Genital Ulcers: Symptoms, Types, Causes and Treatment

Genital ulcers are breaks in the skin or mucous membranes of the genital area, presenting a complex challenge for patients and healthcare professionals alike. These lesions can be painful, distressing, and sometimes alarming due to their association with both sexually and non-sexually transmitted diseases. Understanding the symptoms, types, causes, and available treatments is crucial for effective management, accurate diagnosis, and reducing the risk of complications.

Symptoms of Genital Ulcers

Genital ulcers can manifest in a variety of ways, often causing physical discomfort and emotional distress. Recognizing the symptoms early helps in prompt diagnosis and treatment, reducing the risk of complications and transmission of infectious agents.

Symptom	Description	Associated Conditions	Source(s)
Pain	Ranges from mild to severe	Herpes, chancroid, Lipschutz	2 3 5 8
Ulceration	Open sores, sometimes with borders	Syphilis, HSV, Behçet, trauma	3 5 6 13
Fever	Systemic symptom, not always present	Lipschutz, acute infections	1 2 12
Dysuria	Painful urination	Herpes, acute ulcers	1 3 8
Lymphadenopathy	Swollen lymph nodes	Syphilis, chancroid, HSV	3 5 6 7

Table 1: Key Symptoms

Pain and Discomfort

Pain is often the most prominent symptom, especially with herpes simplex virus (HSV) infections, chancroid, and non-infectious ulcers like those seen in Behçet’s disease. The pain may be accompanied by a burning or stinging sensation, particularly during urination or physical activity 2 3 5 8.

Appearance of Ulcers

The ulcers themselves can vary in size, depth, and appearance. Some present as shallow, round sores with red borders, while others may be deeper or have irregular margins. Herpetic ulcers are often multiple and grouped, while syphilitic ulcers (chancres) are typically single and painless 3 5 6.

Systemic Symptoms

Fever, malaise, and other systemic symptoms can accompany acute genital ulcers, particularly in conditions like Lipschutz ulcers or during primary HSV infection. These symptoms may also include abdominal pain, nausea, or vomiting, especially in pediatric or immunocompromised patients 1 2 12.

Urinary Symptoms

Dysuria, or painful urination, is a frequent complaint, especially when ulcers are located near the urethra. This can lead to hesitation in seeking medical care due to embarrassment or fear 1 3 8.

Lymphadenopathy

Swelling of the lymph nodes in the groin area is common, particularly in infectious causes like syphilis, chancroid, and HSV. The nodes may be tender or enlarged, providing an important clue in the diagnostic process 3 5 6 7.

Types of Genital Ulcers

Genital ulcers are not all the same—they can be classified based on their cause, appearance, and patient demographics. Understanding the different types is essential for targeted treatment and prevention.

Type	Common Features	Typical Patient Group	Source(s)
Infectious	Painful, may be multiple	Sexually active adults	3 5 6 8
Noninfectious	May be recurrent, less painful	Autoimmune, trauma, drugs	2 4 13
Idiopathic	No identifiable cause	Young girls, adults	2 12
Acute/Lipschutz	Sudden onset, painful, fever	Young females, nonsexual	1 2 12

Table 2: Types of Genital Ulcers

Infectious Ulcers

The majority of genital ulcers are caused by infectious agents, primarily in sexually active individuals. Common infectious types include:

• Herpes Simplex Virus (HSV): The most common cause worldwide, often presenting as recurrent, painful clusters of sores 3 5 8.
• Syphilis: Characterized by a single, painless ulcer (chancre) in the primary stage 3 5 7.
• Chancroid: Caused by Haemophilus ducreyi, typically resulting in painful, soft ulcers and swollen lymph nodes 3 5 7.
• Lymphogranuloma Venereum (LGV) and Granuloma Inguinale (Donovanosis): Less common, but important in certain geographic areas 3 5 6.

Noninfectious Ulcers

These ulcers are not caused by pathogens but by other underlying conditions:

• Autoimmune Disorders: Conditions like Behçet’s disease present with recurrent oral and genital ulcers, often accompanied by other systemic symptoms 4 13.
• Trauma: Physical injury or irritation can lead to ulceration.
• Drug Reactions: Fixed drug eruptions can cause localized, recurrent ulcers at the same site after exposure to a certain medication 3 4.

Idiopathic Ulcers

In many cases, especially among young girls or women without sexual activity, no clear cause can be identified. These are often referred to as idiopathic aphthosis or Lipschutz ulcers, believed to be an immunologic reaction to infections elsewhere in the body 2 12.

Acute (Lipschutz) Ulcers

Sudden onset, painful ulcers accompanied by fever are characteristic of Lipschutz ulcers. These predominantly affect young, nonsexually active females and may be triggered by viral infections or, rarely, vaccinations 1 2 12.

Causes of Genital Ulcers

Identifying the cause of genital ulcers is key to effective management. While infections are the leading culprits, noninfectious and idiopathic factors also play significant roles.

