What is non-sexually acquired genital ulceration?
Non-sexually acquired genital ulceration (NSGU) is painful ulceration of the external genitalia, usually in adolescents, unrelated to sexual activity.
NSGU in females have previously been called Lipschütz ulcers and ulcus vulvae acutum. In males, NSGU is probably what was previously called juvenile gangrenous vasculitis of the scrotum.
Who gets non-sexually acquired genital ulceration?
Non-sexually acquired genital ulceration follow an acute systemic illness, such as tonsillitis, an upper respiratory infection or diarrhoeal illness. NSGU mainly affects the vulva of adolescent girls (mean age 14.5 years) who are not sexually active. There have also been rare reports of similar penoscrotal ulcers affecting healthy young adult males.
What is the cause of non-sexually acquired genital ulceration?
The cause of non-sexually acquired genital ulceration is not fully understood. It may arise as a result of an excessive acquired or innate immune response to an infectious agent in a predisposed patient.
As the name suggests, NSGU is not due to a sexually acquired infection (STI).
The majority of cases are associated with Epstein-Barr virus (EBV) infection with the virus able to be isolated from the ulcers. Other infections reported in association with NSGU include:
- Cytomegalovirus (CMV)
- Mycoplasma pneumoniae
- Group A streptococcus
- Influenza A virus
What are the clinical features of non-sexually acquired genital ulceration?
Non-sexually acquired genital ulceration is usually preceded by a febrile illness, often a tonsillitis.
NSGU presents with one or more (usually 1-3) well-defined, deep, punched-out ulcers on the inner (mucosal) aspects and adjacent skin of the vulva, or penoscrotal area in males. The centre of the ulcer is usually yellowish but may become black due to tissue necrosis. There is a red rim around the ulcer, which can vary in size but is usually at least 1 cm in diameter. Mirror-image 'kissing' lesions are often seen where there is contact across a fold. There may be considerable swelling.
The ulcers are typically very painful and result in dysuria or prevent urination altogether (acute retention of urine) requiring admission to hospital and catheterisation. Local lymph nodes may be enlarged and tender.
What is the differential diagnosis of non-sexually acquired genital ulceration?
There are many infections and non-infectious conditions that may present with ulcers in genital sites. See Differential diagnosis of vulval ulcers.
How is non-sexually acquired genital ulceration diagnosed?
The diagnosis may be suspected clinically after taking a careful history and performing an examination.
Suggested algorithm to exclude infectious diseases
- Syphilis - serology, T pallidum on dark-field microscopy
- Herpes simplex - viral swab for PCR or Tzanck smear
- If sexually active - consider gonorrhoea, Chlamydia trachomatis, chancroid
- Fungal microscopy
These investigations are negative in NSGU.
Diagnostic criteria for vulval non-sexually acquired genital ulceration
Diagnosis requires both major criteria and at least two minor criteria.
- Acute onset of one or painful vulval ulcers
- Exclusion of infectious and non-infectious cases of genital ulcers.
- Ulcer(s) of the vestibule or labium minorum
- No history of sexual intercourse in the past 3 months or ever
- Flu-like symptoms (fever, chills, fatigue, malaise)
- Systemic illness in the preceding 2-4 weeks.
Further tests will be directed by the symptoms of the underlying illness but should include tests for infectious mononucleosis.
Biopsy of the ulcer edge is rarely required. Findings are nonspecific in NSGU.
What is the treatment of non-sexually acquired genital ulceration?
Reassurance and symptomatic treatment are most important.
- Analgesics such as paracetamol, nonsteroidal anti-inflammatories, or stronger pain killers
- Bladder catheterisation (short-term) when pain is severe and inhibiting urination
- Topical anaesthetic ointment or jelly
- Local hygiene measures and wound care
A potent topical steroid or oral corticosteroids are sometimes used in severe cases, but this is not universally recommended. A prolonged course of doxycycline or erythromycin may prevent recurrences.
What is the outcome of non-sexually acquired genital ulceration?
The ulcers resolve without scarring within a few weeks (average 15 days) and rarely recur.