This document summarizes an approach to diagnosing and treating cases of genital ulcers. It begins with definitions of genital ulcers and their etiologies, which can be sexually transmitted or non-sexually transmitted infections. It then describes three approaches: traditional clinical, laboratory-assisted, and syndromic management. The syndromic management approach diagnoses based on symptoms and signs and treats for the most common causes. Advantages include being fast, effective, inexpensive and allowing single-dose treatment. Limitations include potential over-treatment. Guidelines for taking history, examination, investigations, and treating common causes like herpes, syphilis, chancroid, and donovanosis are provided.

1. SEMINAR PRESENTATION
APPROACH TO A CASE OF GENITAL
ULCER
MODERATOR
DR.DEEPAK K.MATHUR

2. Definition
• Ulcerative, erosive, pustular or vesicular genital lesion(s) with
or without regional lymphadenopathy caused by a number of
sexually transmitted infections (STIs) and non–STI-related
conditions.

3. Etiology
• STIs:




Herpes simplex virus type 1 or 2 (HSV-1 or HSV-2)
Treponema pallidum spp. causing primary syphilis.
Haemophilus ducreyi causing chancroid.
Chlamydia trachomatis serotype L1, 2 or 3 causing
lymphogranuloma venereum (LGV).
 Klebsiella granulomatis causing granuloma inguinale
(donovanosis)
• Non–STI-related infections or conditions
 Infectious non–STI-related causes of genital ulcers
 Non - Infectious non–STI-related causes of genital ulcers

4. Infectious non–STI-related causes of genital ulcers

5. Non - Infectious non–STI-related causes of genital ulcers

6. APPROACHES
1. Traditional clinical approach
2. Laboratory-assisted approach
3. Syndromic management approach

7. COMPARISON OF APPROACHES
Traditional clinical approach
Lab. assisted approach
Interviews patient for
symptoms
Interviews patient for
symptoms
Does a clinical examination
Does a clinical examination
Uses clinical experience to
Collects samples for testing /
identify symptoms and signs refers to laboratory for tests
of a specific STI
Treats for the specific STI
Treats for STIs identified by
the results of the laboratory
tests
Educates patient for
compliance and prevention,
promotes condoms and
emphasizes the importance
of partner management
Educates patient for
compliance and prevention,
promotes condoms and
emphasizes the importance
of partner management
Syndromic approach
Interviews patient for
symptoms
Picks the relevant flowchart
Does a clinical examination
for finding signs
Uses flowcharts as tools
Syndrome identification
Treats patient for the most
common organisms
responsible for that
syndrome (usually 2-3 STIs)
Educates patient for
compliance and prevention,
promotes condoms and
emphasizes the importance
of partner management 6/7

8. SYNDROMIC MANAGEMENT APPROACH
1. Diagnosis is based on the identification of syndromes
which are a combination of the symptoms the client
reports and the signs the health care provider observes
2.
The recommended treatment is effective for all the
diseases that could cause the identified syndrome
3. Provides single-dose treatment as far as possible
4. Comprehensive: it includes patient education and
counseling

9. SYNDROMIC MANAGEMENT
ADVANTAGES
1. Fast—the patient is diagnosed and treated in one visit
2. Highly effective
3. Relatively inexpensive since it avoids use of laboratory tests
4. No need for patient to return for lab results
5. All possible STIs causing signs and symptoms are treated at once
6. Scientifically tested in many part of the world
7. Easy for health workers to learn and practice for patients
8. Integrated into other primary health care services more easily
9. Can be used by providers at all levels
10. It standardizes treatment regimens

10. SYNDROMIC MANAGEMENT
LIMITATIONS
1. Not useful in asymptomatic individuals
2. Over-treatment if patient has only one STI that causes
a syndrome
3. Financial cost of over-treatment, side-effects
4. Increases potential for creation of antibiotic resistance
especially if full course is not completed
5. Not effective in some cases such as vaginal discharge

11. WHY DOES SYNDROMIC MANAGEMENT HAVE
SPECIFIC RELEVANCE ?
1.
2.
3.
4.
5.
STI clients hesitant to approach doctors
Often choose far-off doctors
Do not prefer to revisit
First visit may be the last chance
If opportunity missed the first time – it is like pushing client
towards HIV (2-9 times)
6. Dealing with 1 STI case is an opportunity to treat at least 1 more
case (may be more)
7. IT IS A PUBLIC HEALTH PROBLEM not about one individual.

