Initial evaluation of a sexually active patient who presents with a new genital ulcer

This algorithm provides a general approach to the initial evaluation of a sexually active patient presenting with a new genital ulcer. However, determining the etiology of a genital ulcer based only upon the history and physical exam can be difficult, because the signs, symptoms, and appearance of genital ulcers due to individual pathogens can vary, and coinfection with multiple organisms can occur. Thus, it is important that diagnostic testing be obtained in an effort to support/confirm the infectious agent.

STI: sexually transmitted infection; GUD: general ulcer disease; HSV: herpes simplex virus; LGV: lymphogranuloma venereum; PCR: polymerase chain reaction; IM: intramuscularly.
* All patients should have the following tests performed, regardless of the clinical presentation: HSV PCR or culture, syphilis serologies, testing for other STIs (including HIV, gonorrhea, and chlamydia).
¶ STIs that present with genital ulcers include syphilis, HSV, LGV, chancroid, and granuloma inguinale. Refer to the UpToDate topic that provides an overview of GUD for specific details of the epidemiology and clinical manifestations of the different infections.
Δ Preferred regimens:

Early syphilis: Single dose of penicillin G benzathine (2.4 million units IM)
Herpes simplex: Acyclovir (400 mg three times daily), famciclovir (250 mg three times daily), or valacyclovir (1000 mg twice daily) for 7 to 10 days
LGV: Doxycycline (100 mg twice daily for 21 days)

Refer to the individual UpToDate topic reviews for alternative regimens.
◊ If a diagnosis is not made during the initial evaluation, additional work-up depends upon the patient's risk factors and the specific clinical manifestations. Refer to the UpToDate topic that discusses the approach to patients with GUD for a more detailed discussion.

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Initial evaluation of a sexually active patient who presents with a new genital ulcer