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  • • Diagnosis is based on the finding of one or more mucocutaneous ulcers involving the genitalia, perineum, or anus.
  • • Careful inspection of all genital mucosa is important, as lesions may be inside the foreskin, labia, vagina, or rectum, and may be painless.
  • • Genital herpes is the most common cause, followed by syphilis.
  • • A specific pathogen often cannot be identified based on clinical findings alone; laboratory testing should include culture or polymerase chain reaction (PCR) amplification for herpes simplex virus (HSV), and serologic testing for syphilis.
  • • Despite appropriate testing, no pathogen is identified in up to 50% of patients.

Genital ulcer disease (GUD) is a syndrome characterized by ulcerating lesions on the penis, scrotum, vulva, vagina, perineum, or perianal skin. In general usage the term refers to genital ulcerations from a sexually transmitted disease (STD), which is the most common etiology; however, nonsexually acquired illnesses, including infectious (bacterial skin infections, fungi) or noninfectious etiologies (fixed drug eruption, Behçet syndrome, sexual trauma), can present with similar ulcers. The clinician should bear in mind that nonvenereal dermatoses (eg, psoriasis) resulting from a variety of causes also can present with anogenital lesions.

The annual global incidence of GUD probably exceeds 20 million cases. The most commonly identified pathogens are HSV types 1 and 2 (HSV-1, HSV-2), syphilis, and chancroid. As recently as 20 years ago, the predominant causes of GUD in much the developing world were bacterial pathogens, especially Haemophilus ducreyi, the etiologic agent of chancroid. However, since the early 1990s the prevalence of chancroid in sub-Saharan Africa has decreased dramatically, while HSV-2 infection has increased. Although this change may be related to more widespread use of antibiotics and syndromic treatment of STDs, the HIV epidemic and behavioral changes in response may have played an equally important role. As a result, genital herpes now constitutes the most common infectious cause of GUD worldwide.

Regardless of the cause, GUD has assumed increased importance in view of its well-recognized role in facilitating HIV transmission. Surveys of HIV prevalence among patients seeking treatment for STDs have found a higher prevalence of coexisting HIV infection in those with genital ulcers than in those without, both in the United States and in the developing world. The presence of GUD in an individual not infected with HIV makes that person more susceptible to HIV infection by breaching the integumentary barrier and by recruiting macrophages and T-helper cells to the genital tract, where they may more readily be infected. Conversely, GUD in an HIV-infected individual increases his or her likelihood of transmitting HIV to a sex partner. HIV-infected patients with GUD who present for care at STD clinics actually have a higher plasma HIV viral load than similar patients without GUD. In a 2001 study of 174 HIV-serodiscordant couples in Uganda, the presence of GUD was associated with an almost fourfold increase in the probability of HIV transmission. A similar magnitude of increased risk of ...

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