What are the other Names for this Condition? (Also known as/Synonyms)

• Genital Sores in Women
• Female Genital Sores

What are Genital Ulcer Sores in Female? (Definition/Background Information)

• An ulcer is defined as a discontinuity of skin or mucous membrane. In simple terms, the skin or mucous membrane is lost, thereby exposing the tissue underneath it
• Genital ulcers can occur in both men and women. Genital Ulcer Sores in Females may involve the skin surrounding the vulva, labia, vagina, perineum, perianal, and anal regions
• Genital ulcers can be caused by infectious factors including sexually transmitted infections such as herpes simplex virus (HSV 2), syphilis, chancroid, lymphogranuloma venereum, granuloma inguinale (donovanosis), secondary bacterial infections (occurring after a primary infection or inflammation), and fungal infections
• The non-infectious factors that cause genital ulcer sores may include sexual trauma, psoriasis, Behcet’s disease, fixed drug eruptions, and acute reactive or recurrent aphthous ulceration following inflammation elsewhere in the body
• Female Genital Sores can be painful or painless, single or multiple, and they may or may not be associated with other symptoms. They usually arise from a sore area (including from blisters)
• Since sexually transmitted infections (STIs) are the most common cause of genital ulcers, evaluation and treatment of both the individual and their partner(s) should be done by a healthcare provider to rule out other associated diseases
• Treatments are available for most genital ulcer sores. However, in some cases there is no cure, but the condition can be controlled. The prognosis of Female Genital Sores is generally good. Nevertheless, the prognosis depends on the causative factor

Who gets Genital Ulcer Sores in Female? (Age and Sex Distribution)

• Any individual irrespective of age, gender, region, race or ethnicity may be affected by genital ulcer sores. However, this may vary depending on the causative factor
• Sexually transmitted infections (STIs) are the most common cause of genital ulcers. Any individual who is sexually-active can potentially contract a STI, which can result in an ulcer. The likelihood of contracting an STI is highest among young adults between the ages of 15-24 years
• Herpes simplex virus infection is one of the most common causes of genital ulcer. It occurs worldwide and the occurrence rates show an increasing trend
• Syphilis is more common in sexually-active adults and is typically seen between the ages of 15 and 40 years. It is most common in South Asia, Southeast Asia, and sub-Saharan Africa than any other regions of the world.
• Chancroid (a sexually transmitted bacterial infection) is more common in sexually-active adults between the ages of 15 and 24 years. It is more common in males than females. This condition is most common in Africa, Southwest Asia, and the Caribbean than any other regions of the world. Chancroid more common in non-Caucasians than Caucasians
• Lymphogranuloma venereum (LGV, a sexually transmitted bacterial infection) typically occurs in sexually-active adults between the ages of 15 and 40 years
  • LGV is more common in developing countries such as India, Africa, Southeast Asia, Caribbean, and Central America. It is equally common in men and women in these countries
  • In the developed countries, it is more common in Caucasians
• Bechet’s disease is a non-infectious condition. It is usually common in the 3rd and 4th decade (20-40 years). It is more common in individuals from East Asia and Middle East Asia. In the US, it is more common in women, though in many other regions, it is more common in men. Certain individuals have a genetic predisposition to Bechet’s disease. Nevertheless, it can affect any individual irrespective of age, gender, region, race, or ethnicity
• Individuals are affected by psoriasis usually between the ages of 15-30 years, and also between the ages of 50-60 years. It is more common in Caucasians than any other races. It affects both men and women and is typically observed in regions farther away from the equator
• Acute reactive aphthous ulceration usually manifests between the ages of 12 to 15 years of age. It is more common in non-sexually active females than any other individuals

What are the Risk Factors for Genital Ulcer Sores in Female? (Predisposing Factors)

Risk factors for Genital Ulcer Sores in Female include:

• For sexually transmitted infections, such as HSV infection, syphilis, chancroid, lymphogranuloma venereum, etc., the risks include:
  • Multiple sexual partners
  • Anonymous sex partners
  • Unprotected sex
  • Uncircumcised penis
  • Skin contact with an individual having ulcers or lesions: In individuals who has been previously been diagnosed with HSV infection, the prophylactic acyclovir, may decrease the risk of getting blisters or ulcer
• Non-infectious factors related risks include:
  • A personal medical history and/or a family history of psoriasis, associated with factors, such as trauma and use of medications (NSAIDs like ibuprofen, ACE inhibitors, beta-blockers, and corticosteroids), increases ones risk to get genital ulcers:
  • Behcet disease: Individuals having the specific antigen (HLA B51/B5) are at increased risk
  • Having certain medications, especially some antibiotics

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases ones chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Genital Ulcer Sores in Female? (Etiology)

Female Genital Sores are most commonly caused by sexually transmitted diseases that include the following:

• Herpes simplex virus infection (HSV1 or HSV2) is the leading cause of genital ulcers
• Syphilis caused by the bacterium Treponema pallidum
• Chancroid caused by the microorganism Haemophilus ducreyi
• Lymphogranuloma venereum caused by Chlamydia trachomatis (bacterium)
• Granuloma inguinale caused by Klebsiella granulomatis
• Genital warts caused by human papilloma virus (HPV)

Usually, women who have genital ulcer sores may have one or more sexually transmitted infection.