12. STEPS OF CLINICAL CASE MANAGEMENT
1. History taking
2. Clinical examination
3. Laboratory tests
4. Diagnosis
5. Treatment
6. Advice and counseling
7. Follow up

13. • Patient History
• General details
• Lesion history: Prodrome, initial presentation (esp presence of vesicles)
duration of lesion, pain, urethritis+/- , other systemic symptoms use of
systemic or topical remedies(as it may alter the initial lesion),any history
of similar symptoms in past / partners with similar symptoms
• In female patients h/o abortion or stillbirth
• In children h/o suggestive of sexual abuse have to be taken
• Medical history: HIV status, skin conditions, drug allergies & medications
• Sexual history: Gender of partners, number of partners,anal/vaginal/oral
intercourse, venue for meeting partners, commercial sex
exposure, partners with symptoms or signs, partners with known herpes
simplex virus (HSV) or recent syphilis diagnosis
• Travel history: Geographical area where sexual intercourse has taken
place.

14. INCUBATION PERIOD AND HEALING TIME IN
GENITAL ULCER DISEASE
Disease
Incubation
period
% of STI-related
GUD
Spontaneous
healing time
On
treatment
Primary syphilis
9-90 days
(avg 3 weeks)
>1%
3-8 weeks
Never exceeds 3m
1-2 weeks
Chancroid
1-14 days
<1%
Self limiting but
may persist for yrs
1-2 weeks
Herpes genitalis
5-21 days
80 - 95%
14-21 days
6-12 days
LGV
3 – 30 days
<1%
2-5 days
-
Donovanosis
1-180 days
<1%
No tendency for
healing
3 weeks

15. •
•
•
•
•
Physical Exam:
Lesion : Inspection and palpation of lesion
Genital exam: Examine genital and perianal area
Lymph node(s) exam
General exam: Thorough examination of oral cavity and skin
of torso, palms, and soles, LN(s),liver,spleen.
• In pts with syphilis exam CVS & CNS system

16. • Inspection • No.,site,size,shape,edge,floor,surrounding skin
• Palpation –
• Base of ulcer , tenderness,induration,bleeding on
manipulation,attachment to surrounding structure & perrectal examination

17. CHARACTERISTIC SYPHILIS
HERPES
CHANCROID
LGV
DONOVANOSIS
Primary lesion
Papule
Vesicle
Pustule
Papule,
vesicle
pustule
Papule
Number of
lesions
Usually 1
Multiple
Multiple
Single
Variable
Diameter
5-15 mm
1-2 mm
Variable
2-10 mm
Variable
Edges
Sharply
demarcated
elevated
Erythemat
ous
Polycylic
Undermined
Ragged
Elevated
Elevated
Round or oval Irregular
Depth
Superficial
or deep
Superficial
Excavated
Superficial
Or deep
Elevated
Base
Smooth
Nonpurulent
Covered
with serous
eudate
Erythemat
ous
Purulent
Dirty grey
Base
Variable
Red
Velvety
Bleeds easily
Induration
Button hole
None
not
indurated
not indurated not indurated

18. CHARACTERISTICS SYPHILIS
HERPES
CHANCROID LGV
DONOVANOSIS
Pain
Absent
Present
Present
Absent
Absent
Lymph nodes
Bilateral
Nontender
Firm,lead
shot,nonsuppurati
ve
Bilateral
Tender
Firm
Nonsuppurati
ve
Unilateral
Tender
Suppurative
UniLocular
Unilateral
Tender
Suppurative
Multilocular
None
Pseudo-bubo seen
Recurrences
No
+(80%)
No
No
No

19. Severe primary HSV infection
with penile edema
Syphilis

20. Donovanosis
Chancroid

21. Chancroid Male, regional
adenopathy
Chancroid - Gram stain of H.
ducreyi

22. LGV
Life-cycle of LGV

23. • Otherwise, per the CDC the following criteria fulfill probable
diagnosis of chancroid:
• One or more painful genital ulcers
• No evidence of T. pallidum infection by darkfield examination
or by serologic test for syphilis performed at least 7 days after
onset of ulcers
• Clinical presentation, appearance of genital ulcers and, if
present, regional lymphadenopathy are typical for chancroid
• A test for HSV performed on the ulcer is negative