Cause	Examples/Pathogens	Distinguishing Features	Source(s)
Viral Infection	HSV, EBV, HIV	Painful, recurrent, clustered	3 6 8 9
Bacterial Infection	Syphilis, chancroid, LGV, donovanosis	Single or multiple ulcers	3 5 6 7
Autoimmune	Behçet’s, lichen planus, aphthosis	Recurrent, systemic symptoms	4 13
Drug Reaction	Fixed drug eruption	Recurs at same site	3 4
Trauma	Sexual/physical injury	History of injury	3 4
Malignancy	Vulvar/vaginal cancer	Chronic, nonhealing, elderly	4 6
Idiopathic	Lipschutz, aphthosis	No clear cause, acute onset	2 12

Table 3: Major Causes of Genital Ulcers

Infectious Causes

• Herpes Simplex Virus (HSV): The most prevalent cause, especially HSV-2, which causes recurrent, painful ulcers. HSV-1 is increasingly identified in genital infections, especially in developed countries 3 8 10.
• Syphilis: Caused by Treponema pallidum, presents as a painless chancre, but can go unnoticed and progress to further stages if untreated 3 5 7.
• Chancroid: Results from Haemophilus ducreyi, more common in developing countries, characterized by painful ulcers and tender lymphadenopathy 3 5 7.
• Other Infections: LGV (caused by Chlamydia trachomatis), granuloma inguinale, Epstein-Barr virus (EBV, especially in young women), cytomegalovirus, and even Mycoplasma pneumoniae can be implicated 3 4 6 9 12.

Noninfectious Causes

• Autoimmune Disorders: Behçet’s disease, lichen planus, and other inflammatory conditions can cause recurrent ulcers, often with oral involvement and systemic symptoms 4 13.
• Drug Reactions: Certain medications can cause fixed drug eruptions, leading to recurrent ulcers at the same site after drug exposure 3 4.
• Trauma: Both sexual and nonsexual trauma can result in ulceration, especially in sensitive skin or mucosa 3 4.

Idiopathic and Other Causes

• Lipschutz Ulcers: Acute, nonsexually transmitted ulcers, often in young girls and women, sometimes associated with viral infections or vaccinations 1 2 12.
• Malignancy: Chronic, nonhealing ulcers in older adults may signal underlying cancer and warrant biopsy 4 6.

Treatment of Genital Ulcers

Effective treatment hinges on identifying the underlying cause, providing symptom relief, and preventing complications such as secondary infections or transmission of sexually transmitted infections (STIs).

Treatment	Indication/Condition	Main Approach	Source(s)
Antivirals	HSV	Oral acyclovir, famciclovir, valacyclovir	3 8 10
Antibiotics	Syphilis, chancroid, LGV, donovanosis	Penicillin, ceftriaxone, azithromycin, doxycycline	3 5 7 11
Immunosuppressive	Behçet’s, autoimmune ulcers	Steroids, apremilast, interferon	4 13
Supportive Care	Idiopathic, Lipschutz, trauma	Analgesia, wound care, hygiene	2 12
Surgical/Biopsy	Malignancy suspicion	Excision, histopathology	4 6

Table 4: Treatment Modalities

Antiviral Therapy

• Herpes Simplex Virus (HSV): Initial or severe episodes are treated with oral acyclovir for 7–10 days. Recurrences may require shorter courses or suppressive therapy with acyclovir, famciclovir, or valacyclovir. Antiviral therapy reduces symptoms, recurrence, and viral shedding, thereby lowering transmission risk 3 8 10.
• Other Viral Causes: EBV-associated ulcers are generally self-limiting and managed supportively 9.

Antibiotics

• Syphilis: Benzathine penicillin G (single intramuscular dose) is the gold standard for primary syphilis. Doxycycline or azithromycin can be alternatives for penicillin-allergic patients 3 5 7.
• Chancroid: Single-dose ceftriaxone or oral azithromycin is effective. LGV and donovanosis require longer courses of doxycycline 3 5 7.
• Mixed or Unknown Infections: Empiric therapy may be considered while awaiting results in high-risk populations 5.

Immunosuppressive and Other Therapies

• Behçet’s Disease: Corticosteroids, colchicine, and immunosuppressants are standard. Apremilast, a phosphodiesterase-4 inhibitor, has shown promise in refractory cases 4 13.
• Other Autoimmune/Inflammatory Ulcers: Treatment is tailored based on the specific condition, often involving topical or systemic immunosuppressants 4.

Supportive and Symptomatic Care

• Idiopathic/Lipschutz Ulcers: Symptom relief is crucial—analgesia, topical anesthetics, good hygiene, and wound care. Most resolve spontaneously without specific therapy 2 12.
• Trauma-Related Ulcers: Wound care and avoiding further injury are key 3 4.

When to Biopsy

If an ulcer is chronic, nonhealing, or has atypical features (especially in older adults), biopsy to rule out malignancy is indicated 4 6.

Prevention and Public Health Considerations

• Safe Sexual Practices: Condom use and regular STI screening reduce the risk of infectious ulcers 8 10.
• Partner Management: Treating sexual partners can prevent reinfection and further transmission 8.
• HIV Risk: Genital ulcers increase HIV acquisition risk, making prompt diagnosis and treatment essential 8 11.

Conclusion

Genital ulcers are a multifaceted clinical issue, often requiring multidisciplinary assessment and individualized management strategies.

Key Takeaways:

• Symptoms vary: Pain, ulceration, fever, dysuria, and lymphadenopathy are common but not universal.
• Types and causes are diverse: Infectious (especially HSV, syphilis), noninfectious (autoimmune, trauma, drug reactions), and idiopathic forms exist.
• Diagnosis can be challenging: Clinical features alone are often insufficient; laboratory tests are crucial.
• Treatment depends on etiology: Antivirals for HSV, antibiotics for bacterial causes, immunosuppressives for autoimmune ulcers, and supportive care for idiopathic cases.
• Prevention matters: Safe practices and early intervention reduce complications and transmission.

By understanding the spectrum of symptoms, types, causes, and evidence-based treatments, both patients and healthcare providers can navigate the challenges of genital ulcers with greater confidence and compassion.