Women's Health Update: Genital Ulcer Diseases

Tagged:  

Women's Health Update: Genital Ulcer Diseases

In the work-up of genital ulcers, the differential includes Herpes Simplex Virus, Syphilis, Lymphogranuloma Venereum (LGV), Granuloma Inguinale, Chancroid, Crohn's Disease, Lichen Planus, Hydranetis Suppurativa, Behcet's Disease and HIV.

The evaluation and diagnosis of genital ulcers requires a logical, orderly approach. Physical exam, bacterial and viral cultures, serology, and biopsy are the mainstays of the work-up. If any sexually transmitted disease is found, other coexisting infections must then be ruled out. The following steps will be helpful in the office work-up of genital ulcers:

Take a careful history of the course and associated symptoms.
Perform a thorough examination of the lesions and the rest of the vulva, cervix and vagina, lymph nodes, skin, mouth, eyes, and axillae.
Obtain a viral culture for herpes simplex.
Stain samples with Gram stain to rule out granuloma inguinale and chancroid.
Examine specimens by darkfield to rule out syphilis.
Obtain bacterial cultures of the lesion and/or bubo to look for chancroid.
Obtain biopsy specimens of the lesion to rule out carcinoma, Crohn's disease, lichen planus and Behcet's disease.
Perform serologic studies to rule out syphilis and LGV.
Consider upper gastrointestinal series, barium enema, or colonoscopy to rule out Crohn's disease.
Perform HIV testing.( 1)
Herpes Simplex

Primary and recurrent herpes simplex infections usually present with a prodromal symptom of tingling or burning, followed by a erythematous papule, which erupts into a vesicle that then quickly becomes an ulcer. The lesions more commonly present as multiple small ulcers 2 to 3 mm in diameter rather than a large individual ulcer. The primary infection may be associated with malaise and fever, but these symptoms usually do not occur in recurrent disease. Diagnosis is made by viral culture for herpes simplex.

Syphilis

The primary lesion of syphilis is the chancre. This is commonly a painless ulcer but often the ulcers are infected and can be swollen and tender. Condylomata lata, the secondary lesions of syphilis, are often seen on the vulva and can also be ulcerative. Condylomata lata are usually multiple and associated with a generalized rash involving the whole body, including the palms and soles. The diagnosis can be made with darkfield microscopy of scrapings of the ulcer and more commonly, by serology.

Lymphogranuloma Venereum

LGV is very unusual in the United States. The primary manifestation of the infection due to Chamydia trachomatis is a small, painless ulcer. The initial lesion may be mistaken for herpes simplex because of the similar vesicular appearance. The lesions appear at the introitus, cervix, or vulva. The incubation time from contact to primary lesion is 3 to 12 days. The secondary stage of the disease is the "inguinal syndrome." The incubation time is anywhere from 10 days to 6 months. Unilateral inguinal adenopathy is present in about two-thirds of patients. The groin swelling may be so extensive a second fold in the groin tissue is created. This is called the "groove sign" and is pathognomonic for LGV. This second stage may be associated with fever, malaise, and flu-like symptoms. Later in the disease, perirectal involvement may lead to severe scarring, strictures, and rectal-vaginal fistulas. Vulvar lesions in this advanced stage can be extensive. The diagnosis is made by a complement fixation test and culture of the bubo aspirate.

Granuloma Inguinale

This is an uncommon disease in most parts of the world, and is rare in the United States. The primary infection is characterized by one or more ulcers of the vulva or cervix that are usually preceded by a papule.( 2) Secondary infection may make these lesions quite inflamed and tender, although they may also be non-tender. The secondary stage involves the formation of subcutaneous granulomas in the inguinal area.( 3) Sometimes these lesions penetrate the skin, producing skin ulcers and become superinfected which may then lead to lymphadenopathy. The advanced stage may cause highly destructive granulation tissue, extensive ulcers, fibrosis and scarring. The diagnosis is made with tissue scrapings or biopsy specimens of the lesions.

Chancroid

This is another infection that is extremely rare in the United States. It is more common in men, particularly in uncircumcised men. Incubation is 4 to 7 days. The lesion on the vulva starts out as a papule. In 24 to 48 hours it becomes pustular, and then an ulcer. The ulcers have a gray necrotic center. The lesions are tender, usually multiple, and may be associated with inguinal adenopathy. Aspiration of the buboes for Gram stain and cultures is the most reliable diagnostic.

Crohn's Disease

Vulvar manifestations of Crohn's disease are surprisingly common and may even precede bowel symptoms in up to one-fourth of patients. The appearance of oral ulcers is an associated symptom as is the formation of fistulas from bowel to vulva. The vulvar lesions are linear, deep and are often described as "knife-cut" lesions. Diagnosis is made by biopsy, gastrointestinal studies, sigmoidoscopy or colonoscopy.

Carcinoma of the Vulva

The ulcers of an invasive malignancy generally have a necrotic base with a sharply defined border with underlying induration, giving it a rolled edge.( 4) Other clinical manifestations of these ulcers are bleeding and exudation. Biopsy specimens of ulcers should be taken between the edge of the lesion and the center.

Hidradenitis Suppurativa

This is an infection of the apocrine glands of the skin of the vulva. These lesions look similar to facial acne and it does not appear before puberty. Usually there are multiple lesions in varying stages. Comedones and blackheads may be followed by small abscesses and then scarring. Subcutaneous nodules and scarring from previous infections suggest hidradenitis suppurativa. Cultures of the lesions are not especially helpful because they show many different organisms normally found on the skin.

Lichen Planus

Lichen planus may involve the skin of the vulva but is often associated with oral lesions as well. The vulvar lesion may appear as an ulcer, but more commonly it appears as an erosion of the vestibule. Vulvovaginitis frequently accompanies this erosion. The vulva may present with a grayish-white, lacy pattern that resembles lichen sclerosis or hyperplastic dystrophy. These lesions are particular, in that they usually occur on the inner surfaces of the labia minora. The diagnosis is made by biopsy specimen.

Behcet's Disease

Behcet's disease is also rare in the United States, and is more commonly found in the Mediterranean countries and Japan. It is classically described as a combination of oral and vulvar ulcers with ophthalmologic abnormalities and other manifestations including Stevens-Johnson syndrome, erythema nodosum, and acne. Central nervous system involvement, arthritis, colitis, and pulmonary embolus may occur. The diagnosis is one of clinical exclusion. One of the most frequent presenting symptoms is aphthous ulcers of the mouth with genital ulcers. The vulvar lesion tends to start out as a vesicle and evolve into an ulcer that develops a crust. The lesions may be found in the vagina or on the cervix or vulva and extensive scarring of involved areas may result. The disease is chronic and the etiology is unknown. The biopsy findings in Behcet's disease are not definitive.

HIV

HIV has now been cultured from genital ulcers. These are primary HIV ulcers. Diagnosis is made with HIV testing.

References
(1.) Nichols M: Vulvar Ulcers. Postgraduate Obstetrics and Gynecology 11:7, April 1991.

(2.) Lal S, Nicholas C: Epidemiological and clinical features in 165 cases of granuloma inguinale. Br J Vener Dis 46: 461, 1970.

(3.) Nichols M: Vulvar Ulcers. Postgraduate Obstetrics and Gynecology 11:7, April 1991.

(4.) Nichols M: Vulvar Ulcers. Postgraduate Obstetrics and Gynecology 11:7, April 1991.

Townsend Letter for Doctors & Patients.

~~~~~~~~

By Tori Hudson

Share this with your friends