STD – Genital Ulcer (INDIA)
Examination:
Ulcer
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Location, number (single, multiple), superficial (erosions) or deep, edge (undermined, punch
out), margins (regular/irregular), floor (presence of exudate, slough, granulation tissue)
Palpation – tenderness, induration of floor and edges, bleeding on maneuvering
Palpation of inguinal nodes – tenderness, increased warmth, superficial or deep, discrete or
matted, free mobility or fixity to deeper structure, consistency (firm or soft) and fluctuance
Ixs:
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HIV
Syphilis serology
Smear from base of ulcer – Gram stain (chancroid), GIemsa stain (herpes and donovanosis)
Biopsy if does not respond to rx
Type-specific serologic tests for HSV – useful to identify pregnant women at risk of HSV.
Offer to uninfected women whose sex partner has HSV infection
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Treat empirically
Rx:
1) If veicles or multiple painful ulcers are present
a. Herpes
i. T acyclovir 400mg tds, 7-10 days
ii. T Famciclovir 250mg tds, 7-10 days
iii. T Valacyclovir 1g bd, 7-10 days
2) If vesicles not seen and only ulcer is seen
a. Treat for syphilis and chancroid and counsel on herpes genitalis
b. Syphilis
i. IM benzathine penicillin 2.4 MU stat
ii. If allergic, T doxycycline 100mg bd x 2/52
PLUS
c. Chancroid
i. T azithromycin 1g stat
ii. IM ceftriaxone 250mg stat
iii. T ciprofloxacin 500mg bd x 3/7
3) Suppressive therapy for recurrent genital herpes
a. T acyclovir 400mg bd
b. T famciclovir 250mg bd
c. T valacyclovir 500mg od
d. T valacyclovir 1g od
Treatment of partner:
- Treat all partners in contact with client in past 3 months
- Partners should be treated for syphilis and chancroid
- Refer for voluntary counselling and testing for HIV, syphilis and hepatitis B
- TCA 1/52
- Sexual abstinence during rx
HIV infected:
- May require repeated or longer course of rx
- Treatment failures can occur with any regime
- Ceftriaxone and azithromycin based regimes used only if followup can be ensured
Pregnant women:
- Quinolones, doxycycline and sulphonamides contraindicated in pregnant women
- Pregnant women with positive RPR:
o Consider infected unless adequate treatment documented in the past and
sequential serologic Ab titres are declining
- Pregnant women with primary, secondary and latent syphilis
o 2 doses of IM benzathine penicillin 2.4MU after test dose at 1 week interval
- Pregnant women who are allergic to penicillin
o T Erythromycin 500mg 4x/day for 15 days
- Neonate to be treated for syphilis after delivery
- All pregnant women should be asked of history of genital herpes and examined for herpetic
lesions
- Women without symptoms and signs of genital herpes or prodrome can deliver vaginally
- Women with genital herpes at time of delivery – deliver via C- section
Neonatal herpes:
- IV acyclovir considered for infants born to women who acquired HSV near term
- Regime – IV acyclovir 20mg/kg tds x 21 days for disseminated/ CNS disease; 14 days for
disease limited to skin and mucous membrane
Specific test for evaluation of genital, anal or perianal ulcers:
- Darkfield microscopy (frm ulcer fluid or LN aspirate) to look for motile treponemes.
- Culture of hemophilus ducreyi – not widely available, sensitivity <80%
- Multiplex PCR – to detect various possible causes of genital ulcer
- Surveillance cultures of mucosal surfaces (for HSV) might be considered for neonates
possibly exposed to maternal herpes
- Donovanosis – visualisation of dark staining Donovan bodies on tissue crush preparation or
biopsy
Causes of Non-responsive ulcers:
- Incorrect dx
- Coinfection with another STD
- HIV
- Non compliance
- Resistance to antimicrobial use
Other factors to be accounted for:
- Large size of ulcer
- Slower healing in uncircumcised men
- Fluctuant lymphadenopathy – may need drainage
- Donovanosis – typically slow healing. Recommended rx – t doxycycline 100mg bd for at least
3/52 or till lesions heal
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