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Genital sores/ulcers Herpes, Syphilis, Donovanosis Recommend See “How to do an STI check” Consult the Public Health Nurse, Syphilis Register on 1800 032 238 If syphilis or donovanosis are likely or cannot be excluded, treatment should be given to cover both infections Background The diagnosis of genital sores can be difficult and is based on a combination of clinical symptoms and signs, laboratory tests and response to treatment Herpes is the most common cause of genital ulcers Scabies and candidiasis may cause genital sores but other signs of these infections should be present Related topics: Flowchart - Management guidelines for genital ulcer disease (GUD), page 494 How to do an STI check, page 466 Hepatitis, page 321 HIV Infection, page 503 1. May present as: Lumps in the genital skin/mucosa: genital warts, molluscum, syphilis Ulceration (where the skin is broken or inflamed): herpes, syphilis, donovanosis Typical sores Painful? Enlarged lymph nodes? Heals without treatment? Treatment Genital warts Solid lumps, may be smooth or warty, asymmetrical no ulceration no inflammation of surrounding skin Genital Herpes Cluster of blisters, which break down to form small shallow ulcers, with irregular borders Surrounding skin may be inflamed Painful or itchy Yes/no Syphilis Primary: (chancre) one or a few sores, 1-2 cm with well defined edges Secondary: (condylomata lata) multiple, often perianal skin, symmetrical, flat Usually painless Yes/no No Yes within 1-2 weeks but usually recurs Genital warts Podophyllotoxin Exclude syphilis before treating (see GENITAL WARTS 414) Genital Herpes Valacyclovir (see below) Yes No primary sores within 2-3 continues to become weeks, larger over time secondary sores may come and go over 12 months Syphilis Donovanosis Always commence treatment for both on clinical presentation with Bicillin LA/Pan benzathine penicillin for syphilis AND Azithromycin for donovanosis (see below) No No Donovanosis Commences as one or more sores or nodules, and may join to form large destructive ulcers, which are beefy red and bleed easily Usually painless No 2. Immediate management: not applicable 3. Clinical assessment (see How to do an STI check) History: Obtain a full history including previous episodes of genital sores and whether the current partner has symptoms or signs of an STI Ask about other symptoms: fever, headache, muscle aches and pains, rashes Examination: Examine the mouth and skin (including palms of hands, soles of feet) for sores, ulcers, rashes and hair loss Examine the genital area for discharge, nodules, sores and ulcers, and the armpits, neck and groin for enlarged nodes Testing (see also STI Specimen collection): Urine pregnancy test on all women of childbearing age (12-52 years) Swab the base of the lesion for herpes virus culture / PCR, or 4. In donovanosis affected areas, use a sterile cotton tipped dry swab eg PCR swab, roll the swab firmly around the edge and across the lesion and place into a dry sterile container for GUMP (genital ulcer multiplex PCR) If donovanosis is likely, press a glass slide onto the lesion, let the slide air dry (Geimsa stain for donovan bodies) In men, obtain a first catch urine for gonorrhoea, chlamydia and trichomonas PCR In women, if sores are multiple or painful do not do a speculum examination but obtain self collected vaginal swabs (PCR and MC&S) or first catch urine for gonorrhoea, chlamydia and trichomonas PCR Syphilis serology testing Offer tests for HIV, Hepatitis B if not immune and Hepatitis C if history suggests exposure. see Hepatitis and HIV Infection Herpes serology is not useful in this context and should not be taken Management: (see How to do an STI check and flowchart, Management guidelines for genital ulcer disease (GUD): Complete the Genital Ulcer Notification Report and fax immediately to the Syphilis Register. Education/Counselling: Give general information on the transmission, complications and prevention of STI/HIV Discuss safer sex practices and provide condoms Advise not to have sex until lesions have healed and contacts have been treated (as appropriate) Encourage compliance with medication Stress the importance of follow up Medication management