Thursday, April 9, 2015

Painless Penile Ulcer

Painless Penile Ulcer:

Case presentation: 

A 35-year-old male presents to the emergency department complaining of a “sore” that he
recently noticed on his penis. He describes the “sore” as painless and he denies any associated penile discharge.  He has never had this problem before. He is currently in a “stable” relationship with a man and recently had an HIV test that was negative. 

painless penile ulcer due to syphilis
On examination, there is a single ulcer on the distal end of the penis. The ulcer is 2 cm in diameter and has a slightly raised indurated margin with a clean base. His inguinal lymph nodes are mildly enlarged bilaterally. They feel slightly rubbery, but are discrete and nontender.
Question: What is the next most appropriate management strategy at this time?

A. Discharge the patient to home without treatment
B. Treat the patient empirically for herpes
C. Be reassured by the patient’s reported negative HIV test result and suggest no further testing for HIV in
the future
D. Treat empirically for syphilis based on the history, physical examination, and knowledge of the
 epidemiology of genital ulcers in your geographic area
E. Perform urinalysis and treat based on the results

Answer: D
Diagnosis: Chancre of primary syphilis Discussion: Genital ulcers occur in sexually active individuals
throughout the world. Physicians encountering patients with ulcers tend to rely heavily on history and
physical examinations in order to make a diagnosis, but this approach may be inappropriate. There is considerable variation and overlap in presentation, and generally additional diagnostic tests need to be performed. Also, concomitant infection with HIV can subtly alter the clinical presentation and compound the diffi culty in diagnosing  the cause of genital ulcers. Physicians need to use the  opportunity of having the patient physically present to administer appropriate therapy under the assumption
that follow-up of patients, although ideal, may not occur.

The Centers for Disease Control and Prevention (CDC) currently recommend an approach to the diagnosis and
treatment of genital ulcers that relies heavily on clinical presentation and a knowledge of local epidemiologic data on the prevalence of causes of genital ulcers in a specific geographic area.

The typical clinical presentation of syphilis is a single painless, indurated ulcer with firm, nontender
inguinal adenopathy. HSV tends to present with   multiple vesicles or a cluster of painful ulcers preceded by vesiculopustular lesions. Tender inguinal lymph nodes are commonly associated.

 Chancroid ulcers tend to be multiple, painful, and purulent, and are often associated with inguinal lymphadenopathy with fluctuance or overlying erythema. The lymphadenopathy is often unilateral and is often painful. Lymphogranuloma venereum and granuloma inguinale rarely cause genital ulcers in the United States.

Diagnostic tests should be performed whenever possible and should be directed towards ascertaining the cause of the genital ulcer, as well as screening for commonly occurring co-infections with other sexually transmitted diseases (such as Chlamydia trachomatis, Neisseria gonorrhoeae, HIV, hepatitis B, and hepatitis C).

For syphilis, options to assist in making a correct diagnosis include: serologic tests (i.e., VDRL and RPR),
dark-field microscopy, and tissue biopsy. For HSV, one can do Tzanck smears, direct fluorescence antibody tests, viral cultures, or polymerase chain reaction. In the case of Haemophilus ducreyi (chancroid), Gram stain and culture on selective media is suggested.

Treatment should ideally be directed towards the identified cause. Since diagnostic tests are often not available at the time of presentation and may not always yield a specific cause, or if patient compliance is in question, empiric therapy should be based on the clinical presentation and the epidemiology of the etiologic agents in a given area. If necessary, patients may require treatment for HSV, syphilis, and chancroid (in areas of high incidence) on the day of their initial visit. Also, all patients should be offered HIV counseling and testing on the day of presentation, and they should be counseled about safesex

Follow-up should be encouraged to discuss laboratory results, ensure treatment was appropriate, and
ascertain if healing of the ulcer has occurred. Finally, patients should be advised to encourage their partners to seek care for potential coexistent sexually transmitted disease.


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