Painful acute vulvar ulcer

Specialty: Gynecology and breast.

• Painful female genital ulceration
• sore on the vulva
• acute vulvar aphtosis

Why it occurs

• Herpes Simplex Virus type 2 or type 1 infection (herpetic primary infection)
• Treponema pallidum infection (primary syphilis, typically painless but can hurt if superinfected)
• Chancroid (Haemophilus ducreyi infection)
• Lipschütz ulcer (acute non-venereal vulvar ulcer, associated with Epstein-Barr virus infection in young women or adolescents)
• Behçet's disease or inflammatory bowel disease (vulvar manifestation of systemic pathology)

Initial workup

Multiplex PCR on ulcer smears for Herpes Simplex Virus (HSV-1, HSV-2), Treponema pallidum and Haemophilus ducreyi. Serology for syphilis (RPR/VDRL and treponemal tests), HIV, Epstein-Barr virus, cytomegalovirus and hepatitis B and C. Biopsy of the edge of the ulcer if it persists for more than 3 weeks without a clear diagnosis to rule out squamous cell carcinoma of the vulva.

Standard management

• Acyclovir 400 mg orally every 8 hours for 7 to 10 days (or Valacyclovir 1 g orally every 12 hours) if primary HSV infection is confirmed or suspected
• Penicillin G benzathine 2.4 million IU intramuscularly in a single dose if primary syphilis is confirmed
• Ceftriaxone 250 mg intramuscularly in a single dose in case of suspected chancroid
• Lidocaine 2% ointment for topical application before urination to relieve severe local pain (note: avoid the use of topical corticosteroids until active infectious etiology has been ruled out).