Genital ulcers are frequently encountered in the cervix. They are mostly due to sexually transmitted infections e.g herpes simplex, chancroid, lymphogranuloma venereum (LGV), and granuloma inguinale (donovanosis). Other less frequent infections causes include aphthous ulcers, Crhon’s disease, primary syphilitic chancre, tuberculous and bilharzial ulcers. Non- infectious ulcers are seen in association with malignancy, Behcet’s disease , trophic and traumatic ulcers.
The residence in tropical countries increases the risk of certain infections such as chancroid and LGV. Donovanosis was first described in India. Bilharziasis is common in Egypt. LGV is common among African races, India, parts of south, East Asia and South America.
Low socioeconomic standards among citizens and immigrant play an important role in the distribution of these infections.
The clinical features of the ulcer (loss of continuity of a surface e.g skin or mucus membrane), provide an important guide to the diagnosis. The site, number, edge, base, floor of the ulcer, the surrounding surface and the draining lymph nodes should all be examined and notified.
The edge: of the ulcer is the demarcation between the ulcer and adjacent surface. The edge of a malignant ulcer is either everted (rolled-out)in squamous call carcinoma, or inverted (rolled-in) in basal cell carcinoma and sometimes overhanging in sebaceous carcinoma. In cases of chronic nonspecific inflammations, the edge is usually sloping or terraced. In specific chronic infections, it differs e.g undermined edge in tuberculosis or punched vertical edge in gammatous ulcer of tertiary syphilis.
The base: of the ulcer means the tissues on which the ulcer rests. In cases of malignant ulcers, it is infiltrated and hence feels indurated. Absence of induration indicates benign or inflammatory nature of the ulcer. Sometimes, the ulcer is no more than an ulcerated part of an underlying tumour. In such cases, the ulceration occurs through pressure necrosis in benign tumours and by actual infiltration in malignant ones. Accordingly, a probe can be passed between the edge and the base of the ulcer in benign and not in malignant tumours.
The floor: of the ulcer means the tissues exposed in the ulcer. It is usually friable, necrotic and bleeds on touch in cases of malignant ulcers.
The surrounding surface: can denote the nature of the ulcer e.g eczematous, pigmented with varicosities in case of varicose ulcers and dry and hyperkeratotic in malignant ulcers.
The draining lymph nodes are firm, tender, usually discrete and not attached to the surrounding in cases of inflammatory ulcers. They disappear spontaneously once the infection is treated. In case of malignant ulcers they are hard, discrete at first but later fixed and they do not disappear if the primary alone is treated.
The most common vulval ulcers are those caused by genital herpes simplex virus (HSV). Chancroid is the second most common cause followed by lymphogranuloma venerum (LGV) and granuloma inguinale (donovanosis).
Other infectious ulcers are aphthous ulcers, associated with crohn’s disease, tuberculosis, and bilharziasis.
Infrequent and non–infectious ulcers include abrasions, Behcet’s disease and vulval carcinoma
A) Herpes simplex ulcers:
Is a sexually transmitted infection caused by HSV type II in 85% of cases. It appears as vesicles mixed with multiple small shallow ulcers on the labia and around the introitus. Concomitant lesions on the urethra, vagina and cervix may be found. These ulcers frequently coalesce to from large ulcers that resolve by crusting and healing in up to 3 weeks in primary infection. Recurrent attacks tend to be milder and of short duration (the virus being dormant in the sacral ganglia.
B- Lymphogranuloma venerium (LGV):
Is a tropical infection caused by Chlamydia trachomatis serotypes (L1,2 and 3). The infection persists and spreads by lymphatics to involve not only the vulval structures, but also the anus and lower vagina. The ulceration can be extensive but rather painless. Diagnosis is made by culture, complement fixation test and PCR.
C) Granuloma inguinule (Donovanosis) ulcers:
The infective organism is a gram negative encapsulated diplobacilli which stains with Gimesa or Leishman stain (Calymmatobacterium granulomatis). The ulcer is usually single chronic red ulcer with rolled edge and spreads directly rather than by lymphatics. The ulcers is painless and the regional lymph nodes are not involved in the early stage of the disease and not suppurate. Diagnosis is based on the presence of Donovan bodies within mononuclear cells .
D) Syphilis ulcers:
The infection is caused by spirochete, treponema pallidum, and it is identified in all lesions (Primary, secondary and tertiary). The primary lesion is chancre found most commonly on the vulva or lower vagina. The ulcer is painless, sharply defined with serpiginous edge. The inguinal nodes enlarge, hard and shotty but painless and do not suppurate.
Diagnosis during the primary stage is made by examining serum from the base of the primary chancre for the presence of T. pallidum using dark – ground illumination microscopy. Serological tests are positive 3-5 weeks after the infection. VDRL slide test is the most widely used but non-specific. The specific test is T. pallidum haemaglutination test (TPHA), however, it is the last test to become positive. Chancre
E) Tuberculous ulcers:
They are shallow superficial ulcers with undermined edges. They tend to spread slowly. They are discharge and tender. Blood – stained purulent discharge is frequent. diagnosis both bacteriologically and histologically. The finding of epithelioid clusters with giant cells is highly suggestive but not conclusive unless tubercle bacilli can be demonstrated in stained preparation. Ziehl – Neelson is satisfactory.
