Chapter 124. Sexually Transmitted Infections: Overview and Clinical Approach (Part 17) Diagnosis Although most genital ulcerations cannot be diagnosed confidently on clinical grounds alone, clinical findings plus epidemiologic considerations (Table 124-7) can usually guide initial management (Table 124-8) pending results of further tests. Clinicians should order a rapid serologic test for syphilis in all cases of genital ulcer and a dark-field or direct immunofluorescence test (or PCR test, where available) for T. pallidum in all lesions except those highly characteristic of infection with HSV (i.e., those with herpetic vesicles). All patients presenting with genital ulceration should be counseled and tested for HIV infection. Table 124-7 Clinical Features of Genital Ulcers Feature Syp hilis Herp es Cha ncroid Lympho granuloma Venereum Don ovanosis Incubati on period 9– 90 days 2–7 days 1– 14 days 3 days– 6 weeks 1–4 weeks (up to 6 months) Early primary lesions Pap ule Vesic le Pust ule Papule, pustule, or vesicle Papu le No. of lesions Usu ally one Multi ple Usua lly multiple, may Usually one; often not detected, despitelymphad Vari able coalesce enopathy Diamete r 5– 15 mm 1–2 mm Vari able 2–10 mm Vari able Edges Sha rply demarcate d, elevated, round, or oval Eryth ematous Und ermined, ragged, irregular Elevated, round, or oval Elev ated, irregular Depth Sup erficial or deep Supe rficial Exca vated Superfici al or deep Elev ated Base Sm ooth, nonpurulen t, relatively Sero us, erythematou s, Puru lent, blee ds easily Variable, nonvascular Red and velvety, bleeds readily nonvascula r nonvascular Indurati on Fir m None Soft Occasion ally firm Firm Pain Unc ommon Freq uently tender Usua lly very tender Variable Unco mmon Lympha denopathy Fir m, nontender, bilateral Firm, tender, often bilateral with initial episode Tend er, may suppurate, loculated, usually unilateral Tender, may suppurate, loculated, usually unilateral None ; pseudobubo es Source: From RM Ballard, in KK Holmes et al (eds): Sexually Transmitted Diseases, 4th ed. New York, McGraw-Hill, 2008. . Chapter 124. Sexually Transmitted Infections: Overview and Clinical Approach (Part 17) Diagnosis Although most genital ulcerations cannot be diagnosed confidently on clinical. confidently on clinical grounds alone, clinical findings plus epidemiologic considerations (Table 124- 7) can usually guide initial management (Table 124- 8) pending results of further tests vesicles). All patients presenting with genital ulceration should be counseled and tested for HIV infection. Table 124- 7 Clinical Features of Genital Ulcers Feature Syp hilis Herp es Cha ncroid