Genital Ulcer Sores in Females may be also caused by non-infectious factors that include:

• Acute reactive aphthous ulceration that occurs as a reactive response following an infection, elsewhere in the body
• Acute recurrent aphthous ulceration that is usually caused by Epstein Barr virus (EBV)
• Intercourse-related trauma to the genital region
• Psoriasis: The exact cause and mechanism of the condition is unknown. Researchers propose that the following factors may play a role:
  • Overactive immune mechanisms (especially T cell, white blood cell)
  • Family history is positive in up to a third of the affected individuals
  • Unknown environmental triggers
• Behcet disease: The exact cause and mechanism is not known. Researchers propose genetic and unknown environmental factors may play a role
• Fixed drug eruptions as a side effect to medications, particularly antibiotics

What are the Signs and Symptoms of Genital Ulcer Sores in Female?

The signs and symptoms associated with Genital Ulcer Sores in Females include:

• Open ulcers or cuts (discontinuity of skin or mucous membrane
• Pain that may or may not be associated with burning sensation
• Abnormal discharge (may have a foul smell)
• Itching
• Blister formation
• Dryness of vagina
• Dysuria - pain during urination
• Lesion or rash at the opening of the vagina
• Dyspareunia - pain during intercourse

Specific set of signs and symptoms for each causative factor may help in the diagnosis and treatment of the condition.

HSV1 or HSV2 infection (genital herpes) is characterized by primary and recurrent or repetitive infections.

• The primary infection may go unnoticed, especially when individuals are infected for the very first time and if they do not present symptoms
  • Or, they may have symptoms 4-7 days following exposure to an infected individual
  • The sores of HSV are initially multiple, small blisters, which then burst to form an ulcer. Following this, they may scab and heal
  • The sores of HSV are initially multiple, small blisters, which then burst to form an ulcer. Following this, they may scab and heal
  • The sores may be seen in the genitals or adjoining skin, or occur inside the vagina, rectum, or cervix
  • There may be vaginal discharge or a burning sensation during urination           
  • The individual may also generally feel unwell
• Most of the times an individual gets permanently infected; she may or may not have recurrent signs and symptoms
• Recurrent infections may appear anytime and are usually accompanied by tingling sensations or pain in the buttocks or legs, 48 hours before the genital lesions appear. They are usually less in severity than the primary infection

Syphilis initially begins with a painless sore (called chancre) that is like a pimple, blister, or ulcer with the following features:

• The lesion may appear 2-5 weeks following exposure to an infected individual
• It is usually single or solitary
• It is typically seen in the genital areas, but may also occur in the nearby region. If it is inside the vagina or rectum, it may go unnoticed because it is painless
• The lesions can also occur on other areas of the body
• The nearby lymph nodes may be enlarged
• The chancre may mimic a chancroid ulcer; but unlike in chancroid, syphilis lesions are usually painless
• Syphilis can progress to secondary or tertiary stages, if left untreated

Chancroid lesions may be noticed anytime up to 2 weeks following exposure to an infected individual.

• Initially, a small bump may be observed which then becomes an ulcer within a day
• The ulcer is painful, soft to touch, and may measure up to 2 inches in size. The ulcer base may be covered with a yellowish material and may bleed on removal of the yellow material
• Usually more than 4 ulcers are seen in the outer labia
• Other sites that may become involved include the perianal region and nearby skin
• Individuals may experience pain while passing urine or while having intercourse
• They may have enlargement of the lymph nodes (called buboes). These may break and discharge pus material

Lymphogranuloma venereum lesions are seen anywhere from days to months following exposure to an infected individual

• In the initial stages a painless lump may be seen, which may then become a painless ulcer. The lump or ulcer is usually seen inside the vagina, cervix, or outside, in the vulva or perineum
• In the later stages, a painful enlargement of nodes (which may burst) may be observed. This stage is followed by painful bowel movements or blood in the stools, especially in individuals who practice anal receptive intercourse

The signs and symptoms of Genital Ulcer Sores in Females associated with non-infectious causes include:

