A genital ulcer is an open sore located on the genital area, which includes the vulva, penis, perianal region, or anus. Genital ulcers are most commonly caused by infectious agents (fungal infections, secondary bacterial infections, or
sexually transmitted disease
Sexually transmitted infections (STIs), also referred to as sexually transmitted diseases (STDs) and the older term venereal diseases, are infections that are spread by sexual activity, especially vaginal intercourse, anal sex, and oral ...
s such as
genital herpes
Genital herpes is an infection by the herpes simplex virus (HSV) of the genitals. Most people either have no or mild symptoms and thus do not know they are infected. When symptoms do occur, they typically include small blisters that break open ...
,
syphilis or
chancroid). However, this is not always the case, as a genital ulcer may have noninfectious causes as well.
Overview
A genital ulcer may be located on the vulva, penis, perianal region, or anus. Globally, the incidence of genital ulcers is estimated to be approximately 20 million cases annually.
The most likely cause of a genital ulcer varies depending on the characteristics of a population and location. The most common cause of genital ulcers in the United States is herpes simplex infections, with syphilis the second most common cause, and chancroid the third.
These common causes of genital ulcer disease (HSV-1, HSV-2 and treponema pallidum) can all be efficiently transmitted through oral sex.
Important signs associated with genital ulcers that may assist in the diagnosis of the cause of the genital ulcer may include the presence of tender or non-tender enlarged lymph nodes in the groin area, a painful or non-painful genital ulcer, or the presence of vesicular lesions, which are small, painful, elevated blisters.
The most common causes of a genital ulcer include infectious agents, with sexually transmitted diseases being the most common, but which can also include fungal infections and secondary bacterial infections.
While infectious agents are the most common cause, a genital ulcer may also be the result of non-infectious causes such as
Behcet's syndrome,
lupus, or
psoriasis
Psoriasis is a long-lasting, noncontagious autoimmune disease characterized by raised areas of abnormal skin. These areas are red, pink, or purple, dry, itchy, and scaly. Psoriasis varies in severity from small, localized patches to complete ...
.
Since it is difficult to determine a cause of a genital ulcer from history, examination, and population characteristics alone, further testing is often needed. The most common diagnostic tools used are targeted towards the most common etiologies of genital ulcers: syphilis (syphilis serology,
PCR testing, or
dark-field examination), herpes simplex virus (PCR, culture, or type specific HSV
antibodies), and haemophilus ducreyi (culture on special media currently not widely available in most hospital systems) if the individual is in a known endemic region.
Further diagnostic tools such as a biopsy or culture are often utilized if ulcers appear unusual or do not respond as expected to therapy.
Since genital ulcers are often infectious in origin, there is an increased risk of acquiring HIV in a HIV negative patient through viral introduction through the open sore
[Powers KA, Poole C, Pettifor AE, et al.: Rethinking the heterosexual infectivity of HIV-1: a systematic review and meta-analysis.Lancet Infect Dis 2008; 8: pp. 553-563.][Bruisten SM, Cairo I, Fennema H, et al.: Diagnosing genital ulcer disease in a clinic for sexually transmitted diseases in Amsterdam, The Netherlands.J Clin Microbiol 2001; 39: pp. 601-605.] Conversely, there is an increased risk of HIV transmission through increased shedding of viral HIV in the presence of a genital ulcer in a patient with a history of HIV.
The CDC recommends testing for HIV in any individual presenting for a genital ulcer who does not already have a history of HIV.
Infectious sexually transmitted causes
Risk factors for sexually transmitted genital ulcers are similar to the risk factors for most sexually transmitted diseases which include multiple sex partners, alcohol, illicit drug use, homelessness, poverty, inmates, men who have sex with men, sexually active teenagers, sexual contact without contraceptive use, and unstable housing.
The most common cause of genital ulcers in the North America and Western Europe are the result of HSV or syphilis infections, while the most common cause in other parts of the world is chancroid.
Most sexually active adolescents with genital ulcers have a herpes simplex virus infection, more commonly type 2.
Meanwhile, according to 2017 CDC reports, syphilis is more common in men who have sex with men populations although rates of syphilis have been rising in heterosexual men and women in the United States.
[Centers for Disease Control and Prevention : Sexually transmitted disease surveillance. https://www.cdc.gov/std/stats17/2017-STD-Surveillance-Report_CDC-clearance-9.10.18.pdf] Following syphilis and genital herpes infections, a chancroid is the third most common cause but tends to occur in focused outbreaks over time.
While rates of H. ducreyi infection seem to be declining according to a 2017 report, it is possible this may be due to lack of testing since H. ducreyi requires a very specialized culture medium which is not commonly available.
Less common causes include lymphogranuloma venereum, which is more common in men who have sex with men, and granuloma inguinale, which is more common in tropical regions globally. rather than in the United States.
Non-infectious causes
Genital ulcers are not strictly a sign of a sexually transmitted illness, although non-infectious sources are significantly more infrequent in comparison. The most common non-infectious sources of genital ulcers are first Behcet's disease, and second drug reaction.
