Non-sexually acquired genital ulceration
What is non-sexually acquired genital ulceration?
Non-sexually acquired genital ulceration or NSGU refers to painful ulcers in the genital area. It is classified into two types:
- acute reactive aphthous ulceration
- acute recurrent aphthous ulceration.
As the name suggests, NSGU is not due to sexually acquired STI or any other form of infection.
Non-sexually acquired genital ulceration affects mucosal surfaces and the adjacent skin. The ulcers often arise in association with oral aphthous ulcers, which are quite similar in appearance.
Genital ulcers have previously been called complex aphthosis, Lipschütz ulcers, Mikulicz ulcers, Sutton ulcers, and ulcus vulvae acutum.
Reactive genital ulcers
Reactive genital ulcers follow an acute systemic illness, such as tonsillitis, an upper respiratory infection or diarrhoeal illness. They mainly affect the vulva of adolescent girls but may sometimes arise in adult women.
The ulcers may be very painful and result in dysuria (pain passing urine) or prevent urination altogether (acute retention of urine) requiring admission to hospital and catheterisation. Local lymph nodes may be enlarged and tender.
The ulcers resolve within a few weeks and rarely recur.
Recurrent genital ulcers
Recurrent aphthous genital ulcers are more common in females than in males. They may arise continuously, regularly, eg, prior to menstruation each month, or infrequently.
Although they tend to be smaller than the ulcers occurring in reactive genital ulceration, sometimes they are large and numerous.
Some cases of recurrent aphthous genital ulceration appear to be provoked by a specific infection, most often Epstein-Barr virus. Some patients later prove to have Behçet disease or Crohn disease (they have genital Crohn disease).
What does NSGU look like?
NSGU presents with one or more erosions or deeper aphthous ulcers on the inner (mucosal) aspects of the vulva and adjacent skin. The centre of the ulcer is usually yellowish but may become black due to tissue necrosis. There is a red rim aound the ulcer, which can vary in size from 1 mm to over 1 cm in diameter. They may be accompanied by considerable swelling.
What is the cause of NSGU?
The cause of genital aphthous ulcers is not fully understood. They may arise as the result of excessive acquired or innate immune response. They have been associated with several infections.
- Epstein Barr virus (EBV)
- Cytomegalovirus (CMV)
- Group A streptococcus
- Human immunodeficiency virus (HIV)
- Lyme disease.
Similar ulcers may be induced by drugs. These include:
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
Differential diagnosis of non-sexually acquired genital ulceration
There are many infections and non-infectious conditions that may present with ulcers in genital sites. See differential diagnosis of vulval ulcers.
What investigations should be done?
Further tests will be directed by the symptoms of the underlying illness but should include tests for infectious mononucleosis.
Biopsy of the ulcer should include surrounding skin. Findings are nonspecific in NSGU.
Treatment of NSGU
Treatment of genital aphthous ulcers will depend on cause but may include:
- Analgesia such as paracetamol, nonsteroidal anti-inflammatories or stronger pain killers
- Bladder catheterisation (short-term) when pain is severe and inhibiting urination
- Topical anaesthetic ointment or jelly
- Topical corticosteroid ointment or paste
- Intralesional steroid injections
- Oral steroids, eg, prednis(ol)one
- Antistaphylococcal antibiotics if secondarily infected
- Prolonged course of doxycycline or erythromycin to prevent recurrences.