24. INVESTIGATIONS

25. LAB DIAGNOSIS OF GENITAL ULCER
LAB TEST
SYPHILIS
CHANCROID HERPES
LGV
DONOVANOSIS
Microscopy
Dark field
direct
immuno
Fluorescence
Gram stain
Antigen
detection by
DFA
Immuno
peroxide
Staining &
ELISA
Direct
immunostaining
ELISA rapid
assay
Giemsa stain
Tissue smear
Culture
Not available
Enriched
gonococcal
agar base.
Mueller
Hinton agar
+5%
chocolate
Horse blood
Human
diploid
Fibroblast
cell culture
Green
monkey
kidney
Cell culture
HeLa-229
McCoy cells
Baby
hamster
kidney cell
BHK-21
none

26. LAB TEST
SYPHILIS
HERPES
CHANCROID LGV
DONOVANOSIS
Collection
Transport
media
Not
available
Thioyoglycol
ate hemin
Medium
containing
L glutamine
& bovine
albumin
At 4 C
Swab wire
shaftwith
cotton tip
Viral
transport
media at 4 C
(freeze at 70
C if more
time
required)
Swab plastic
shaft with
Rayon swab
and
cytobrush
with plastic
shaft
none
Serology
1.NonELISA
treponemal Immuoblot
Tests(VDRL/ techniques
RPR)
2.Treponem
al test (ELISA
FTAAbs,TPHA
MHA-TP)
Monoclonal
antibodies
to HSV1 and
HSV2,ELISA
DNA
hybridizatio
n
CFT and
immuno
fluorescent
antibody
test
Experimental

27. LAB TEST
SYPHILIS
HERPES
CHANCROID
LGV
DONOVANOSI
S
Molecular
techniques
PCR
PCR
PCR
PCR
Not available
3 zones seen
Surface zoneNarrow consisting
of neutrophils
fibrin,RBC’s
Necrotic tissue
Middle zoneWide with newly
formed blood
vessels
With marked
proliferation of
endothelial cells
Deeper zoneDense inflamm.
of plasma cells
& lymphoid cells
Degeneration
Of
keratinocytes
resulting of
Acantholysis
2 types of
degeneration
seen
1.Ballooning
2.Reticular
Small
areas of
Necrosis
With
Proliferatin
g
Epitheloid
Cells
With
Stellate
abscess
Acanthosis
Pseudo
Carcinomatous
Hyperplasia
At edge of
ulcer
Dermis- dense
Inflammation
of histiocytes
Plasma cells
With absence
Of
lymphocytes
Small
neutrophillic
Abscess,
Donovan
bodies
Histopathol Perivascular
ogy
Infiltrate of
lymphocytes
Plasma cells
Accompanied
by
endarteritis
obliterans

28. • The preferred method of
diagnosis is by crush impression
prepared from the deep surface
of excised tissue and stained with
Giemsa stain.
• Histiocytic cells with up to 20
vacuoles containing clusters of
organisms in various states of
maturity are diagnostic.
• Immature unencapsulated forms
often show bipolar condensation
of chromatin resembling a closed
safety pin.

29. Genital Ulcers – TREATMENT(NACO
GUIDELINES 2007)
•
•
•
If vesicles or multiple painful ulcers are present treat for herpes Tab. Acyclovir 400mg orally, three times a day for 7 days
If vesicles are not seen and only ulcer is seen, treat for syphilis and chancroid and
counsel on herpes genitalis
•
•
•
•
•
To cover syphilis give
Inj Benzathine penicillin 2.4 million IU IM after test dose in two divided doses (with
emergency tray ready)
(In individuals allergic or intolerant to penicillin, Doxycycline 100mg orally, twice
daily for 14 days)
+
Tab Azithromycin 1g orally single dose or
Tab. Ciprofloxacin 500mg orally, twice a day for three days to cover chancroid
•
•
•
•
•
Treatment should be extended beyond 7 days if ulcers have not epithelialized .
Refer to higher centre
If not responding to treatment
Genital ulcers coexistent with HIV
Recurrent lesion
•

30. GRANULOMA INGUINALE
• Doxycycline 100 mg BD for 21 days
ALTERNATIVE REGIMENS
• Trimethoprim-sulfamethoxazole double strength bid for 21
days
• Erythromycin 500 mg qid for 21 days
• Ciprofloxacin,tetracycline,azithromycin
LYMPHOGRANULOMA VENEREUM
• Doxycycline 100 mg BD for 21 days
• Erythromycin 500 mg qid for 21 days

