- • 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
- • 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 ...