Genital Ulcers

Ted Rosen, MD

What causes genital ulcers? Are you treating patients who present with genital ulcers? Dr Rosen provides us with his clinical pearls from MauiDerm NP+PA Fall 2014…

  1. Ulceration is defined as loss of epidermis and then some or all of dermis and subcutaneous tissue leading to an “open sore.”
  2. There are many general reasons for ulcers to occur. They include: atherosclerotic vascular disease, non-atherosclerotic vascular disease, infections, inflammation of unknown etiology, neoplasms, and exogenous causes
  3. It is often necessary to use ancillary aids to diagnose genital ulcers; these may include serologic tests (eg. RPR), cultures, and biopsy with molecular technique analysis.
  4. STDs commonly cause genital ulcers. You are NOT likely to see the minor STDs in the USA (eg. Donovanosis, chancroid or LGV). However you may see syphilis and herpes. STDs can be distinguished by lesion size, number, degree of pain, presence or absence of inguinal adenopathy.
  5. Genital herpes due to HSV-2 continues to shed virus for at least a decade after initial infection. Genital herpes should prompt an investigation for other STDs (10+% will be HIV+)
  6. Amebiasis of the genitalia may result from anal intercourse with an individual with amoebic dysentery. Or, it may ensue from fecal contamination of the genital skin.
  7. Neoplasms which cause genital ulcers are >90% likely to be squamous cell carcinoma
  8. Multi-system disease which may be associated with genital ulcerations include Behcet’s Syndrome and extra-intestinal Crohn’s disease. Pathergy helps confirm the diagnosis of Behcet’s disease; biopsy confirms cutaneous Crohn’s disease. Topical TCI may help the latter.
  9. Lichen planus is typically the cause of painful erosions in women, but not in men. Treatment is with ultrapotent topical steroids until healing (~75% of women will heal totally). Alternate treatments include topical TCIs and oral cyclosporine-A
  10. Zoon balanitis is a superficially eroding disorder of men with sheets of plasma cells on biopsy. (Hence the name: balanitis plasmacellularis). Topical steroids treat this.
  11. Unusual causes of genital ulceration can be diagnosed by PE and historical data. These include ecthyma gangrenosum, pyoderma gangrenosum, and calciphylaxis. Beware of EG in neutropenic patients, PG in those with RA or IBD, and calciphylaxis in those with CRF on dialysis.
  12. Exogenous factors causing genital ulcers: self-mutiliation, drugs, vacuum erection device and genital bite wounds. The latter respond best to amoxicillin-clavulanate in high dose.