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

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