Genital Ulcer Syndrome (GUS)

Investiagations

Medicine treatment

Referral

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 benazthine benzylpenicillin, IM, 2.4 MU in 6 mL lidocaine 1% without adrenaline (epinephrine). 
    LoE:III¹⁰

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.:  
  LoE:II¹¹
  • Aciclovir, oral, 400 mg 12 hourly.
    - Review annually for ongoing suppressive therapy. 
    LoE:III¹²

REFERRAL

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

Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults 2019 Edition