31. STI TREATMENT GUIDELINES
*CDC 2010
*WHO 2011

32. Disease
CDC2010
•
•
•
chancroid
•
•
•
•
WHO 2011
Azithromycin 1 g orally in Azithromycin, 1 g
a single dose
orally, as a single
dose
OR
OR
Ceftriaxone 250 mg
Ceftriaxone, 250 mg
intramuscularly (IM) in a by intramuscular
single dose
injection as a single
dose
OR
OR
Ciprofloxacin* 500 mg
Ciprofloxacin, 500 mg
orally twice a day for 3
orally, twice daily for
days*
3 days
OR
OR
Erythromycin base,
Erythromycin base 500
500 mg orally 4 times
mg orally three times a
daily for 7 days
day for 7 days
COMMENT
*Ciprofloxacin is
contraindicated
during pregnancy and
lactation.
*No adverse effects
of chancroid on
pregnancy outcome
have been reported.
*HIV-infected
patients might
require repeated or
longer courses of
therapy and
treatment failures
can occur.
*Both are similar in
dose & duration.

33. Disease
Genital Herpes
(FIRST EPISODE)
Severe Disease
CDC2010
WHO 2011
Acyclovir 400 mg orally
Acyclovir 400 mg orally, 3
three times a day for 7–10 times daily for 7 days
days,OR
OR
Acyclovir 200 mg orally, 5
Acyclovir 200 mg orally
times daily for 7 days
five times a day for 7–10
OR
days,OR
Famciclovir 250 mg orally,
Famciclovir 250 mg orally 3 times daily for 7 days ,
three times a day for 7–10 OR
Valaciclovir 1 g orally,
days,OR
twice daily for 7 days
Valacyclovir 1 g orally
twice a day for 7–10 days
Acyclovir 5–10 mg/kg IV
every 8 hours for 2–7 days
or until clinical
improvement is observed,
followed by oral therapy
to complete at least 10
days of total therapy.
Acyclovir, 5—10 mg/kg IV,
every 8 hours for 5—7
days or until clinical
resolution
is attained
COMMENT
*Treatment can be
extended if healing is
incomplete after 10 days
of therapy in
CDC,otherwise similar in
both
*CDC-Duration 10 day
(IV+ORAL)
* WHO- 5-7 day,
otherwise similar in both

34. Disease
Suppressive
Therapy for
Recurrent Genital
Herpes
CDC2010
Acyclovir 400 mg
orally twice a day
OR
Famiciclovir 250
mg orally twice a
day
OR
Valacyclovir 500
mg orally once a
day*
OR
Valacyclovir 1 g
orally once a day
WHO 2011
Acyclovir, 400 mg
orally, twice daily,
for one year
OR
Valaciclovir, 500
mg orally, once
daily, for one year
OR
Famciclovir, 250
mg orally, twice
daily, for one year
COMMENT
-Reduces the
frequency of
genital herpes
recurrences by
70%–80% .
*Valacyclovir 500
mg once a day
might be less
effective in
patients who
have very
frequent
recurrences (i.e.,
≥10 episodes per
year).

35. Disease
Episodic Therapy for
Recurrent Genital
Herpes
CDC2010
WHO 2011
Acyclovir
Acyclovir, 400 mg orally, 3
400 mg orally TDS for 5 days times daily for 5 days
OR
OR
800 mg orally BD for 5 days
Acyclovir, 200 mg orally, 5
OR
800 mg orally TDS for 2 days times daily for 5 days
OR
OR
Valaciclovir, 500 mg
Famciclovir
125 mg orally BD for 5 days
orally, twice daily for 5
OR
days
1000 mg orally twice daily for
OR
1 day
Famciclovir, 125 mg
OR
500 mg once, followed by 250 orally, twice daily for 5
days
mg twice daily for 2 days
Valacyclovir 500 mg orally
twice a day for 3 days
OR
Valacyclovir 1 g orally once a
day for 5 days
COMMENT
Effective episodic
treatment of recurrent
herpes requires initiation
of therapy within 1 day of
lesion onset or during the
prodrome that precedes
some outbreaks.

36. COUNSELING OF PERSONS WITH GENITAL HSV
INFECTION
•
Should be educated concerning natural history of disease with emphasis on 

asymptomatic viral shedding

•
recurrent episodes
attendant risks of sexual transmission
Persons experiencing 1st episode of genital herpes should be advised that suppressive
therapy is available & effective in preventing symptomatic recurrent episodes and that
episodic therapy often is useful in shortening the duration of recurrent episodes.
•
All persons with genital HSV infection should be encouraged to inform their current sex
partners that they have genital herpes and to inform future partners before initiating a
sexual relationship.

