Genital Ulcer Diseases in Women and Pregnancy
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Direct answer
Genital ulcer diseases are sexually transmitted conditions told apart by the pain, base and edges of the ulcer and by the inguinal nodes. Syphilis gives a painless, indurated ulcer with a clean base, and herpes gives painful grouped vesicles that erode. Chancroid gives a painful ragged ulcer with suppurative nodes, granuloma inguinale a painless beefy red ulcer, and lymphogranuloma venereum a transient papule followed by painful nodes.
What you must remember
- Syphilis chancre: Painless, indurated, clean-based ulcer with non-tender bilateral inguinal nodes; confirmed by serology or dark-field microscopy.
- Chancroid: Painful, soft ulcer with undermined edges and a purulent base; Haemophilus ducreyi shows a school-of-fish pattern on Gram stain.
- Herpes simplex: Multiple grouped vesicles that erode into shallow, painful ulcers; PCR of the lesion base is the most sensitive test.
- Lymphogranuloma venereum: A small transient papule, then painful inguinal buboes with the groove sign, caused by Chlamydia trachomatis serovars L1 to L3.
- Granuloma inguinale: A painless, progressive, beefy red ulcer with pseudobuboes and no true nodes; Donovan bodies are seen in macrophages on tissue smear.
- Pregnancy caution: Doxycycline is avoided in pregnancy, so LGV and donovanosis are treated with an alternative, preferably azithromycin (erythromycin is the older option), on specialist advice.
Comparing the ulcers by pain, base and nodes
Genital ulcers are classified by their pain, base, edges and nodes before any test is sent. The table compares the five causes most often set in NEET-PG vignettes.
| Disease | Ulcer features | Inguinal nodes |
|---|---|---|
| Syphilis (primary) | Painless, indurated, clean base | Bilateral, rubbery, non-tender |
| Chancroid | Painful, ragged, undermined edges, purulent base | Unilateral, tender, may suppurate |
| Herpes simplex | Grouped vesicles eroding to shallow painful ulcers | Tender, often bilateral |
| Lymphogranuloma venereum | Small, transient, often unnoticed | Painful, groove sign, may be bilateral |
| Granuloma inguinale | Painless, beefy red, granulating, spreading | Pseudobuboes, no true nodes |
Pain and nodes separate most diagnoses, so a painful ulcer with suppurative nodes points to chancroid, while a painless ulcer with rubbery nodes points to syphilis. The table is a starting point only, because the appearance of an ulcer changes with its age and with any previous treatment.
Every genital ulcer also needs syphilis serology and HIV testing, because co-infection is common and changes management. A non-healing ulcer that does not respond to first-line treatment is a reason to repeat the tests and consider a biopsy.
Where the examiner tries to catch you
The classic errors involve the painless ulcers, which look alike at first sight.
- Trap: Calling every painless genital ulcer syphilis Correct: Granuloma inguinale is also painless, and its beefy red base and pseudobuboes separate it from the clean-based chancre.
- Trap: Treating a painful ulcer with suppurative nodes as herpes because pain is typical Correct: Chancroid has ragged, undermined edges and unilateral suppurative nodes, whereas herpes gives grouped vesicles that erode.
- Trap: Expecting the groove sign in every LGV case Correct: The groove sign is classic but not universal, so the diagnosis rests on history, serology and nucleic acid testing.
Frequently asked questions
Which genital ulcer is painless with a clean base and rubbery nodes?
Primary syphilis is the genital ulcer that is painless, indurated and clean-based, with bilateral non-tender rubbery inguinal nodes. It is confirmed by treponemal serology or by dark-field microscopy of material from the lesion.
What Gram stain finding points to chancroid?
Haemophilus ducreyi, the cause of chancroid, shows a school-of-fish pattern of small gram-negative coccobacilli on Gram staining of the ulcer material. Culture is difficult, so the diagnosis is usually clinical after syphilis and herpes have been excluded.
How is chancroid treated in a non-pregnant adult?
Chancroid is treated with a single dose of oral azithromycin or a single intramuscular dose of ceftriaxone, as per current CDC guidance. Ciprofloxacin and erythromycin are listed as alternative regimens for the same infection.
Why is doxycycline avoided in pregnant women with LGV?
Doxycycline is avoided in pregnancy because tetracyclines affect fetal bone and tooth development. LGV in a pregnant woman is therefore treated with azithromycin (weekly for about three weeks) or, as an older alternative, erythromycin for an extended course, on specialist advice.