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Genital ulcers

Are they all sexually acquired?
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Genital sores are punched-out erosions and ulcers that can be found over the external genital region, affecting the vulva in females and the penis and scrotum in males. These sores may occasionally extend to the surrounding pubis and anal region.

Often, due to the acute extensive clinical presentation of ulcers and associated pain, patients do seek medical assistance. The first shiver that runs down most of our spines is whether this is a case of STD. Is it possible genital ulcers are not due to an STD?

In this article, we delve into both the non-STD causes and STD causes of genital ulcers.

Genital ulcers can be due to non-STD and STD-related causes.

Causes of genital ulcers

STD-related genital ulcers

Commonly, genital ulcers are associated with infectious causes, particularly an underlying STD. According to the Centers for Disease Control and Prevention (CDC), Herpes Simplex Virus (HSV) remains the most common cause of genital ulcers.

STDs that can present with genital ulcers(most common to least common)How do they present?
1.     Herpes Simplex Virus (HSV)The ulcers present as small blisters that progress over time into ulcers, open wounds, or erosions.
2.     SyphilisThe ulcer is usually solitary and painless (chancre).
3.     Chlamydia trachomatis(Lymphgranuloma venereum)The ulcer is a painless individual ulcer. One can have associated abnormal urinary symptoms such as painful urination, itching, or urethral discharge.
4.     Haemophilus ducreyiThe ulcers (chancroid) can be extremely painful and associated with painful pustular surrounding lymph nodes.
5.     Klebsiella Granulomatis(Donovanosis)Painless beefy-red genital ulcers that are slow to progress and associated with surrounding lymph nodes.
6.     MonkeypoxUlcers are painful, firmed, and deep-seated, with a ‘dot’ on top of the lesion. They can be individual or multiple in appearance. Ulcers can occur in the mouth. There can be an associated body rash and systemic symptoms such as fever and flu-like symptoms.

STD-related genital ulcers, if left untreated, run a risk of transmitting further to other sexual partners. Furthermore, untreated open sores increase the risk of a person getting infected with subsequent STDs, including the risk of acquiring HIV infection. It is worth noting that there are beneficial evidence-based treatments for most STDs. STDs are not able to resolve on their own with a person’s immune system, and treatment will be required to manage the disease.  

If you are concerned that you may be exposed to STDs, reach out to your healthcare provider for screening and early treatment of STDs.

Non-STD-related genital ulcers

Less commonly, genital ulcers can occur without being sexually acquired. This can happen in both females and males, though with a slight predisposition in females. The underlying mechanism of non-STD-related genital ulcers remains poorly understood. There are suggestions that an exaggerated immune response may trigger the formation of genital ulcers following a recent infection or inflammation in the body.

In non-STD-related genital ulcers, one may commonly present with recent viral-like symptoms such as fever, chills, lethargy, sore throat, respiratory symptoms, or gastrointestinal (diarrhoea) symptoms.

Common infectious viruses that can be associated with non-STD-related genital ulcers include:

  • Epstein Barr Virus (EBV)
  • Cytomegalovirus (CMV)
  • Hand foot mouth disease (HFMD)/Coxsackie Virus
  • Salmonella infection
  • Mumps
  • Covid-19 infection

Occasionally, genital ulcers can be associated with shingles, a case usually mistaken for a herpes (HSV) outbreak.

Shingles occur when an old virus (Varicella Zoster Virus) that has been dormant in the nerve root of the body reactivates. It is important to promptly pick up shingles rather than manage them as a case of herpes genital ulcer, as the treatment dose of shingles differs. The delay in treatment of shingles can be associated with complications such as chronic pain (post-herpetic neuralgia), brain inflammation (encephalitis), respiratory infection (pneumonia), etc.

Shingles occur when a dormant virus (Varicella Zoster Virus) is reactivated in the nerve root of the body.

Non-infectious genital ulcers

  • Fixed Drug Eruptions (FDE): genital ulcers can also but rarely be secondary to a drug reaction. This is a type 4 delayed hypersensitivity allergic reaction. Upon repeated exposure to the same culprit medication, one will develop a blister and ulcer over the same part of the body. In fixed drug eruptions, the ulcer can occur over the genital region or other mucous regions such as the lips or mouth. Common drugs that can be associated with FDE include antibiotics and non-steroidal anti-inflammatory drugs (NSAIDS).
  • Autoimmune causes: another rare cause, genital ulcers, can be due to underlying autoimmune conditions such as inflammatory bowel disease (IBD) or Behcet’s disease. In inflammatory bowel diseases such as Crohn’s disease, one can present with genital ulcers and mouth ulcers, with an associated main presentation of recurring bloody diarrhoea. Behcet’s disease is very rare and seen more frequently in people from the eastern Mediterranean, East Asia, and Central Asia. Patients typically present with painful recurring genital and mouth ulcers, infected red eyes, blood vessel inflammation (vasculitis), joint inflammation, skin rash, or complications such as blood vessel thrombosis, blindness, or stroke.