37. •
Sexual transmission of HSV can occur during asymptomatic periods.
•
Asymptomatic viral shedding is more frequent in genital HSV-2 infection than
genital HSV-1 infection and is most frequent during the first 12 months after
acquiring HSV-2.
•
All persons with genital herpes should remain abstinent from sexual activity
with uninfected partners when lesions or prodromal symptoms are present.
•
Episodic therapy does not reduce the risk for transmission & its use should be
discouraged for persons whose partners might be at risk for HSV acquisition.

38. •
Infected persons should be informed that male latex condoms, when used
consistently and correctly, might reduce the risk for genital herpes transmission.
•
Sex partners of infected persons should be advised that they might be infected
even if they have no symptoms. Type-specific serologic testing of the
asymptomatic partners of persons with genital herpes is recommended to
determine whether such partners are already HSV seropositive or whether risk for
acquiring HSV exists.
•
The risk for neonatal HSV infection should be explained.

39. •
Pregnant women who are not known to be infected with HSV-2 should be advised to abstain
from intercourse with men who have genital herpes during the third trimester of pregnancy.
•
Similarly, pregnant women who are not known to be infected with HSV-1 should be
counseled to avoid genital exposure to HSV-1 during the third trimester (e.g., oral sex with a
partner with oral herpes and vaginal intercourse with a partner with genital HSV-1 infection).
•
Asymptomatic persons diagnosed with HSV-2 infection by type-specific serologic testing
should receive the same counseling messages as persons with symptomatic infection.
•
In addition, such persons should be educated about the clinical manifestations of genital
herpes.
•
When exposed to HIV, HSV-2 seropositive persons are at increased risk for HIV acquisition.
•
Patients should be informed that suppressive antiviral therapy does not reduce the increased
risk for HIV acquisition associated with HSV-2 infection

40. Management of Sex Partners
• The sex partners of patients who have genital herpes can benefit
from evaluation and counseling.
• Symptomatic sex partners should be evaluated and treated in the
same manner as patients who have genital lesions.
• Asymptomatic sex partners of patients who have genital herpes
should be questioned concerning history of genital lesions and
offered type-specific serologic testing for HSV infection.

41. Special Considerations
Allergy, Intolerance, and Adverse Reactions
• Allergic and other adverse reactions to acyclovir, valacyclovir,
and famciclovir are rare.
HIV Infection
Acyclovir, valacyclovir, and famciclovir are safe for use in
immunocompromised patients in the doses recommended for
treatment of genital herpes

42. HIV C0 -INFECTION
Recommended Regimens for Daily Suppressive Therapy in Persons with HIV (CDC
2010)
Acyclovir 400–800 mg orally twice to three times a day
OR
Famciclovir 500 mg orally twice a day
OR
Valacyclovir 500 mg orally twice a day
Recommended Regimens for Episodic Infection in Persons with HIV(CDC2010)
Acyclovir 400 mg orally three times a day for 5–10 days
OR
Famciclovir 500 mg orally twice a day for 5–10 days
OR
Valacyclovir 1 g orally twice a day for 5–10 days

43. HSV resistance
•
All acyclovir-resistant strains are resistant to valacyclovir, and the majority
are resistant to famciclovir.
•
Foscarnet, 40 mg/kg IV every 8 hours until clinical resolution is attained, is
frequently effective for treatment of acyclovir-resistant genital herpes.
•
Intravenous cidofovir 5 mg/kg once weekly might also be effective.

44. Disease
CDC2010
WHO 2011
Doxycycline 100 mg orally twice a day Azithromycin, 1 g orally on the
Alternative Regimens
first day, then 500 mg orally,
COMMENT
-Healing typically
proceeds inward from
the ulcer margins
Azithromycin 1 g orally once per week once a day
-Patients should be
followed clinically until
Ciprofloxacin 750 mg orally twice a day Doxycycline, 100 mg orally, twice
signs and symptoms
OR
daily
have resolved.
OR
Erythromycin base 500 mg orally QID
Granuloma
Inguinale
(Donovanosis)
OR
OR
OR
Erythromycin, 500 mg orally, 4
Trimethoprim-sulfamethoxazole one
times daily
double-strength (160 mg/800 mg)
OR
tablet orally BD
Tetracycline, 500 mg orally, 4
(All for at least 3 weeks and until all
times daily
lesions healed)
OR
-Persons who have had
sexual contact with a
patient who has
granuloma inguinale
within the 60 days
should be offered
therapy.
-Value of empiric
therapy in the absence
mg/sulfamethoxazole 400 mg,
of clinical signs and
2 tablets orally, twice daily
symptoms has not been
(Treatment should be continued established.
Trimethoprim 80
until all lesions have completely
epithelialized)