at time of presentation: If lesions are typical of genital herpes: Consult MO before starting treatment if pregnant Keep the lesions clean and dry with salt baths and topical Betadine solution Apply topical Lignocaine gel 2% to the sores for pain relief for 2 –3 days DTP IHW / SRH / NP / IPAP Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO Sexual Reproductive Health Endorsed Registered Nurses may proceed Nurse Practitioners may proceed Route of Form Strength Recommended Dosage Duration Administration Gel 2% Topical Adults Apply thinly for pain relief 2 – 3 days Provide Consumer Medicine Information if available: Management of Associated Emergency: Schedule 2 Lignocaine Gel 2% Always treat with Valaciclovir if a primary (first) or moderately severe episode: DTP IHW / RIN / SRH / NP / IPAP Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO Sexual and Reproductive Health Program and Rural and Isolated Practice Endorsed Registered Nurses may proceed Nurse Practitioners may proceed Route of Form Strength Recommended Dosage Duration Administration Tablet 500mg Oral Adult 500mg bd (Dose should be 5 days reduced to 500mg once daily if significantly impaired renal function) Provide Consumer Medicine Information if available: Management of Associated Emergency: Schedule 4 Valaciclovir If lesions are not typical of herpes, and syphilis or donovanosis are likely treat or both syphilis and donovanosis Check if the patient is allergic to Penicillin or Erythromycin group of antibiotics (includes Azithromycin) If allergic to penicillin consult the Syphilis Register 1800 032 238 Observe the client taking the treatment if possible For syphilis: Penicillin Benzathine DTP (LA Bicillin) IHW / IPAP/ RIN / SRH / NP Authorised Indigenous Health Workers and Isolated Practice Area Paramedics must consult MO Rural and Isolated Practice and Sexual and Reproductive Health Endorsed Registered Nurses may proceed Nurse Practitioners may proceed Route of Form Strength Recommended Dosage Duration Administration Disposable 900 mg in 2mL IM 1.8g Stat syringe (1.2 million units) (2.4 million units) (give in 2 separate injections) Provide Consumer Medicine Information if available: Management of Associated Emergency: As for severe allergic reactions. See Anaphalaxis Bicillin LA (Prefilled syringe) injection technique Apply EMLA cream to the injection site 30 – 60 minutes prior to injection Allow to warm up to room temp Apply pressure to the injection site 10+ seconds prior to administration Schedule 4 Note: Jarisch-Herxheimer Reaction is uncommon but may occur with treatment of syphilis. Symptoms may occur 4 to 6 hours after treatment and include headache, shivers, aches and pains, flu-like symptoms, and can normally be managed with Paracetamol for 24 hours. It may cause preterm labour, but this should not prevent or delay treatment. And for Donovanosis: DTP IHW / RIN / SRH / NP / IPAP Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO Rural and Isolated Practice/Sexual and Reproductive Health Program Endorsed Registered Nurses may proceed Nurse Practitioners may proceed Route of Form Strength Recommended Dosage Duration Administration Tablet 500mg Oral 1 gram 1 dose given under observation If a diagnosis of donovanosis is made continue Azithromycin treatment weekly for 4 doses or until completely healed Provide Consumer Medicine Information if available: Management of Associated Emergency: Schedule 4 Azithromycin The diagnosis of genital ulcers is based on a combination of clinical findings, laboratory tests, and response to treatment. Test results for herpes and donovanosis may be negative. Consult Syphilis Register or Specialist MO regarding the likely diagnosis and ongoing management. Contact tracing: Ensure confidentiality; obtain a list of the names of sexual contacts up to 12 months (if practical) Do not write the names of contacts in the client’s medical record Contacts should have an STI check, including examination and blood for syphilis Serology 5. Herpes: contact tracing is not necessary, however partner(s) may need to be counselled regarding the infection Primary, secondary or early latent syphilis (syphilis less than 2 years duration): treat on the spot with Bicillin LA 1.8g as a single