Genital ulcer diseases include syphilis, chancroid, lymphogranuloma venereum, granuloma inguinale, and herpes genitalis. Syphilis is caused by Treponema pallidum and passes through primary, secondary, and tertiary stages. Secondary syphilis causes a rash and mucous patches. Chancroid is caused by Haemophilus ducreyi and presents as painful genital ulcers. Lymphogranuloma venereum is caused by Chlamydia trachomatis and presents with lymph node swelling. Granuloma inguinale, caused by Klebsiella granulomatis, presents as painless

1. GENITAL ULCER DISEASES
Rebeka , Nishanth

2. Genital Ulcer Diseases
● Syphilis
● Chancroid
● Lymphogranuloma Venereum
● Granuloma Inguinale
● Herpes Genitalis

3. Syphilis
● Causative organism -Treponema Palladium
● Majority of infections are acquired by direct sexual
contact with an infected person in early stages .
● Secondary syphilis is most contagious due to greater
amount and variety of lesions.
● Incubation period: 9-90 days

4. Acquired Syphilis
Primary Syphilis
● Painless chancre(primary chancre,Hunterdon
chancre,Hard chancre) -single,clean based,indurated,
doesn't bleed on touch.
● Inguinal lymph nodes-indolent bubo ,bilateral
enlargement , nontender ,non supportive, firm,
shotty.
● Heals with scarring in 3-6 weeks without treatment.
● Chancre redux is rare.

5. Secondary Syphilis
● Due to hematogenous dissemination.
● Appear after 3- 12 weeks of primary lesion.
● Constitutional symptoms-fever, arthralgia,myalgia.
● Rash-symmetric,polymorphous, non pruritic.
● All types of morphology is seen except vehicles and bullae-The
great imitator
● Examination of palms and soles is characteristic.

8. ● Bushcke Olendorff Sign-deep dermal pain on
pressing lesion With blunt end of pin.
● Greyish white mucous patches ,snail track ulcers.
● Condylomata lata-flat topped moist plaques in
intertrigenous areas.
● Generalized lymphadenopathy -inguinal ,
posterior cervical , epitrochlear are characteristic.
● Moth eaten ,non scarring alopecia.

9. Tertiary syphilis
● Gummatous :nontender pink to dusky red
nodules,vary in size .
● Cardiovascular :Aortic aneurysm , regurgitation.
● Neuro syphilis:Taber dorsalis , general paresis of
insane.

10. Congenital Syphilis
● Treponema cross placenta and infect fetus.
● Kassowitz’s law :ability of mother to infect fetus
diminishes but never disappears in latent , late
stages.
● Early - < 2yrs
● Late - > 2yrs

11. Early congenital syphilis
● Snuffles - persistent rhinitis
● Cutaneous lesions
● Furuncle of Barlow
● Hepatosplenomegaly
● Pseudoparalysis of parrot
● Sawtooth metaphysis
● Salt and pepper fundus -syphilitic chorioretinitis

12. Late congenital syphilis
● Hotcross bun deformity of skull,saddle nose
● Mulberry molars /notched molars/moon’s molars.
● Hutchinson’s teeth + interstitial keratitis + 8th nerve
deaf ness- Hutchinsons’s triad.
● Rhagades, Clutton’s joints(Painless joint swellings).
● Sabre tibia,palate perforation ,
neurosyphilis,paroxysmal cold hemoglobinuria.

14. Diagnosis
● Dark field microscopy( most sensitive,specific)-cork screw
motility.
● Nonspecific tests -VDRL , RPR .Significant titre is >/=1:8.
● Treponemal tests - Treponemal pallidum
hemeagglutination assay(TPHA) ,
Microhaemagglutination assay (MHA-TP) ,Fluoroscent
treponemal antibody absorption test (FTA-ABT).

15. ● Silver staining.
● CSF examination , chest X ray for tertiary syphilis.
● Skin biopsy-Endarteritis obliterans ,perivascular
infiltration of lymphoid cells and plasma cells.

16. Treatment
● Injection Benzathine Penicillin 2.4 million units
,deep IM.
● Single dose for early syphilis
● 3 doses for late syphilis once weekly.
● Neurosyphilis:inj Aqeous crystalline penicillin ,18-
24 million units per day,IV ,10-14 days.
● If allergic to penicillin -Doxycycline 100 mg BD

17. Chancroid
● Soft sore,soft chancre , ulcus molle.
● Haemophilus ducreyi(gram negative bacillus)
● 1-5 days is incubation period.
● Lesion erodes to form extremely painful ,deep
ulcer-soft,friable ,non indurated, ragged
undermined margins,foul smelling, yellow grey
erudite, surrounding erythema.
● Inflammatory bubo-Unilateral ,painful inguinal
lymphnodes.May rupture to form ulcer.

18. Diagnosis
● Gram stain:gram negative coccobacilli ,school of
fish appearance.
● Ito-Reenstierna test:Intradermal test with vaccine
containing killed H.ducreyi in suspension
,producing inflammatory papule after 48 hours.

19. Treatment
● Azithromycin 1g orally single dose (or)
● Ceftriaxone 250 mg IM stat. (or)
● Ciprofloxacin 500 mg orally BD for 3 days (or)
● Erythromycin base 500 mg orally TDS for 7 days.

20. Herpes Genitalis
• Caused by HSV 1 (20%) and HSV 2 (80%).
• Incubation period is between 3 to 14 days.
• Primary lesion: small grouped vesicles.
Ulcerative lesions( Superficial and tiny)
• The floor is erythematous and covered with serous exudates.
(2-4 days)

22. Diagnosis
• Tzanck smear – multi-nucleate giant cells
• Definitive diagnosis is done by viral culture of the lesion which
can differentiate between HSV 1 and HSV 2
• Direct immunofluorescence
• Specific monoclonal antibodies directed against HSV 1 and HSV 2

23. Treatment
• Tab Acyclovir 400 mg thrice daily for 7 to 10 days.
• Syndromic management- kit no 5 (red)
• Recurrent episodes – tab acyclovir 400 mg thrice daily for 5
days.
• Famciclovir and Valacyclovir can also be used.

24. Lymphogranuloma Venerum
• Causative organism – Chlamydia trachomatis immunotypes L1, L2, L3
• Incubation period 3 to 30 days
• First stage – small painless papule or pustule that erodes to form an
asymptomatic herpetiform ulcer this heals without scarring in 1 week
• Second stage begins within 2-6 weeks and consists of painful inflammation and
infection of inguinal and femoral lymph nodes
• Groove sign of green Blatt – enlarged lymph node above and below the inguinal

26. Diagnosis
• Nuclei acid amplification test
• ELISA
• Direct immunofluorescence
• Frei test

27. Treatment
• Doxycycline 100 mg twice daily for 21 days
• Erythromycin 500 mg four times daily for 21 days

28. Donovanosis :
• Causative agent : Klebsiella granulomatis.
• Incubation period : 8 to 12 days.
• Site of inoculation: Single or multiple subcutaneous nodules
or papules( thigh, genitalia, groin, perineum).
• These enlarge and erode to form painless, soft, beefy, red,
exuberant ulcerations with clean friable based and distinct
raised rolled margins.

29. Diagnosis:
• Bipolar staining.
• Biopsy and histopathological examination.
Treatment :
• Doxycycline 100 mg BD for atleast 3 weeks.
• Alternate regimens: Azithromycin 1g OD or Ciprofloxacin 750
mg BD or Erythromycin base 500 mg QID or Cotrimoxazole(DS)