Control of genital ulcer disease (GUD) has become an important public health priority. Ulcerative lesions may produce significant local genital pain, some pathogens may be transmitted from mothers to their infants, and genital lesions increase the risk of human immunodeficiency virus (HIV) acquisition and transmission during sexual intercourse. Table 61.1 lists the infectious and noninfectious etiologies that may produce genital ulcerations with or without adenopathy. The most common sexually transmitted etiologies of GUD include syphilis, which is caused by Treponema pallidum; genital herpes caused by herpes simplex viruses (HSV) 1 and 2; chancroid, caused by Hemophilus ducreyi; lymphogranuloma venereum (LGV), caused by the L1, L2, and L3 serovars of Chlamydia trachomatis; and granuloma inguinale (donovanosis), caused by Calymmatobacterium granulomatis. Trauma, erosive balanitis, and fixed-drug eruptions are the most common nontransmissible causes of GUD. Neoplasia, fungi, and mycobacteria should be excluded by biopsy if the ulcer persists. Because of the limitations of diagnostic tests, a specific diagnosis is obtained in about 80% of patients.

Considerable geographic variation exists in the etiology and prevalence of GUD (Table 61.2). In Europe and North America, fewer than 10% of patients present to sexually transmitted disease (STD) clinics with a genital ulcer compared with 20% to 40% of patients presenting to these clinics in Africa and Asia. HSV is the most common cause of genital ulcerations in Europe and North America, whereas chancroid has been the most common cause of genital ulcerations in regions of Africa and Asia.