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UROWALA

Genital ulcer: diagnostic algorithm

Tap what you see and feel at the bedside. The tool ranks the likely causes and lists the tests that confirm them. Open any card for details.

Always test for HIV and syphilis serology in every genital ulcer. Mixed infections are common. Ulcer present over 2–4 weeks, or not healing on therapy: biopsy to exclude squamous cell carcinoma, donovanosis, mpox or tuberculosis. Educational aid for clinicians; it does not replace clinical judgment.

Step 1. Bedside features

Step 2. Likely cause

Select at least one feature above.

Scores are a teaching heuristic built from classical features. The clinical picture alone is unreliable: confirm with tests.

How to tell them apart

Descriptions and tests

Other causes to keep in mind
  • Mpox: recent close or sexual contact; firm, deep-seated, umbilicated pustules that ulcerate, often with fever and lymphadenopathy. Test a lesion swab by PCR.
  • Non-infectious: Behçet disease (recurrent oral and genital ulcers, uveitis), fixed drug eruption (recurs at the same site after a drug), trauma, erosive lichen planus, aphthous ulcer, balanitis with erosions.
  • Malignancy: penile or vulvar squamous cell carcinoma can look like a chronic ulcer or plaque. Biopsy any persistent lesion.
  • Other infections: primary HIV, CMV, EBV, tuberculosis, and cutaneous leishmaniasis in endemic regions.

Treatment

Treatment is locked. Enter the access code to view drug regimens.

Sources

Guidelines used
  • CDC. Sexually Transmitted Infections Treatment Guidelines, 2021: Genital ulcer disease (MMWR Recomm Rep 2021;70(4)).
  • WHO. Guidelines for the management of symptomatic sexually transmitted infections, 2021.
  • IUSTI / European guidelines on syphilis, genital herpes, chancroid and lymphogranuloma venereum.
  • EAU Guidelines on Urological Infections (sexually transmitted infections section).

Regimens are summarised from these guidelines. Check the current full text and local resistance and availability before clinical or patient use.

Prepared for UROWALA. Reviewed and adapted by Dr. Mohit Sharma, MCh Urology.

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