• Bechet’s disease genital ulcers are red and painful. They usually heal by scarring
• Psoriasis related genital ulcers can involve the vulva and present themselves as red, smooth lesions. They are not scaly, unlike those observed on other regions of the body. They usually cause itching, which may become secondarily infected with bacteria. They can ulcerate, if the area is traumatized or if certain medications are taken. Generally, the lesions do not involve the mucous membranes
• Acute reactive aphthous ulcers, which usually occurs in non-sexually active adolescent girls is most commonly seen on the vulva
  • The ulcers may be painful
  • It may cause pain during urination or cause enlargement of the lymph nodes
  • These ulcers are usually accompanied by ulcer formations in the mouth
• Acute recurrent aphthous ulcers are more common in women and may appear frequently or infrequently
• Fixed drug eruption genital ulcer: It appears several days or weeks following exposure to the medication. It may start as a red, flat, itchy, burning, patch and may then ulcerate

How is Genital Ulcer Sores in Female Diagnosed?

The tools that may be used in the diagnosis of Genital Ulcer Sores in Females include:

• The initial diagnosis is based on a thorough evaluation of history and a complete physical examination
• The healthcare provider may ask questions about the individual’s sexual practices such as number of partners, orientation, preferences, previous history of STIs, protection used, etc. The physician may also ask about medication use, other infections in the body (if any), family history of skin lesions, etc.
• The presence of any sore or ulcer needs to be evaluated at the earliest possible opportunity, in order to establish a diagnosis and prescribe treatment, as the ulcers/lesions may disappear later and clues may be lost

Multiple sexually transmitted infections (STIs) may be present in those affected with genital ulcers/lesions, so diagnostic procedures may include testing for common STIs.

• It is important to perform diagnostic tests on both the affected individuals and their partner(s) at the same time, if possible, to avoid reinfection and prevent further spread to others
• Blood tests for genital herpes, syphilis, and HIV may be undertaken simultaneously
• Syphilis: The screening blood tests are VDRL and RPR, which are serological tests to check for the presence of antibodies. If they are positive, confirmatory tests may be done
  • These confirmatory blood tests include FTA-ABS and TP-PA
  • Darkfield microscopy test to detect Treponema pallidum pathogen is the most definitive test. The test specimen is taken from the lesion or aspirated from a lymph node
• Herpes simplex virus (HSV): It is usually clinically diagnosed based on the characteristic signs and symptoms
  • Sometimes, a culture or polymerase chain reaction (PCR) test of the blister or ulcer may be done
  • Blood tests to detect antibodies to HSV are available, though they may not be very reliable
• Chancroid: It is usually diagnosed based on the signs and symptoms and negative results for HSV and syphilis. A culture for Haemophilus ducreyi organism may be performed based on the clinical situation and suspicion of the condition (sometimes, in consultation with Centers for Disease Control and Prevention or CDC)
• Lymphogranuloma venereum is diagnosed from the material taken from the lesion or aspirate from the lymph nodes, through culture studies or direct immunofluorescence tests

Testing for Female Genital Sores that are due to non-infectious factors:

• There are no tests for Bechet’s disease. It is based on clinical signs and symptoms criteria
• Psoriasis is usually diagnosed by clinical history and physical examination
  • A biopsy may be required in some cases, if there is a possibility of other diseases
  • A biopsy is usually not required, if it goes away after initial treatment

Biopsy: In this procedure, the physician removes a sample of the ulcer and adjacent skin tissue. It is sent to a laboratory for a histopathological examination. The pathologist examines the biopsy under a microscope and arrives at a definitive diagnosis, after a thorough evaluation of the clinical and microscopic findings, as well as on correlating the results of special studies on tissues, if any performed.

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Genital Ulcer Sores in Female?

The complications associated with Genital Ulcers in Women could include:

• Increased risk of contracting or having other STIs, including HIV or AIDS
• Emotional stress
• If pregnant, the STI can spread to the fetus or infant and cause long-term complications in them
• Recurring, longstanding symptoms may occur in individuals infected with HSV
• HSV infection and chancroid may sometimes be complicated with urethral problems, especially those relating to urination
• Untreated syphilis may progress to secondary or tertiary syphilis, which may cause central nervous system and cardiovascular associated abnormalities
• Lymphogranuloma venereum infection can be complicated with rectal conditions or long duration inflammation and swelling of the genital organs
• Cancers may develop in the genital organs due to associated STI, especially human papilloma virus
• Scarring may result from Bechet’s disease ulcers

How is Genital Ulcer Sores in Female Treated?

