The relative prevalence of causative organisms for genital ulcer disease varies considerably in different parts of the world and may change dramatically over time. Clinical differential diagnosis of genital ulcers is inaccurate, particularly in settings where several aetiologies are common. Clinical manifestations and patterns of genital ulcer disease may be further altered in the presence of HIV infection.

After examination to confirm the presence of genital ulceration, treatment appropriate to local aetiologies and antibiotic sensitivity patterns should be given. For example, in areas where both syphilis and chancroid are prevalent, patients with genital ulcers should be treated for both conditions at the time of their initial presentation to ensure adequate therapy in case of loss to follow-up. In areas where granuloma inguinale is also prevalent, treatment for this condition should be included. In areas where granuloma inguinale or lymphogranuloma venereum (LGV) is prevalent, treatment for these conditions should be included. In many parts of the world, genital herpes is the most frequent cause of genital ulcer disease. Where HIV infection is prevalent, an increasing portion of cases of genital ulcer disease is likely to harbour herpes simplex virus. Herpetic ulcers may be atypical and persist for long periods in HIV-infected patients.

Laboratory-assisted differential diagnosis is rarely helpful at the initial visit, as mixed infections are common. In addition, in areas of high syphilis prevalence, a reactive serological test may reflect a previous infection and give a misleading picture of the patient's present condition.

Recommended syndromic treatment

• therapy for syphilis (for details see section 3.4)

PLUS EITHER

• therapy for chancroid where it is prevalent (for details see section 3.5)

OR

• therapy for granuloma inguinale where it is prevalent (for details see section 3.6)

OR

• therapy for LGV where it is prevalent (for details see section 3.3)

AT A GLANCE

Genital Ulcer

For details, see sections 3.3 - 3.6

The decision to treat for chancroid, granuloma inguinale or LGV depends on the local epidemiology of the infections.

Depending upon local availability, management for herpes could include specific antiviral therapy (see section 3.6), but in all settings, appropriate counselling is essential.