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Genital Ulcer Disease
What is Genital Ulcer Disease?
It is ulcer on genitalia which could be caused by various etiology
In the United States, the majority of young, sexually active patients who have genital ulcers have either genital herpes, syphilis, or chancroid. The frequency of each condition differs by geographic area and patient population; however, genital herpes is the most prevalent of these diseases. More than one of these diseases can be present in a patient who has genital ulcers. All three of these diseases has been associated with an increased risk for HIV infection. Not all genital ulcers are caused by sexually transmitted infections.
A diagnosis based only on the patient’s medical history and physical examination frequently is inaccurate. Therefore,according to CDC all patients who have genital ulcers should be evaluated with a serologic test for syphilis and a diagnostic evaluation for genital herpes
what needs to be done if you see sore on your genital?
If you had sexual encounter and notice ulcer on your genital area then you need to be evaluated by your doctor.
Genital Ulcer Disease (GUD) is very important. Ulcer on genital must not be overlook as a "sore" which would be heal on its own. Unfortunately many ulcer may heal on its own with persistence of underlying infectious disease such as syphilis or chancroid. It is also important that your doctor see the ulcer before it goes away.
What Tests are important?
2 major tests play significant role for evaluation of GUD
1) syphilis
2) Herpes
There has been a technical issue of testing of chancroid
definitive diagnosis of chancroid is by identification of H ducreyi on special culture ,however this culture is not widely available and also the sensitivity of the culture is less than 80%. so diagnosis to be establish by exclusion and clinical experience of an experienced physician.
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Syphilis is a sexually transmitted disease (STD) caused by the bacterium Response pallidum. It has often been called “the great imitator” because so many of the signs and symptoms are indistinguishable from those of other diseases.
Signs and Symptom
"Many people infected with syphilis do not have any symptoms for years, yet remain at risk for late complications if they are not treated. Although transmission appears to occur from persons with sores who are in the primary or secondary stage, many of these sores are unrecognized. Thus, most transmission is from persons who are unaware of their infection.
The chancres are painless and usually heal on their own in about 3-6 weeks.
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If left undiagnosed and untreated, the disease then progresses into the second stage marked by the development of a rash on the palms of the hands or on the soles of the feet. The rash does not itch. Sometimes the rash is so faint it is unnoticeable. Because of such symptoms, it is possible to have syphilis and not know it.
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Second stage symptoms may also include fever, sore throat, and headaches. Once the second stage symptoms disappear, the disease progresses into the latent stage that may lead to damage of the cardiovascular and neurological systems. This damage may eventually lead to death.
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Herpes
Herpes is a sexually transmitted disease which get transmitted by virus called HSV or
Herpes simplex Virus. There are 2 type of Herpes virus, type 1 and type 2
Herpes Virus:
It is an enveloped virus with DNA with fragile membrane. The herpes virus with damage
envelope is not as infectious . It easily fall apart and virus could only be obtain by direct mucosa contact.
It means it is unlikely to get it with sharing dishes or going to public bathroom. Herpes virus invade human
body by direct mucosa/ skin contact. The Virus use host cell for reproduction and destroy the host cell, as
result the classic symptom of blister formation (if symptomatic) tingling and pain occur
Herpes evaluation by examination ?
The most important part of herpes evaluation is experience doctor examination. We had numerous patients
in our center for genital rash that did not appeared to be herpetic eruption and we did not performed herpes
test and we reassure these patients . On the other hand, we have diagnosed herpes with physical examination
and patients was treated on the same day without even testing ( saving for non-insured patients)
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"Lymphogranuloma venereum (LGV) is caused by C. trachomatis serovars L1, L2, or L3. The most common clinical manifestation of LGV among heterosexuals is tender inguinal and/or femoral lymphadenopathy that is typically unilateral. A self-limited genital ulcer or papule sometimes occurs at the site of inoculation. However, by the time patients seek care, the lesions might have disappeared. Rectal exposure in women or MSM might result in proctocolitis (including mucoid and/or hemorrhagic rectal discharge, anal pain, constipation, fever, and/or tenesmus). LGV is an invasive, systemic infection, and if it is not treated early, LGV proctocolitis might lead to chronic, colorectal fistulas and strictures. Genital and colorectal LGV lesions might also develop secondary bacterial infection or might be coinfected with other sexually and nonsexually transmitted pathogens.
Diagnosis is based on clinical suspicion, epidemiologic information, and the exclusion of other etiologies (of procto-colitis, inguinal lymphadenopathy, or genital or rectal ulcers), along with C. trachomatis testing, if available. Genital and lymph node specimens (i.e., lesion swab or bubo aspirate) may be tested for C. trachomatis by culture, direct immunofluorescence, or nucleic acid detection. Nucleic acid amplification tests (NAAT) for C. trachomatis are not FDA-cleared for testing rectal specimens. Additional procedures (e.g., genotyping) are required for differentiating LGV from non-LGV C. trachomatis but are not widely available.
Chlamydia serology (complement fixation titers >1:64) can support the diagnosis in the appropriate clinical context. Comparative data between types of serologic tests are lacking, and the diagnostic utility of serologic methods other than complement fixation and some microimmunofluorescence procedures has not been established. Serologic test interpretation for LGV is not standardized, tests have not been validated for clinical proctitis presentations, and C. trachomatis serovar-specific serologic tests are not widely available.
In the absence of specific LGV diagnostic testing, patients with a clinical syndrome consistent with LGV, including proc-tocolitis or genital ulcer disease with lymphadenopathy, should be treated for LGV as described in this report"
Symptoms
The first symptom may be a small, painless pimple or lesion occurring on the penis or vagina. It is often unnoticed. The infection then spreads to the lymph nodes in the groin area and from there to the surrounding tissue. Complications may include inflamed and swollen lymph glands which may drain and bleed.The incidence is highest among sexually active people living usualy in tropical and subtropical area. It has also occurred in some areas of the southern United States.
*Painless genital ulcer
*Swollen Groin Lymph nodes
*Redness and inflammation on groin
*Pain while having bowel movement
*Pus or blood in stool
*Lymph node drainage
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Chancroid
It is one of the most underdiagnosed STD in USA because it is hard to diagnose and needs experience Physician to make it. It is curable if get diagnosed. The causative organism, Haemophilus ducreyi, was found by Ducrey in 1889. After an incubation period of 1 day to 2 weeks, chancroid begins with a small bump that becomes an sore. It get transmitted with oral, anal and vaginal sex.
Risk
Uncircumcised men are at higher risk than circumcised men for contracting chancroid. Patient with chancroid is at higher risk to contract HIV virus.
Course of Chancroid
It takes 1 day to 2 weeks for chancroid begins with a small bump that becomes an ulcer within a day of its appearance. The ulcer :
- Ranges in size (from 1/8 inch to 2 inches )
- Has sharply defined borders and painful
- Has irregular or ragged borders
- It could bleed with manupulation
- Has a base that is covered with yellowish-grey discharge or material
50% of infected men have only a single ulcer. Women frequently have 4 or more ulcers.
Common locations in men (most common to least common) are:
- Foreskin > coronal sulcus>Shaft>glans of penis> urethral opening>scrotum
In female the most common site is labia majora.
Diagnosis is made by evaluating the patient and considering eliminating syphilis and herpes as part of differential diagnosis. There are no lab tests for chancroid like there is for syphilis
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