Genital ulcers and lumps

     

Causes

  • Herpes — most common
  • Syphilis
  • Genital warts
  • Bartholin’s cyst
  • Molluscum contagiosum
  • Local injury from scratching, eg scabies, lice, bad thrush
  • Donovanosis — rare
  • Cancer — if not better after 4 weeks — medical consult, may need biopsy

Ask

  • How long have they had sores, are they getting worse
  • Have they had sores like these before
  • Are sores painful
  • Do sexual partners have sores

Check

  • Full STI check — men,  women — with attention to
    • Type of sore — single, multiple, tender, painless, hardened
    • Enlarged lymph nodes near sores 

Do

  • Full STI check must include syphilis serology ALSO syphilis POC Test if available
  • Swab sores — NAAT for herpes, syphilis, donovanosis
  • Treat straight away — do not wait for test results
    • If multiple recent small painful vesicles (blisters) — treat as herpes
    • All other genital sores or ulcers — treat as syphilis and donovanosis
  • STI and safer sex education at first visit
  • Consider discussing contraception
  • Advise that having sex before sores have healed completely may delay healing and give infection to partners
    • If no sores wait until 7 days after treatment and until partner is treated before having sex

Follow-up

  • Review at 1 week
    • Check if symptoms resolved
    • If sores not healed, no cause found — medical consult and add recall for 4 week review

Syphilis and donovanosis

Do if pregnant

  • Medical consult — this is an STI emergency

Do

  • Take blood for syphilis serology before starting treatment for accurate baseline (pre-treatment) RPR level
  • Give benzathine benzylpenicillin (Bicillin L-A) IM — adult 2,400,000 units/4.6mL (1.8g) (2 x 2.3mL syringes), single dose — to start treatment for syphilis
    • If allergy to penicillin — medical consult
  • If donovanosis suspected — sexual health consult
  • Contact tracing — very important if you suspect new syphilis infection. Get advice from sexual health unit
  • Talk about STIs and safer sex

If recent syphilis — often get harmless febrile reaction to treatment (Jarisch-Herxheimer). Starts in 3–4 hours, gets better within 24 hours

  • Give paracetamol — adult 1g up to 4 times a day (qid)

Follow-up

  • Review at 1 week
    • Check test results. If positive — see STI management
    • If ulcer not healing and tests negative — medical consult and add recall for 4 week review
    • If you suspect donovanosis but tests negative — sexual health consult 

Genital herpes

  • Herpes simplex virus (HSV) causes genital and oral herpes (cold sores)
  • Antiviral treatment reduces risk of spreading infection, duration and severity of symptoms — but doesn't cure
  • Lifelong risk of recurrent episodes and shedding of herpes virus
  • Infection with both herpes and syphilis possible

Do

  • Keep sores clean with normal saline washes
  • Give pain relief — can put lidocaine (lignocaine) gel on sores
  • If kidney disease — medical consult. May need lower doses of antivirals

First episode

Can be severe. Lasts 2–3 weeks

  • Full STI check if not done previously — must include syphilis serology
  • Medicines are most helpful if blisters present for 3 days or less
    • Give valaciclovir oral — adult 500mg, twice a day (bd) for 5–10 days
  • Review at 1 week
    • Positive herpes NAAT confirms genital herpes
    • Negative herpes NAAT does not exclude genital herpes — ask to return for another swab if sores come back

Recurrent episodes

Usually less severe. Lasts 1 week or less

  • Medicines are most helpful if given before or on the first day blisters appear
    • Give valaciclovir oral — adult 500mg, twice a day (bd) for 3 days

OR famciclovir oral — adult 1g, twice a day (bd) for 1 day 

  • If getting sores often and/or causing a lot of trouble — medical consult about having tablets at home to take as soon as sores start

Do if pregnant

  • Medical/specialist consult about management of pregnant woman if
    • First presentation of herpes in pregnancy
    • History of herpes, previously or in current pregnancy —may need prophylactic antiviral treatment
    • Woman or her partner had blood test in past showing positive herpes serology
  • If first clinical episode
    • Do herpes serology
    • Give valaciclovir oral — adult 500mg, twice a day (bd) for 5 days
  • If recurrent episode — give valaciclovir oral — adult 500mg, twice a day (bd) for 3 days
  • If severe episode — medical consult to send to hospital 
  • Advise woman with no history of herpes but whose partner has history of herpes to avoid sex (including oral sex) in third trimester of pregnancy

At time of birth

  • Women with herpes lesions need obstetrician/gynaecology consult about possible caesarean section
  • If vaginal birth — avoid invasive foetal monitoring and instrument delivery​

Genital warts

Painless, solid lumps with hard smooth surface or cauliflower-like appearance. May look like condylomata lata (secondary syphilis)

Do not

  • Do not treat as genital warts until secondary syphilis is excluded
  • Do not give podophyllotoxin if woman is OR could be pregnant OR is breastfeeding

Do

  • If first episode — medical consult
  • Give podophyllotoxin 0.5% solution to apply twice a day (bd) for 3 days THEN no treatment for 4 days — repeat cycle up to 4 times
    • Do not use if pregnant
  • Always show how to put on the medicine
    • Use cotton swab or applicator for lotion
    • Wash hands straight away
    • Only put on wart — can burn skin and cause ulcers
  • If not improving — medical/sexual health consult about other treatments
  • If pregnant or if warts are large, inside vagina or lots of warts — medical consult