F) Bilharzial ulcers:
Adult S. haematobium worms live in the genitourinary veins. The lesions are predominant in hollow viscera of the genital tract from the vulva to the ovaries can be involved. The commonest genital site is the cervix. Vulval lesions are mostly seen in children. Vulval ulcers are chronic with surrounding induration which simulates malignancy. Sanguineous discharge is common. Diagnosis by examination of biopsy material. The inflammatory reaction shows each bilharzial ovum surrounded by giant cells, epithelial cells, lymphocytes and eosinophils.
G) Aphthous ulcers:
Simple aphthous ulcers similar to those seen in the mouth may appear on the vulva. They are small painful ulcers with a yellow floor. The ulcers are less painful than herpetic ulcers and with no constitutional upset.
H) Noma vulvae (Tropical ulcers):
Acute necrosis of vulval tissues associated with fusospirochaetal infection (anaerobic fusobacterium and spirochete lining in symbiosis). Some consider them a secondary invaders rather than the causal agents, and can arise as a complication of malnutrition and debilitation.
I) Crhon's disease ulcers:
Crhon's disease may affect the vulva in 25% of cases and sometimes precedes the intestinal symptoms by few years. The ulcers are knife cut and sometimes edematous, irregular with discharging sinuses.
J) Traumatic ulcers:
The ulcers may have a traumatic basis and sometimes self – inflicted e.g prompted by sexual perversion or other psychological upsets.
K) Malignant ulcers:
Vulval invasive squamous all carcinoma is common in old age and can present with an eroding ulcer with everted edge. The floor is friable and bleeds on touch and the bases is indurated and even fixed to the underlying tissues. The inguinal lymph nodes are usually enlarged, however, both lymphatic metastasis as well as the associated secondary infection represent the underlying cause. The basal cell carcinoma is unusual vulval lesion (2% of vulval malignancies) with the usual features of rodent ulcer.
Malignant ulcer of vulva
1- Infectious ulcers:
Infectious ulcerative lesions of the vulva, commonly involve the lower part of the vagina especially those associated with sexually transmitted infections such as herpes simplex (HSV), primary syphilitic chancre and LGV.
2- Traumatic and trophic ulcers:
Traumatic ulcers are inflicted due to articles inserted in the vagina with the subsequent pressure necrosis and secondary infection. Among primitives, nuts, seeds and plant leaves are inserted in the vagina for supposed therapeutic effects. Among high cultures toilet and hygiene articles are mostly inserted. In children, all types of articles can be inserted accidentally .
Other traumatic lesions include those self–inflicted, following accidents, rape and child birth. Burns also, can result in denudation of large areas of vaginal wall with cellulitis and deep ulceration. Burns are due to idiosyncrasy to chemicals (contraceptives or antiseptics), radium, clumsy use of electrocautery or diathermy. In rural Arab localities, the custom of using rock – salt into the puerperal vagina with the assumption that this restore the vagina to its nulliparous dimensions is still practiced. Ulcerative lesions also, can complicate the anatomical and vascular changes with accompany utero–vaginal prolapse.
3- Malignant ulcers:
Primary invasive squamous cell carcinoma of the vagina is rare (1-2% of genital malignancies), occur in old age posterior vaginal fornix. It usually takes the form of ulcer with raised edges and hard base which becomes fixed to the underlying structures at an early stage.
4- Idiopathic ulcers:
There are some isolated cases of troublesome chronic multifocal vaginal resistant ulceration, the cause of which is unknown.
1- Infectious ulcers:
As with the vagina, the sexually transmitted infections such as herpes genitalis (HSV)and syphilis can cause ulcerative lesions of the portio – vaginalis of the cervix, however, with some variable clinical presentations e.g. on the cervix the primary chancre may be mistaken for erosion and sometimes presents as a diffuse induration of the cervix. The herpetic lesions are frequently less painful (cervical involvement occurs in approximately 80% of primary infections) and in such case vaginal discharge is a frequent symptom.
Tuberculosis of the cervix is commonly a cauliflower growth rather than an ulcer and is seen in nearly 3-5% of all cases of genital T.B.
3- Traumatic and trophic ulcers:
Are less frequent in the cervix. Puerperal lacerations, often associated with chronic cellulitis, can result in denudation which can be either partial (desquamation of a part of the squamous epithelium), or total involving the whole layers and leading to true ulceration (infected erosions).
2- Malignant ulcers:
Carcinoma of the cervix is either squamous cell (80 – 90%), or columnar cell (5 – 10%). The remainder are of mixed type and include many varieties. Both lesions, the squamous cell carcinoma and adenocarcinoma can be ulcerative.
Malignant cervical ulcer