45. Special Considerations
Pregnancy
•
Pregnancy is a relative contraindication to the use of sulfonamides.
•
Pregnant and lactating women should be treated with the erythromycin regimen, and
consideration should be given to the addition of a parenteral aminoglycoside (e.g., gentamicin).
•
Azithromycin might prove useful for treating granuloma inguinale during pregnancy, but published
data are lacking.
•
Doxycycline and ciprofloxacin are contraindicated in pregnant women.
HIV Infection
•
Persons with both granuloma inguinale and HIV infection should receive the same regimens as
those who are HIV negative; however, the addition of a parenteral aminoglycoside (e.g.,
gentamicin) can also be considered.

46. Disease
LGV
CDC2010
WHO 2011
Doxycycline 100 mg
Doxycycline, 100 mg
orally twice a day for 21 orally, twice daily for
days
14 days
OR
Alternative Regimen
Erythromycin, 500 mg
orally, 4 times daily for
Erythromycin base 500 14 days
mg orally four times a OR
day for 21 days
Tetracycline, 500 mg
orally, 4 times daily for
14 days
COMMENT
-Patients should be
followed clinically until
signs and symptoms have
resolved
-Management of Sex
Partners
If sexual contact within
the 60 days should be
treated with a chlamydia
regimen (azithromycin 1
gm orally single dose or
doxycycline 100 mg
orally twice a day for 7
days).

47. Special Considerations
Pregnancy
•
Pregnant and lactating women should be treated with erythromycin.
•
Azithromycin might prove useful for treatment of LGV in pregnancy, but no published data
are available regarding its safety and efficacy.
•
Doxycycline is contraindicated in pregnant women.
HIV Infection
•
Persons with both LGV and HIV infection should receive the same regimens as those who are
HIV negative.
•
Prolonged therapy might be required, and delay in resolution of symptoms might occur.

48. Disease
CDC2010
Adults-
WHO 2011
COMMENT
Benzathine benzylpenicillin
G,
Benzathine penicillin G 2.4
2.4 million IU by
million units IM in a single dose intramuscular injection as a
single dose
Infants and ChildrenOR
Benzathine penicillin G 50,000 Procaine benzylpenicillin,
units/kg IM, up to the adult
1.2 million IU by
dose of 2.4 million units in a
intramuscular injection,
Primary, Early Latent single dose
daily for 10 consecutive
Syphilis(chancre
days
redux)
OR
Azithromycin, 2 g orally as
a single dose.
Alternative regimens for
penicillin-allergic nonpregnant patients
Azithromycin, 2 g orally
single dose
OR
Doxycycline, 100 mg orally,
twice daily for 14 days

49. Disease
Syphilis
During
Pregnancy
CDC2010
WHO 2011
Pregnant women should be
treated with the penicillin
regimen appropriate for their
stage of infection
Not allergic to
penicillin, should be
treated with penicillin
according to the dosage
schedules recommended
for the treatment of nonpregnant patients at
a similar stage of the
disease.
Pregnant patients who
are allergic to penicillin
Alternative regimen
should be desensitized
for penicillin-allergic
and treated with penicillin pregnant patients-
Azithromycin, 2 g
orally as a single dose
OR
Erythromycin*, 500 mg
orally, 4 times daily for
14 days
COMMENT

50. Syphilis and HIV coinfection
• Benzathine penicillin G 2.4 million units IM / week - 3 doses
FEW POINTS –
• Atypical presentations common
• Compared with HIV-negative patients, HIV-positive patients who have
early syphilis might be at increased risk for neurologic complications
• Have higher rates of treatment failure with currently recommended
regimens.

