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Referral and warning signs
When to refer
Refer for specialist management if: Ulcers persist >10 days despite appropriate syndromic treatment and partner management. Diagnosis is uncertain (consider biopsy for malignancy, non-infectious causes). Complications arise (e.g., severe buboes needing aspiration, significant tissue destruction). Suspected neurosyphilis or systemic involvement.
Red flags
- Ulcers persisting despite standard syndromic treatment
- Large, destructive ulcers (possible Granuloma Inguinale or malignancy)
- Signs of systemic illness (fever, rash, neurological symptoms)
- Highly suspicious lesions for malignancy
Signs and symptoms
- Presence of single or multiple ulcers/sores on genitals (penis, vulva, vagina, cervix, perineum, anus).
- Ulcers may be painful (Herpes, Chancroid) or painless (Syphilis).
- Associated inguinal lymphadenopathy (swollen groin glands) may be present.
- Specific ulcer characteristics:
- - Syphilis (Primary): Typically single, painless ulcer (chancre) with clean base, indurated margins.
- - Syphilis (Secondary): Multiple, painless ulcers (mucous patches or condylomata lata).
- - Genital Herpes: Multiple, small, painful vesicles or shallow ulcers, often recurrent.
- - Chancroid: Multiple, large, painful, irregular ulcers with undermined edges and purulent base; often associated with painful suppurative inguinal lymphadenopathy (bubo).
- - Granuloma Inguinale: Irregular, beefy-red, painless ulcer that bleeds easily and expands.
- - LGV: Often transient small ulcer followed by significant inguinal lymphadenopathy.
Risk factors
- Unprotected sexual intercourse
- Multiple sexual partners
- HIV infection (can alter ulcer appearance and healing)
- Travel to endemic areas (for Chancroid, LGV, Granuloma Inguinale)
Diagnosis
Clinical assessment
Based on history (number, pain, recurrence of ulcers) and examination of ulcer characteristics (size, shape, base, edge, induration, pain) and regional lymph nodes.
Investigations
- Blood: Syphilis testing (RPR/VDRL essential, TPHA for confirmation), HIV testing.
- Swab from ulcer base/edge: Darkfield microscopy (for Syphilis, rarely available), Gram stain (look for Haemophilus ducreyi - 'school of fish'), PCR for HSV, Syphilis, Chancroid (specialized labs).
- Viral culture for HSV (less sensitive than PCR).
Diagnostic criteria
Presence of genital ulcer(s), managed syndromically based on clinical features (especially history of recurrence/pain) and syphilis serology.
Management
Non-pharmacological management
- Take history and examine.
- Advise abstinence or consistent condom use.
- Partner notification and treatment.
- Provide health education and risk reduction counseling.
- Offer HIV counseling and testing (HCT).
Pharmacological treatment
- Follow UCG Flowchart (Figure 10):
- 1. History of recurrent painful ulcers/vesicles? (Likely Herpes):
- - Give Aciclovir 400 mg PO every 8 hours (or 200mg 5x/day) for 7 days.
- - Perform RPR/VDRL test. If positive, ALSO treat for Syphilis (below).
- - If vesicles/ulcers persist after 7 days, repeat Aciclovir course for another 7 days.
- - Consider topical acyclovir cream (though systemic treatment more effective).
- 2. No history of recurrent painful ulcers/vesicles OR first episode:
- - Treat for Syphilis + Chancroid:
- - Benzathine Penicillin G 2.4 million units IM single dose (1.2 MU in each buttock).
- - PLUS Ciprofloxacin 500 mg PO BID for 3 days (Contraindicated in pregnancy).
- - Alternative if Penicillin allergic: Erythromycin 500 mg PO QID for 14 days (covers both Syphilis and Chancroid).
- - Alternative for Chancroid if Cipro contraindicated (e.g., pregnancy): Azithromycin 1g PO single dose OR Ceftriaxone 250mg IM single dose.
- 3. If ulcer persists >10 days AND partner was treated:
- - Add Erythromycin 500 mg PO QID for 7 days (covers potential Granuloma Inguinale/LGV or secondary infection).
- 4. If ulcer still persists:
- - Refer for specialist management (consider biopsy, alternative diagnoses).
Monitoring
Review patient after 7-10 days to assess healing. Monitor for persistence or recurrence.
Complications
- Increased risk of HIV acquisition and transmission
- Secondary bacterial infection of ulcers
- Inguinal lymph node suppuration (bubo formation), potential rupture
- Phimosis or paraphimosis (if ulcer on prepuce)
- Urethral fistula (rare)
- Scarring
- Psychological distress
Prevention
- Consistent and correct condom use
- Mutual monogamy with an uninfected partner
- Abstinence
- Partner notification and treatment
- Regular STI screening for high-risk individuals
- Prompt treatment of existing ulcers
Patient education
- Explain the possible causes based on syndromic approach.
- Stress importance of completing full treatment course.
- Advise on partner notification and treatment.
- Educate on abstinence or condom use during treatment and until ulcers heal.
- Discuss prevention strategies.
- Advise return if ulcers do not heal or worsen.
- Explain significance of syphilis and HIV testing.
Uganda-specific notes
Syphilis, Herpes, and Chancroid are the main targets of the syndromic GUD algorithm. Benzathine Penicillin availability is crucial. RPR/VDRL testing should be performed. Consider HIV co-infection which can affect presentation and healing.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 3, Section 3.2.4, Figure 10