History and Examination:
- History: Inquire about duration, pain, discharge, sexual history, systemic symptoms (fever, malaise), and risk factors (STIs, immunosuppression).
- Examination: Assess size, shape, depth, edges, base, and surrounding skin. Note presence of lymphadenopathy or systemic signs.
- Differential Diagnosis:
- Infectious Causes:
- Herpes Simplex Virus (HSV): Painful, grouped vesicles/ulcers, often recurrent.
- Syphilis (Chancroid, Granuloma Inguinale): Painless, indurated ulcers (syphilis), painful, non-indurated (chancroid), beefy-red granulation tissue (granuloma inguinale).
- Bacterial (e.g., Streptococcus, Staphylococcus): Painful, purulent, often with fever.
- Fungal (e.g., Candida): White exudate, satellite lesions, often in immunocompromised.
- Non-Infectious Causes:
- Traumatic/Mechanical: History of trauma, irregular edges, no systemic symptoms.
- Neoplastic (e.g., Squamous Cell Carcinoma): Non-healing, indurated, irregular borders, possible lymphadenopathy.
- Autoimmune (e.g., Behçet’s, Lichen Sclerosus): Recurrent ulcers (Behçet’s), white plaques (lichen sclerosus).
- Investigations:
- Swab for PCR: HSV, syphilis, chlamydia, gonorrhea.
- Biopsy: If chronic, non-healing, or suspicious for malignancy.
- Serology: Syphilis (RPR/VDRL, TPHA), HIV.
- Blood Tests: FBC, ESR, CRP for systemic inflammation.
- Management:
- Empirical Treatment: If STI likely, treat for HSV (acyclovir), syphilis (benzathine penicillin), or chancroid (azithromycin).
- Wound Care: Clean with saline, avoid trauma, consider topical antiseptics (e.g., chlorhexidine).
- Referral: To dermatology or infectious diseases if diagnosis unclear or chronic.
Rationale: Genital ulcers require thorough evaluation due to their association with STIs and potential for malignancy. Empirical treatment is often initiated based on clinical suspicion, with definitive diagnosis guided by investigations. Chronic or atypical ulcers necessitate biopsy to exclude malignancy.