51. FOLLOW-UP
Herpes Simplex Virus
LGV & Granuloma Inguinale
•Reexamination needed only if symptoms and
signs do not resolve
•Follow patients until signs and symptoms have
resolved.
•All cases of confirmed LGV should be reported to
the state/local health department.
Syphilis
Chancroid
• Patients should be examined 3-7
days into therapy.
• If clinical improvement is not
apparent consider an alternate
diagnosis, treatment nonadherence or treatment failure
due to antimicrobial resistance.
• All cases of confirmed chancroid
should be reported to the
state/local health department.
•
•
•
•
•
HIV uninfected persons - Nontreponemal
titers should be checked at 6, 12 and 24
months
CSF analysis should occur if titers increase
fourfold, an initially high titer (>1:32) fails to
decline fourfold or signs/symptoms
attributable to syphilis develop
HIV infected persons - Nontreponemal
titers should be checked at 3,6, 9, 12 and 24
months after therapy for those who are HIV
infected
For those affected with neurosyphilis,
practitioners should re-evaluate CSF every six
months until the cell count is normal
All cases of confirmed syphilis should be
reported to the state/local health
department

53. MANAGEMENT OF SEX PARTNERS
Herpes Simplex Virus
• Offer serologic testing to determine whether infection has already occurred
• Counsel about the risk of transmission associated with subclinical shedding and prevention
modalities for the future
Syphilis
• Contacts of patients with:
• Early syphilis
• Routine history
• Physical examination for signs of syphilis
• Syphilis serology and HIV testing
• Administer empiric treatment for all contacts within the preceding 3 months
(i.e., benzathine penicillin G 2.4 million U IM).
• Late latent syphilis
• Determine treatment based on syphilis serology
Chancroid
• Sex partners of patients diagnosed with chancroid should be examined and treated if they had
sexual contact in the past 10 days prior to the patient's onset of symptoms
LGV
• Routine STD exam, including testing for chlamydia and treated with a chlamydia regimen
(azithromycin 1 gm orally single dose or doxycycline 100 mg orally twice a day for 7 days)for all
contacts within the preceding 2 months
Granuloma Inguinale
• Persons who have had sexual contact with a patient diagnosed with granuloma inguinale within 60
days before the onset of a patient's symptoms should have a clinical exam and empiric therapy

54. Educate and counsel the patient (group
work)
 Nature of the infection and medication
 Promote safer sexual behaviour
 Demonstrate and provide condoms
 Compassionate and sensitive counselling
Informing partner
HIV testing
Complications, i.e. infertility or incurable
disease
Preventing future infections
Communicating with partner
Confidentiality, disclosure
Risk of violence or stigma

55. Management of Inguinal Bubo
Treatment
• Cap. Doxycycline 100mg orally twice daily for 21 days (to cover LGV),Plus
• Tab Azithromycin 1g orally single dose OR
• Tab. Ciprofloxacin 500mg orally, twice a day for three days to cover
chancroid
• A bubo should never be incised and drained at the PHC even if it is
fluctuant, as there is a high risk of a fistula formation and chronicity.
• If bubo becomes fluctuant always refer for aspiration to higher centre.
• In severe cases with vulval edema in females, surgical intervention may be
required for which they should be referred to higher centre.

56. Partner management
•
Treat all partners who are in contact with client in last 3 months
•
Partners should be treated for chancroid and LGV
•
Tab Azithromycin 1g orally single dose
+
•
Cap Doxycycline 100mg orally, twice daily for 21 days
•
Advise sexual abstinence during the course of treatment.
•
Provide condoms, educate on correct and consistent use.
•
Refer for voluntary counseling and testing for HIV, syphilis and Hepatitis B.
•
Schedule return visit after 7 days and 21 days.

60. Detection & discrimination of HSV,H. ducreyi, T. pallidum
and C.(Klebsiella) granulomatis from genital ulcers.
Mackay IM, Harnett G, Jeoffreys N, et al. Clin Inf Dis. 2006; 42(10):1431-8
• GUMP was developed as an inhouse nucleic acid
amplification technique targeting serious causes of GUD
• Amplification products from GUMP were detected by ELAHA
• GUMP-ELAHA was sensitive and specific in detecting a target
microbe in 34.3% of specimens
• GUMP-ELAHA permitted comprehensive detection of
common and rare causes of GUD and incorporated
noninvasive sampling techniques

61. Consider 4Cs to improve treatment results and
prevention
• Compliance-Avoid sexual contact during treatment and until
partner has been treated & Ensure follow-up visit
• Counseling for prevention
• Condom use
• Contact management

62. THANK YOU