Management of Genital Ulcers

Diagnosis

A combination of painful ulcer with painful inguinal adenopathy is highly suggestive of chancroid, according to the Centers for Disease Control and Prevention (CDC) 1
Approximately 25% of patients with genital ulcers may not have a confirmed diagnosis even after complete laboratory evaluation, as reported by the CDC 1

Required testing for genital ulcers includes:

Test	Indication
Serologic test for syphilis	All patients
Darkfield examination or direct immunofluorescence for Treponema pallidum	All patients
Culture or antigen test for HSV	All patients
Culture for Haemophilus ducreyi	In settings where chancroid is prevalent
HIV testing	All patients, especially those with syphilis or chancroid, as recommended by the CDC [2, 1]

The treatment should be directed towards the most likely causes based on the clinical presentation in cases of genital ulcers without laboratory diagnosis, as recommended by the CDC 1
Recommended regimens for specific causes include:

Gentle cleansing with sterile saline solution and application of plain petrolatum ointment directly to the ulcer, followed by covering with a non-adherent dressing or petrolatum-impregnated gauze, is recommended for optimal wound care, as suggested by the Journal of Clinical Oncology guidelines 3
The dressing should be secured with a bandage that provides protection without excessive pressure, promoting a moist wound environment that facilitates healing, as suggested by the Journal of Clinical Oncology guidelines 3
Re-examination is recommended 3-7 days after treatment initiation, as suggested by the CDC 1
Signs of treatment failure include no symptomatic improvement within 3 days, no objective improvement within 7 days, worsening symptoms despite appropriate therapy, or development of new lesions during treatment, as stated by the CDC 1

HIV co-infection may require longer courses of therapy and closer monitoring, as recommended by the CDC 1
In pregnancy, ciprofloxacin should be avoided, and azithromycin safety is not established, as noted by the CDC 1
Uncircumcised status in male partners may also affect healing time, as mentioned by the CDC 1
Patients with ulcers that do not respond to appropriate therapy, extensive or rapidly spreading lesions, suspected malignancy, and recurrent ulcerations despite appropriate treatment should be referred for further evaluation and management, as recommended by the CDC 2, 1
Sexual partners should be examined and treated appropriately, and missing co-infections, such as T. pallidum or HSV, should be considered in patients with chancroid, as recommended by the CDC 2, 1