treatment as above Donovanosis: treat on the spot with Azithromycin 1g and if confirmed treat weekly for a minimum of 4 doses Follow up : To check that: Client was compliant with treatment and symptoms and signs have resolved Contacts have been tested and treated as appropriate Test results have been given An STI check including an HIV test are offered (if not done at initial visit) Genital herpes: Follow up within 2 weeks to check that symptoms have resolved Partners should have an STI check and counselling, but do not need to be treated Consult MO if symptoms have not resolved within 2 weeks, or the client has frequent or severe recurrences Primary, secondary or early latent syphilis (syphilis of less than 2 years duration): Follow up at 2 weeks to ensure that symptoms have resolved and contacts have been tested and treated Follow up syphilis serology should be taken between 3 to 6 months and again at 12 months A 2 titre or fourfold fall in syphilis serology (eg 1 in 64 to 1 in 16) by 6 months indicates adequate response to treatment If the syphilis serology has not fallen by 2 titres within 6 months call the Public Health Nurse, Syphilis Register on 1800 032 238 Consult MO if symptoms have not resolved or if client is pregnant Donovanosis: Follow up weekly for 4 to 6 weeks to continue treatment and ensure lesions are responding to treatment Check that contacts have been examined and treated Consult MO if sores have not significantly responded to treatment within 4 weeks (a snip or punch biopsy should be taken to exclude other causes) Consult MO if sores have not healed by 6 weeks Follow up at 2-3 months: Offer a full STI check including syphilis serology and HIV test 6. Referral / Consultation: Consult MO as above if allergic, if pregnant or if symptoms do not respond to treatment Management Guidelines for Genital Ulcer Disease (GUD) (including Donovanosis) Patient presents with genital ulcer* Possible Diagnosis 1. Painless ulcers or beefy red/crusty sores, smelly, discharge, bleeds easily: consider Donovanosis 2. Raised, firm, painless, punched out: consider syphilitic chancre 3. Painful or itchy multiple blisters or shallow ulcers: consider herpes Remember these infections may co-exist Testing for other STIs Offer a full STI check: Gonorrhoea (PCR/NAA) History, Chlamydia (PCR/NAA) Examination and Swabs of any discharge for M/C&S tests for other STIs Hep B and Hep C serology, HIV GUD Testing Swab taken for herpes simplex virus (HSV) culture or PCR (NAA) or dry swab for PCR / GUMP. If donovanosis likely, press slide for Donovan bodies & blood for syphilis Notify Syphilis Register 1800 032238 GUD Syndromic Management (treat immediately do not wait for results) Benzathine penicillin IMI (LA Bicillin 1.8 gm) and Azithromycin 1.0 gm orally If clinically suggestive of herpes discuss with Syphilis Register or SHU and treat as per PCCM Review patient in one week Check lesion & all laboratory results Contact trace sexual partners Follow up guidelines for Genital Ulcer Disease (GUD) (including Donovanosis) Review patient in one week Check lesion & all laboratory results Clinically suggestive of syphilis & Clinically suggestive of Donovanosis and/or and/or or syphilis serology test returns Donovanosis test returns positive positive Seek advice re further management from syphilis register or local Sexual Health Unit Azithromycin 1.0gm once a week for 3 more weeks (total 4 weeks) or Azithromycin 500mg DAILY for 7 days only R/V ulcer each week if possible Examination at 4 weeks is required to determine further management If no response to treatment at 4 weeks, medical officer review is required. A biopsy to investigate other causes may be needed & or Clinically suggestive of herpes and/or HSV test returns positive. Treat primary episode and significant recurrent episodes with anti-viral medications as per PCCM Consider suppressive treatment if multiple recurrences Review at 3 to 6 months and at 12 months – include syphilis serology and PCR for gonorrhoea / chlamydia * STIs in children, in women who are pregnant or breast feeding and in patients with a history of allergy to the antibiotic, require specialist management. Please contact your local Sexual Health Unit (SHU) if you have any questions.
