Genital Ulcer Syndrome (GUS)

A60.9/A51.0

Genital ulcer disease that persists despite appropriate syndromic management should be investigated. Referral letter from PHC should include all relevant information (including HIV status, treatment history and partner notification and management).

INVESTIGATIONS

  • All NHLS standard laboratory forms must include the following information:
    • Name and contact details (cellphone number + email address) of requesting healthcare worker.
  • Genital specimen collection and test requests:
    • Materials: Two cotton-tip swabs (plastic shaft); one Dacron swab (wire shaft); glass slide, slide box (all obtained from local NHLS laboratory)
    • Cotton swab 1: Prior to taking specimen, roll a cotton-tip swab across the lesion gently to remove exudates from secondary infection and/ or debris in a way that minimizes bleeding. Discard cotton swab.
    • Cotton swab 2: Roll a second cotton-tip swab over the base of the ulcer, including the ulcer edges. Make a thin smear by rolling evenly over the centre of a labelled-glass slide to the size of a R2 coin. Air dry slide and place in slide box. Discard cotton swab.
    • Dacron swab: Collect material from base of ulcer lesion; place swab in sterile universal container or tube and cut off wire shaft. Close container.
      • Test request: Transport glass slide and Dacron swab on ice to NICD STI Reference laboratory as soon as possible for microscopy for Donovanosis and PCR genital ulcer pathogens.
      • Presumptive diagnosis: Persistent genital ulcer disease
  • Venous blood specimen: 5 mL in serum separator tube for syphilis serology – send to local NHLS laboratory.

MEDICINE TREATMENT

Ask patient to return in two weeks for follow-up of laboratory results and further clinical evaluation. Treat accordingly, but note that syphilis does not require re-treatment if benzathine penicillin was used to treat GUS.

If the syndromic treatment at PHC used doxycycline instead of benzathine penicillin and syphilis is detected on PCR, treat with:

  • Benzathine benzylpenicillin, IM, 2.4 MU immediately as a single dose.
    • Dissolve benzathine benzylpenicillin, IM, 2.4 MU in 6 mL lidocaine 1% without adrenaline (epinephrine).

LoEIII [10]

Recurrent herpes

For frequent recurrences of herpes simplex (i.e. ≥4 episodes of clinically apparent reactivations per year), suppressive antiviral therapy may be considered.

  • Antiviral (active against herpes simplex) e.g.: LoEII [11]
    • Aciclovir, oral, 400 mg 12 hourly.
      • Review annually for ongoing suppressive therapy.

LoEIII [12]

REFERRAL

If ulcer PCR results for STI pathogens are inconclusive and genital ulceration persists, refer to specialist for genital ulcer biopsy and histopathological examination to exclude a non-infectious cause, which includes cancer.