when available, HSV testing by culture or PCR or type-specific serology, and HIV testing. If suspicion and culture capacity exist, obtain H. ducreyi culture for chancroid. Donovanosis can be supported by identifying intracellular Donovan bodies on Giemsa or Wright stain from lesion scrapings or biopsy, with biopsy favored when malignancy is possible. Chancroid culture can be sensitive but is limited by availability of selective media; a probable diagnosis relies on painful ulcers typical of chancroid with negative testing for syphilis and HSV. LGV diagnosis is supported by serology or by isolating C. trachomatis with confirmation of L1–L3 serovars. Molluscum can be confirmed by histology and electron microscopy. Chancres may be missed by patients, and early syphilis serology can be falsely negative; when diagnosis is uncertain or cancer is possible, biopsy is indicated.
Treatment
Medications
Chancroid can be treated with single-dose azithromycin 1 g orally or ceftriaxone 250 mg intramuscularly. Condylomata acuminata have no single best therapy; options include imiquimod 5% cream three times weekly for up to 16 weeks or podofilox 0.5% solution or gel twice daily for three days followed by one day off, repeated in cycles. Donovanosis can be treated for more than three weeks with trimethoprim-sulfamethoxazole, tetracycline, or doxycycline. Genital herpes is treated with acyclovir, famciclovir, or valacyclovir for 7–10 days, with intravenous acyclovir for severe disease. Tuberculous genital lesions require systemic antituberculosis therapy. LGV is treated with doxycycline 100 mg twice daily for 21 days. Molluscum contagiosum can be managed with lesion destruction via desiccation, cryotherapy, or curettage.
Complementary and Alternative Therapies
Alternative chancroid regimens include erythromycin for seven days or ciprofloxacin for three days. Wart management can include cryosurgery, excision, electrosurgery, or laser therapy. Donovanosis alternatives include prolonged ciprofloxacin, erythromycin, or chloramphenicol. LGV can also be treated with erythromycin four times daily for 21 days.
Ongoing Care and Follow-Up
Patients should be encouraged to have sexual partners evaluated and treated. HIV testing should be performed at diagnosis and repeated with syphilis serology about three months later if initially negative. Consider cervical cytology screening for patients evaluated for sexually transmitted infections who have not had a Pap smear within the past year, and counsel patients with HPV on the need for ongoing screening.
Pediatric Considerations
Sexually transmitted genital lesions in a child require evaluation for sexual abuse.
Complications
Untreated primary syphilis can disseminate and progress to secondary disease within weeks. Chancroid, genital herpes, and syphilis increase susceptibility to HIV transmission.
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