The treatment options of Genital Ulcer Sores in Females depend on the causative factors. They include:

• A medical or health counselling on sexually transmitted infections is important. This may include safe sexual practices. An open line of communication is advised with the healthcare provider to ensure complete treatment for all possible associated diseases or infections
• As a general rule for all diseases, the treatment should be taken for its entire course, even if the symptoms recede or disappear. This can help avoid a potential spread of the infection to the partner(s). Also, any treatment options must include treating one’s partner(s) too
• Antibacterial antibiotics are administered for genital ulcers especially due to syphilis (penicillin), chancroid (azithromycin or ciprofloxacin), lymphogranuloma venereum, or granuloma inguinale. Simultaneous treatment may be initiated for other STIs if suspicion is high, after collecting blood or lesion material for diagnostic tests
• Enlarged lymph nodes due to chancroid are usually aspirated with a needle, before they burst and cause complications

Herpes simplex virus infection:

• Generally, there is no cure for HSV infections
• The symptoms may decrease completely and then keep recurring
• The symptoms may be reduced using suppressive medications such as antiviral acyclovir or valcyclovir. This can also help decrease the infection spread to other individuals
  • If there are less than 6 attacks per year, the healthcare provider may treat the condition with acyclovir or valcyclovir each time there is an attack
  • If there are more than 6 attacks per year, then acyclovir or valcyclovir may be prescribed for a year
• Other symptomatic treatment for recurrent or first time genital sores may include:
  • Having prophylactic valcyclovir when there are symptoms such as buttocks, thigh, or hip pain, which is a warning sign before the blisters/sores appear
  • Keep the lesions clean with regular or salt water
  • Keeping ice (wrapped in a cloth), tea bags, or baking soda (mixed with water) over the sores
  • Applying petroleum jelly on the sores
  • Washing hands after touching the blisters
  • Avoiding tight fitting dress
  • Sitting in a pan or tub filled with cold water
  • Washing hands after touching the blisters
  • Prophylactic acyclovir for cesarean section may be required in pregnant women to prevent the spread of infection to their child
• For trauma-induced genital ulcer and extensive ulcers due to any cause, local wound care and dressing may be required
• For Bechet’s disease, topical corticosteroids, oral colchicine or subcutaneous medication (under the skin injection of pegylated interferon alfa-2a) may be helpful. As a multisystem condition with possible long term sequelae, multiple medications might be tried
• In individuals with fixed drug eruption genital ulcer, discontinuing the offending drug and symptomatic treatment may help
• For aphthous ulcers, symptomatic treatment through oral pain killers and ointments (anesthetic or corticosteroids) may be helpful

How can Genital Ulcer Sores in Female be Prevented?

The preventative measures of Genital Ulcer Sores in Female may include:

• In case of sexually transmitted diseases, an open and honest communication with one’s (potential) sexual partner is extremely important in the prevention of genital infections, sores, and ulcers
• Practicing safe sex with partner(s) will also greatly decrease the risk; this includes avoiding multiple or anonymous partners
• Regular screening for sexually transmitted infections may be performed for individuals at higher risk for STIs
• The U. S. Preventive Services Task Force recommends that healthcare providers routinely screen all sexually-active individuals for HSV infections
• Male condoms or female condoms prevent STIs to a certain extent. It does not, however, prevent the spread of infection, if it does not cover the lesions
• Individuals with STI should avoid sexual activity until they are completely cured (as informed by the attending healthcare provider)

What is the Prognosis Genital Ulcer Sores in Female? (Outcomes/Resolutions)

• The prognosis of Genital Ulcer Sores in Females depends on the cause of STI. With the exception of HSV infection, most genital ulcer causing STIs can be cured with prompt diagnosis and appropriate treatment
• HSV infection causing genital blisters/ulcers cannot be cured. The condition can, however, be controlled with early diagnosis and suitable treatment. In some individuals, the symptoms may decrease in severity and frequency over time
• Non-sexually transmitted genital ulcers can be cured (or controlled); but, they have the potential to reappear or recur
• Bechet’s disease is an uncommon disorder. It is a long-standing illness with frequent symptomatic and asymptomatic periods. Some individuals become symptom-free for longer time periods eventually
• Psoriasis is a long-standing illness with frequent symptomatic and asymptomatic periods

Additional and Relevant Useful Information for Genital Ulcer Sores in Female:

• Herpes simplex viral (HSV) infection is the most common cause of genital ulcer in the United States. The condition is more common in women than men
• In the US, up to 20% of women and 11% of men between the ages of 14 and 49 years get HSV infection. Also, it is more common in individuals of African origin than any other races
• In the US, HSV followed by non-infectious causes are the most common causes of genital ulcer sores