An ulcer is characterized by a disruption in the integrity of the skin or mucous membrane, wherein a specific region experiences damage and an inability to undergo the healing process.
Genital ulcers are formed in the genital region of an individual. Various bacteria or viruses can serve as potential causes for ulcers.
The following sections will discuss the causology, symptoms, management, and complications of genital ulcers as well as when to seek medical and lifestyle advice.
Ulcers can appear anywhere in the body, both inside and outside. There are a variety of different causes to why an ulcer forms, but a genital ulcer is typically caused by sexually transmitted diseases(STDs). Although STDs are a common cause of genital ulcers, there are certain conditions which can also give rise to ulcers in the genital areas, such as trauma, cancer, certain conditions which affect the skin, such as Steven-Johnson syndrome, and gastrointestinal conditions such as Crohn's disease.1
What do ulcers look like?
Ulcers can have very specific characteristics. Depending on the cause, ulcers can be both painful and painless. In the naked eye, an ulcer looks like a crater, where the particular area of the skin is depressed, and the surrounding skin is elevated, giving it a crater-like appearance.2 Genital ulcers are a common health issue both in the developed and developing world. Unlike ulcers in other parts of the body, genital ulcers require very specific management and diagnostic criteria.
Causes of genital ulcers
Genital ulcers, or genital ulcer disease (GUD), as it is referred to in the clinic, most exclusively is caused by three different pathogens.3,4,5
- Herpes simplex virus: Herpes Simplex Virus-1 (HSV-1) and Herpes Simplex Virus-2 (HSV-2) both have the ability to cause genital ulceration. While HSV-2 is a more common cause of genital herpes, HSV-1 can also cause genital herpes due to sexual contact
- Treponema pallidum: This particular bacteria causes syphilis, a sexually transmitted disease which occurs due to unprotected sexual intercourse with someone with an active infection. It can also occur via orogenital, and anogenital contacts as well as via blood transfusion and organ transplant procedures
- Haemophilus ducreyi: This is also known as chancroid. The bacteria causes ulcerations via skin abrasions during unprotected sexual intercourse with an individual
Regardless of different bacterial infections, the most common cause of genital ulcers is unprotected sexual intercourse.
Signs and symptoms of genital ulcers
Genital ulcerations have very specific symptoms and signs depending on the cause of the infection. Each bacterial infection has a very distinct ulceration feature.
Syphilis: Infection by Treponema Pallidum has three different stages of infection. During the first stage of infection, there is a painless, small, firm sore in the area of exposure. This is called a ‘Chancre’. It can occur in different places, such as the mouth, within the vagina and the rectum. This is the first stage of genital ulceration. Some individuals may get cancer inside the mouth within the first few weeks of exposure, which can resemble the characteristics of an aphthous ulcer. During the secondary stages, symptoms such as fever, muscle aches, and swollen lymph nodes (glands) in the inguinal/groin area appear. A painless rash on the palms and soles of an individual is also a characteristic sign of syphilis.4
Herpes simplex virus: While HSV-1 most exclusively causes painful small blisters on the lips, it can also be transmitted through orogenital contacts which can give rise to genital ulcers. HSV-2 is thought to be the main culprit which causes genital ulcers. Unlike the genital ulcers arising from Syphilis, herpes-induced genital ulcers are painful fluid-filled blisters which can cause recurrent infection. The recurrence of this particular ulcer is due to the virus staying inactive within the nerve root. The characteristics are pain, tingling, and painful blister formation which ultimately results in an ulcer formation. Unprotected sex with someone with an active herpes infection is one of the main causes.3,5
Chancroid: Chancroid rarely causes genital ulcers. Unlike Chancre, which is caused by the Treponema Pallidum virus (Syphilis), Chancroid is caused by Haemophilus Ducreyi virus, which is also transmitted due to unprotected sexual intercourse with an affected individual. Chancroids cause painful small ulcers in the genital region, which have raised edges. The ulcers cause infection and discharge. They can be painful in males, while females may not be aware of the ulcers as they can be within the vaginal wall and not painful.5
HIV: Human immunodeficiency virus causes AIDS. Individuals who are HIV-positive often develop ulcers on their genitals. It occurs during the early stage of infection. These ulcers are small painful open ulcers which can occur in different sites of the body, such as the mouth and the anal region. HIV is a systemic disease which means it also causes general unwellness, such as unintended weight loss, fever, and loss of appetite. Unprotected sex with an individual is the primary cause of transmission among individuals6
A summarisation of symptoms and signs of genital ulcer as a whole would be:
- Painful and painless sores on the genital region.
- Discharge clear fluid or pus from the ulcerated sore.
- Generalized unwellness, such as fever, loss of appetite, and nausea.
- Swollen painful glands in the groin region
- Rash or ulcers inside the mouth, palm or soles
- History of unprotected sexual intercourse
Management and treatment for genital ulcers
Management of genital ulcers largely depends on the cause. An individual with a genital ulcer should seek immediate medical attention. Healthcare systems around the world provide support and advice for sexual health, such as the GUM Clinic run by the NHS in the UK. These services provide the patient with discreet diagnostics and management plans.
Partner Notification Programme is an NHS service aimed towards the prevention of the spread of STDs. The partner notification can be done by the individual affected or the clinic itself, where the clinic invites partners to undergo testing discreetly.