Behcet's syndrome is a chronic systemic vasculitis infection that is defined by recurrent oral and genital aphthous ulcers but can also affect many other organ systems, such as the eyes, ears, nervous system, heart, lungs, joints, and intestines.
[Sehgal VN, Pandhi D, Khurana A. Nonspecific genital ulcers. ''Clin Dermatol''. 2014;32(2):259-274. doi:10.1016/j.clindermatol.2013.08.024] Behcet's syndrome commonly presents in the 30-40 age range
and is more common in the Middle East and Asia.
There is a familial component to Behcet's syndrome since it has associations with the HLA-B51 gene.
Causes of drug induced genital ulcers take the form of
Stevens–Johnson syndrome
Stevens–Johnson syndrome (SJS) is a type of severe skin reaction. Together with toxic epidermal necrolysis (TEN) and Stevens–Johnson/toxic epidermal necrolysis (SJS/TEN), it forms a spectrum of disease, with SJS being less severe. Erythema ...
,
toxic epidermal necrolysis
Toxic epidermal necrolysis (TEN) is a type of severe skin reaction. Together with Stevens–Johnson syndrome (SJS) it forms a spectrum of disease, with TEN being more severe. Early symptoms include fever and flu-like symptoms. A few days later ...
,
erythema multiforme
Erythema multiforme (EM) is a skin condition that appears with red patches evolving into target lesions, typically on both hands.
It is a type of erythema possibly mediated by deposition of immune complexes (mostly IgM-bound complexes) in th ...
, and
fixed drug eruptions in response to a diverse list of medications.
Stevens–Johnson syndrome and toxic epidermal necrolysis are more likely than erythema multiforme to have genital manifestations although all present with a toxic appearing patient.
A fixed drug eruption in comparison does not present as a toxic appearing patient but rather single or multiple erythematous patches that vary in size and shape which eventually turn dark brown in color and become itchy.
The defining characteristic is that these drug eruptions appear in the same location each time the offending medication is used, and will resolve on their own.
Other potential causes of non-infectious genital ulcers are diverse, but can include sexual trauma,
Lipschutz ulcers, inflammatory bowel diseases such as Crohn's disease, lichen planus, lichen sclerosis, and immunobullous disease such as pemphigous vulgaris, since bullous pemphigoid is less likely to occur on the genitals.
Cancers of the vulva and penis, with the most common subtype being squamous cell carcinoma, can also present as genital ulcers, but leukemias such as chronic lymphocytic leukemia and acute promyelotic leukemia have also been identified.
Infectious non-sexually transmitted causes
Even lesser common etiologies of genital ulcers include fungal infection, secondary bacterial infections, and parasitic infections.
Fungal infections are rare causes of genital ulcers, but
candida albicans
''Candida albicans'' is an opportunistic pathogenic yeast that is a common member of the human gut flora. It can also survive outside the human body. It is detected in the gastrointestinal tract and mouth in 40–60% of healthy adults. It is usu ...
infection is typically the most common source, and is more prevalent in patients with a history of diabetes mellitus, chronic steroid use, or other immunodeficiencies.
There have also been rare case reports of paracoccidioidomycosis, zygomycosis and histoplasmosis infections causing genital ulcers.
Parasitic infections such as
amoebiasis
Amoebiasis, or amoebic dysentery, is an infection of the intestines caused by a parasitic amoeba '' Entamoeba histolytica''. Amoebiasis can be present with no, mild, or severe symptoms. Symptoms may include lethargy, loss of weight, colonic ...
and
leishmaniasis can present in cutaneous form in the genital regions. This can be confused with a sexually transmitted disease or sepsis due to their tendency to present with additional systemic symptoms.
Genital
tuberculosis
Tuberculosis (TB) is an infectious disease usually caused by '' Mycobacterium tuberculosis'' (MTB) bacteria. Tuberculosis generally affects the lungs, but it can also affect other parts of the body. Most infections show no symptoms, i ...
can also present as a genital ulcer, either in the form of cutaneous tuberculosis from a systemic infection, or a primary tuberculosis chancre at the site of inoculation via direct genital contact with infected sputum.
Cutaneous tuberculosis typically presents initially as red or yellow nodules that eventually break down to form soft, painful, and roughly circular ulcers, which as a rule are covered in a pseudomembrane.
Primary tuberculosis chancre, on the other hand, often presents as a painless ulcer with well defined edges that appears rather nonspecific.
References
External links
Genital herpes - self-care A.D.A.M.
Genital herpes treatment WebMD
WebMD is an American corporation known primarily as an online publisher of news and information pertaining to human health and well-being. The site includes information pertaining to drugs. It is one of the top healthcare websites.
It was fou ...
Diseases Characterized by Genital, Anal, or Perianal Ulcers Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention (CDC) is the national public health agency of the United States. It is a United States federal agency, under the Department of Health and Human Services, and is headquartered in Atlanta, Georgi ...
Diagnosis and Management of Genital Ulcers American Family Physician
''American Family Physician'' (''AFP'') is the editorially independent, peer-reviewed and evidence-based medical journal published by the American Academy of Family Physicians. Published continuously since 1950, each issue delivers concise, easy-t ...
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Sexually transmitted diseases and infections