Genital Ulcers


Sexual (most common)

  • HSV1/2 (95% of genital ulcers)
    • Painful vesicles on erythematous base
  • Chancroid (Haemophilis ducreyi)
    • Painful, single or multiple necrotizing ulcers
  • Syphilis (Treponema pallidum)
    • Painless papule evolving to chancre, indurated with serous exudates
    • Most cases single ulcer with smooth margin/base
  • Lymphogranuloma venereum (Chlamydia trachomatis)
    • Painless papule which may ulcerate, followed weeks later by tender lymphadenopathy ("buboes")
      • MSM characterized by proctocolitis
  • Granuloma inguinale / Donovanosis (Klebsiella granulomatis)
    • Painless progressive enlarging ulcer(s), beefy red, friable, with rolled margins
  • Primary HIV
    • Painful ulcer (can also be oral, esophageal, anal), fever, flu-like illness


  • Infectious
    • Bacterial (Staph, Strep, Pseudomonas, Mycoplasma, Salmonella, Lyme)
    • Viral (EBV, CMV, HZV, Influenza, Parvovirus, Paramyxovirus, Mumps)
    • Fungal (candida)
    • Parasitic (Toxoplasma, scabies)
  • Malignancy (SCC)
  • Drug / Fixed drug eruption
    • NSAIDs
    • Imiquimod
    • Hydroxyurea
    • Hydralazine


  • Sexual history
    • Exposure last 90 days
    • Sites of contact
    • Travel
    • History of STIs
    • Drugs/alcohol/high-risk behaviours
  • Painful (HSV, chancroid)
  • Painless (syphilis, LGV, granuloma inguinale)
  • Urinary symptoms (concomitant urethritis)
  • Constitutional symptoms
  • Recurrent episodes (HSV, Behçet syndrome, drug)

Physical Exam

  • Oral, rectal
  • Genital/urethral exam
  • Hepatomegaly
  • Lymphadenopathy
    • Tender (HSV, chancroid, LGV)
    • Non-tender (late primary syphilis)
    • Significant inguinal, cervical, axillary (HIV)


  • STI screen (HIV, Syphilis, Gono/chlam)
  • HSV PCR (or viral culture, or direct fluorescent antibody)


  • Avoid sexual intercourse
  • Consistent barrier contraception for prevention
  • Consider empiric treatment for HSV
    • May consider empiric treatment for other genital ulcer diseases in certain cases (eg. poor follow-up) after consulting with specialist
  • Consider early referral/follow-up in atypical, immunosuppressed, travel, systemic disease
  • Treat partners except for HSV

Specific Treatment

    • HSV
      • Acyclovir 400mg PO TID x 7-10d
    • Chancroid
      • Azithromycin 1g PO x1 or Ceftriaxone 250mg IM x1
    • Syphilis
      • Pen G 2.4 million units IM
      • Re-test for syphilis
    • LGV
      • Doxycycline 100mg PO BID x 21d
    • Granuloma inguinale
      • Azithromycin 1g PO weekly or 500mg PO daily until lesions have healed (minimum 3 weeks)