Following diagnosis, the individual can start on certain courses of antibiotics. It is important for the individual to complete these courses of antibiotics according to the doctor's advice and refrain from any type of sexual activity. Different treatments are provided according to the cause, including.3,7,8,9:
- Chancroid: Azithromycin, Ceftriaxone, Ciprofloxacin, Erythromycin for Chancroid
- Herpes: Antivirals such as Acyclovir, Valacyclovir, Famciclovir
- Syphilis: Benzathine Penicillin G for all different stages of Syphilis infection
- HIV: Antivirals such as Atazanavir, Ritonavir, Lopinavir, Darunavir etc., are used for the treatment of HIV and have shown tremendous success rates enough to keep the viral load below normal and allow an individual to live a regular life
For diagnostic purposes, it is important for the affected individual to provide a thorough history of sexual intercourse as well as the symptoms. Depending on the type of ulcer, medical professionals may undertake further investigations to discover the cause.10
Further tests may include:
- Serology tests for Syphilis
- rtPCR for both herpes and HIV
- Swab tests for Syphilis and Chancroid
How can I prevent genital ulcers?
To prevent genital ulcers, avoid having unprotected sexual intercourse. It is encouraged that individuals, along with partners, should have regular sexual health checks before commencing unprotected sexual activity. Using condoms during sexual activity provides protection against most STDs, hence preventing genital ulcers. However, it is important to note that orogenital and anogenital contacts can also cause the transmission of STDs.3,4,5,6
How common are genital ulcers?
The prevalence of genital ulcers largely depends on the geographic location and sexual practices amongst the population within the defined area. It is estimated that 95% of the world’s population has an HSV-related genital ulcer, with Africa having the highest genital ulcer burden.
What do genital ulcers look like?
Genital ulcers are small sores or indentations in the skin. It can have distinct rolled edges, red or pink colour, with a crater in the middle. They can release discharge,(fluid) or pus.
What do genital ulcers feel like?
Genital ulcers can be both painful and painless, depending on the cause. They give a sense of discomfort. Certain ulcers, such as those caused by the Herpes Simplex virus, can give a sensation of tingling pain as it affects the nerves.2
Who is at risk of genital ulcers?
Individuals who perform unprotected sexual intercourse or sexual activity are the ones who are at risk the most. Healthcare workers who are prone to needle stick injuries, or handle blood products are also at risk.3
When should I see a doctor?
If you’re noticing discomfort or pain within the genital region, within the genital region, the affected individual should make an appointment with the doctor. If a sexual partner has STDs, individuals should also get themselves checked.
Genital ulcers can evolve to be a serious health problem as well as a nuisance to sexual and reproductive health if not treated. While there is social stigma involving discussing sexual health, openness towards seeking medical advice goes a long way in reducing the spread of pathogens. Healthcare professionals are trained to keep an individual's health record discreet and secure. Seeking advice only benefits the patient's suffering, and treatments are generally not gruesome. Hence it is encouraged that every sexually active individual monitors their sexual health by regular follow-ups and tests.
- Genital Ulcer - an overview | ScienceDirect Topics [Internet]. www.sciencedirect.com. Available from: https://www.sciencedirect.com/topics/medicine-and-dentistry/genital-ulcer
- Ulcer | pathology | Britannica. In: Encyclopædia Britannica [Internet]. 2019. Available from: https://www.britannica.com/science/ulcer
- Dhawan B, Ahmed J, Rawre J, Dhawan N, Dudani P, Khanna N. Genital ulcer disease: A review. Journal of Family Medicine and Primary Care [Internet]. 2022;11(8):4255. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9638565/
- Syphilis - Symptoms and causes [Internet]. Mayo Clinic. Available from: https://www.mayoclinic.org/diseases-conditions/syphilis/symptoms-causes/syc-20351756#:~:text=This%20rash%20is%20usually%20not
- Genital Ulcers: Causes, Symptoms, Diagnosis & Treatment [Internet]. Cleveland Clinic. Available from: https://my.clevelandclinic.org/health/diseases/23320-genital-ulcers
- HIV Genital Sores Singapore | HIV Genital Sores | Shim Clinic [Internet]. [cited 2023 Jun 18]. Available from: https://www.shimclinic.com/singapore/hiv-genital-sores#:~:text=of%20HIV%20infection.-
- CDC. Herpes - STI Treatment Guidelines [Internet]. www.cdc.gov. 2022. Available from: https://www.cdc.gov/std/treatment-guidelines/herpes.htm#:~:text=Acyclovir%2C%20famciclovir%2C%20and%20valacyclovir%20appear
- CDC. CDC – Syphilis Treatment [Internet]. www.cdc.gov. 2022. Available from: https://www.cdc.gov/std/syphilis/treatment.htm#:~:text=A%20single%20injection%20of%20long
- Which Medications Are Available to Help Treat HIV? [Internet]. Healthline. Available from: https://www.healthline.com/health/hiv-aids/medications-list
- E. Hope-Rapp, V. Anyfantakis, S Fouéré, Bonhomme P, Louison JB, Tandeau de Marsac, et al. Etiology of Genital Ulcer Disease. A Prospective Study of 278 Cases Seen in an STD Clinic in Paris. 2010 Mar 1;37(3):153–8.