The prevalence of genital ulceration in patients presenting with sexually transmitted diseases is much higher in the developing world than in the UK. This has recently acquired greater significance, as it is now believed that genital ulceration is an important factor in the heterosexual transmission of HIV in Africa and Asia.

Chancroid (syn. Soft sore) Common throughout the tropics and sub-tropics, but very rarely imported into the UK. Previously the commonest cause of tropical genital ulceration, but recent studies suggest incidence is falling, possibly due to changing patterns of HIV and HSV infection.

Clinical features: Incubation period is =1 week. Painful papules develop on external genitalia of both sexes and rapidly ulcerate. Ulcer is typically sloughy, irregular, painful, non-indurated and haemorrhagic. ‘Kissing’ lesions develop on adjacent skin surfaces such as scrotum or thigh. Cervical and vaginal wall ulcers are rare. Sup-purative local lymphadenopathy is common, progressing to bubo and sinus formation. Local complications include phimosis and urethral stricture.

Organisms: Haemophilus ducreyi (>298).

Microbiological investigations: Gram stain (‘shoal offish’ appearance) and culture of material obtained from ulcer or aspirated from lymph nodes. Concurrent syphilis and gonorrhoea should be excluded. PCR possible, but is not widely available.

Antibiotic management: Erythromycin for 1 week, or azithromycin or ciprofloxacin or parenteral cephalosporin, all as a single dose. Patients with HIV may respond less well.

Supportive management: Aspiration of bubo may be required.

Lymphogranuloma venereum

Lymphogranuloma venereum causes inconspicuous genital ulceration, followed by severe local sequelae. Clinical infection is much commoner in men than women. Asymptomatic infection in women may serve as a reservoir. lymphogranuloma venereum occurs throughout the tropics, but is very rarely imported into the UK.

Clinical features: Incubation period is 3-30 days. Primary lesion is an inconspicuous, transient, painless genital ulcer which heals without scarring and is recalled by =20% of cases. Extremely tender local lymphadenopathy then develops, with fever, headache, weight loss and sometimes meningoencephalitis, pneumonia, arthritis and erythema nodosum. Lymphadenopathy may be very marked, with cleavage of the inflammatory mass by the inguinal ligament (the ‘groove’ sign). Multiple abscesses with sinus formation may follow, with fibrosis of the sacral and iliac lymphatics leading to lymphoedema of the perineum. Haemorrhagic proctitis with perirectal abscess, rectal stricture and fistula formation may occur.

Organisms: Chlamydia tmchomatis serovars L1, L2 andL3.

Microbiological investigations: Diagnosis is based on clinical features. Serology for anti-chlamydial antibodies is also helpful. Immunofluorescent and ELISA antigen capture assays for chlamydial antigens are available but are not specific for lymphogranuloma venereum serovars. Culture is possible but not widely available in the countries where lymphogranuloma venereum occurs.

Antibiotic management: Doxycycline or erythromycin for 3 weeks.

Supportive management: Aspiration of lymph nodes maybe required to avert sinus formation, but surgical debridement should be avoided.

Granuloma inguinale

(syn. Donovaniasis)

Endemic in South India, Papua New Guinea and certain Caribbean islands. Non-sexual transmission also occurs; infection is common in children in endemic areas.

Clinical features: Painless, non-purulent,’beefy-red’ ulcerprogressively enlarging over months to 5 cm or more in diameter, commonly on the prepuce or labia. Local extension, healing and fibrosis may all occur simultaneously. Secondary infection may cause increasedpurulence and necrosis. Other cutaneous sites may be involved, often in patients who also have genital disease. Metastatic haematogenous spread to bones, joints and liver has been reported very rarely. Regional lymphadenopathy is rare.

Organisms: Calymmatobacterium gmnulomatis has recently been officially redesignated Klebsiella gmnulomatis (>297).

Microbiological investigations: Microscopy of Giemsa-stained material from ulcers shows bipolar intracellular bacteria, visible as ‘Donovan bodies’ with characteristic safety pin appearance. Culture and serology are not available.

Antibiotic management: Azithromycin (1 g weekly) or erythromycin or co-trimoxazole or doxycycline for 3 weeks.

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