How can I differentiate whether my genital ulcers are STD or non-STD-related?

A careful history of the progression of the ulcers, together with a sexual history (if any), can be instrumental in differentiating the cause of the genital ulcers. A physical examination by your doctor, with whom you are comfortable, is important. If it is not possible to tease out the underlying cause, laboratory testing with swabs for viruses/bacteria can be beneficial. Depending on the risk of suspicions, your doctor may offer appropriate STD testing to reach the correct diagnosis.

What is the importance of finding out whether my genital ulcers are STD-related or non-STD-related?

Genital ulcers due to untreated underlying STDs pose a risk of spreading the undiagnosed and untreated STDs to other partner(s). Furthermore, untreated STD-related genital ulcers increase a person’s risk of acquiring different forms of STDs due to impaired skin barrier, low immune system, etc. It is important to note that untreated STDs cannot be resolved by one's immune system unless one receives the correct treatment.

Untreated STD-related genital ulcers increase a person’s risk of acquiring other forms of STDs.

What are the treatment options for non-STD-related genital ulcers?

Symptomatic relievers are usually offered for non-STD-related genital ulcers. Management of non-STD-related genital ulcers revolves around good wound care. Medications such as anti-inflammatories, pain relievers, and topical numbing cream may be offered to aid recovery.

What are the treatment options for STD-related genital ulcers?

Delivering the right medication for the STD that causes the genital ulcer is critical in managing the infection and symptoms. To do so, arriving at the correct diagnosis with an appropriate screening test is vital.

What is the outcome of non-STD-related genital ulcers?

The prognosis of non-STD-related genital ulcers is generally favourable if the underlying cause resolves over time. Non-STD-related genital ulcers usually resolve spontaneously without scarring and seldom recur.

What is the outcome of STD-related genital ulcers?

With the correct diagnosis and course of treatment, and if the underlying STD is addressed, the genital ulcers resolve with treatment.

What have I learnt today?

  • Not all genital ulcers are due to STDs, though STD such as Herpes Simplex Virus infection is the most common cause of genital ulcers.
  • Non-STD-related genital ulcers can occur following a non-STD-related infection, drug allergy, or due to underlying immune system disorders.
  • In sexually active individuals, STD screening tests can be discussed and offered in the presence of genital ulcers.
  • Treatment for STD and non-STD-related genital ulcers are different.
  • Determining the causes of genital ulcers is vital in ensuring the proper treatment is being offered.

References

  1. Brambilla I, Moiraghi A, Guarracino C, Pistone C, Tondina E, Riccipetitoni G, Raffaele A, Cavaiuolo S, Bertozzi M, Brazzelli V. Recurrent reactive non-sexually related acute genital ulcers: a risk factor for Behcet's disease? Acta Biomed. 2022 Jun 6;93(S3):e2022196
  2. Krapf JM, Casey RK, Goldstein AT. Reactive non-sexually related acute genital ulcers associated with COVID-19. BMJ Case Rep. 2021 May 5;14(5):e242653.
  3. Kirshen C, Edwards L. Noninfectious genital ulcers. Semin Cutan Med Surg. 2015 Dec;34(4):187-91.
  4. Roett MA. Genital Ulcers: Differential Diagnosis and Management. Am Fam Physician. 2020 Mar 15;101(6):355-361. 
  5. Farhi D, Wendling J, Molinari E, et al. Non–Sexually Related Acute Genital Ulcers in 13 Pubertal Girls: A Clinical and Microbiological Study. Arch Dermatol. 2009;145(1):38–45.
  6. Ahmed J, Rawre J, Dhawan N, Dudani P, Khanna N, Dhawan B. Genital ulcer disease: A review. J Family Med Prim Care. 2022 Aug;11(8):4255-4262. 
  7. https://www.cdc.gov/std/treatment-guidelines/genital-ulcers.htm
  8. https://www.cdc.gov/poxvirus/mpox/index.html

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