A genital ulcer is an associated open sore set on the venereal space, which has the female genitalia, penis, orifice region, or anus. Genital ulcers are most typically caused by infectious agents (fungal infections, secondary bacterial infections, or sexually transmitted diseases like herpes, syphilis, or chancroid). However, this is not always the case, as genital ulcers might have noninfectious causes as well.
A genital ulcer may be set on the female genitalia, penis, orifice region, or anus. Globally, the incidence of genital ulcers is estimated to be about twenty million cases annually. The most likely reason for genital ulcers varies depending on the characteristics of a population and location. The most common reason for genital ulcers within the US is herpes simplex infections, with syphilis the second-most common cause, and chancroid the third. These common causes of genital ulcer disease (HSV-1, HSV-2, and Treponema pallidum) can all be efficiently transmitted through sexual contact.
Important signs related to genital ulcers that assist in the diagnosis of the cause may include the presence of tender or non-tender enlarged lymph nodes in the groin area, a painful or non-painful genital ulcer, or the presence of sac lesions, which are small, painful, elevated blisters.
The most common causes of genital ulcers include infectious agents, with sexually transmitted diseases being the most common. These can also include fungal infections and secondary bacterial infections. While infectious agents are the most common cause, genital ulcers may also be the result of non-infectious causes like Behçet’s syndrome, lupus, or skin disease.
Since it is difficult to see the cause of a genital ulcer based on history, examination, and population characteristics alone, testing is usually required. The most common diagnostic tools used are targeted towards the most common etiologies of genital ulcers: syphilis (serology, PCR testing, or dark-field examination), herpes simplex virus (PCR, culture, or type-specific HSV antibodies), and Hemophilus ducreyi (culture on special media not widely available in most hospital systems) if the individual is in a known endemic region. Any additional tools like a biopsy or culture are typically utilized if ulcers appear uncommon or don’t respond to standard medical care.
Since genital ulcers are typically infectious in origin, there is an increased risk of acquiring HIV in an HIV-negative patient through viral introduction via the open sore. Conversely, there is an increased risk of HIV transmission through increased shedding of viral HIV in the presence of genital ulcers in a patient already living with HIV. The CDC recommends testing for HIV in anyone presenting with a genital ulcer who doesn’t already have a known HIV status.
Risk factors for sexually transmitted genital ulcers are similar to the risk factors for most sexually transmitted diseases, including:
- Multiple sex partners
- Alcohol or illicit drug use
- Low immunity
- Poverty
- Inmates
- Men who have sex with men
- Sexually active teenagers
- Sexual contact without contraceptive use
- Unstable housing
The most common reason for genital ulcers in North America and Western Europe is herpes or syphilis, while in other parts of the world, chancroid is more common. Most sexually active adolescents with genital ulcers have a herpes simplex infection, more commonly type 2. Meanwhile, syphilis is more common among men who have sex with men, according to a 2017 CDC report, although rates of syphilis among heterosexual men and women are rising in the US.
Following herpes and syphilis, chancroid is the third most common cause, but it tends to occur in targeted outbreaks over time. While rates of H. ducreyi infection seem to be declining per the 2017 report, it’s possible this is due to a lack of testing since H. ducreyi requires a specialized medium that isn’t widely available. Less common causes include LGV (more common in men who have sex with men) and donovanosis (more common in tropical regions globally rather than in the US).
What are the most common causes of genital ulcers?
Herpes Simplex Virus (HSV-1/HSV-2), syphilis, and chancroid are the most common causes.
Are genital ulcers always sexually transmitted?
No, some may be caused by autoimmune disorders or skin conditions like lupus or Behçet’s disease.
Can genital ulcers increase HIV risk?
Yes, they can increase both the risk of acquiring and transmitting HIV.
Do genital ulcers go away on their own?
Some may, but clinical diagnosis and treatment are necessary to prevent complications.
Should my partner also get checked?
Yes. If one partner has symptoms, the other should also be evaluated by a healthcare provider.
