Vaginal ulcers are open sores that form on the mucosal tissue of the vagina or the external genital area (vulva). These lesions represent a break in the protective outer layer of the skin, exposing underlying tissue and often causing discomfort or pain. Since they can indicate a range of underlying health issues, from common infections to inflammatory conditions, any unexplained lesion warrants prompt medical evaluation.
Defining Vaginal Ulcers and Their Appearance
The appearance of the ulcer can vary significantly, offering initial clues to its underlying cause. Ulcers may be solitary or appear as multiple sores that cluster together, ranging in size from a few millimeters to several centimeters. The edges might be clearly defined and raised, or irregular and soft, while the base can be clean, purulent, or covered by a gray-white membrane. A key feature is the presence or absence of pain; some ulcers are tender, while others are completely painless.
Primary Causes of Vaginal Ulcers
Infectious Causes
The majority of vaginal ulcers are caused by infectious agents, primarily those transmitted through sexual contact. Herpes Simplex Virus (HSV), particularly type 2, is the most frequent cause, typically presenting as multiple, small, and painful superficial ulcers. These lesions often begin as tiny blisters that rupture quickly, resulting in shallow erosions, commonly accompanied by flu-like symptoms and tender lymph nodes in the groin. The primary stage of syphilis, caused by the bacterium Treponema pallidum, manifests as a single lesion called a chancre. This chancre is a firm, round, and painless ulcer with a clean base and a raised, hardened border. Another bacterial cause, chancroid (Haemophilus ducreyi), produces one or more painful, soft ulcers with ragged edges and a discharge.
Non-Infectious Causes
Non-infectious etiologies stem from systemic inflammatory or autoimmune disorders. Behçet’s disease, a form of vasculitis, frequently causes recurrent, deep, and painful genital ulcers that often heal with scarring, and are associated with similar sores in the mouth. Another inflammatory bowel disease, Crohn’s disease, can also lead to vulvar ulcers, sometimes preceding the onset of intestinal symptoms. These lesions may take the form of “knife-cut” linear ulcers in the skin folds or present as swollen, aphthous-like sores. Trauma, such as friction from tight clothing or intense sexual activity, and chemical irritation from hygiene products, also represent mechanical causes of ulceration.
Diagnosis and Medical Evaluation
The evaluation of a vaginal ulcer begins with a thorough physical examination and detailed patient history to assess the lesion’s morphology and identify potential exposures, such as whether the ulcer is painful or painless, single or multiple, or accompanied by systemic symptoms. Since clinical appearance alone can be misleading, laboratory testing is necessary for a definitive diagnosis. For viral causes like HSV, a swab from the ulcer base is analyzed using Polymerase Chain Reaction (PCR), which detects viral DNA with high sensitivity. Diagnosis of syphilis involves a two-step serology process, starting with non-treponemal screening tests (RPR or VDRL) and confirmed by a specific treponemal test (FTA-ABS). If an infectious cause is ruled out, a small punch biopsy may be performed to diagnose inflammatory conditions or exclude malignancy.
Treatment Approaches
Treatment for Infectious Causes
Treatment for a vaginal ulcer depends entirely on the specific underlying cause identified. For viral infections like HSV, oral antiviral medication (such as acyclovir, valacyclovir, or famciclovir) is prescribed to shorten the outbreak and reduce symptom severity. Patients with frequent recurrences may be recommended for suppressive therapy, involving a daily regimen of these antivirals. Bacterial etiologies, including syphilis and chancroid, are managed with antibiotics. Primary and secondary syphilis is typically treated with a single intramuscular injection of Benzathine penicillin G, while chancroid is often treated with a single dose of azithromycin or ceftriaxone.
Treatment for Inflammatory Causes
For non-infectious causes related to systemic inflammation, the focus shifts to managing the overactive immune response. Ulcers from Behçet’s disease or Crohn’s disease are often treated initially with topical corticosteroids to reduce local inflammation and pain. More severe inflammatory ulcers may require systemic anti-inflammatory medications like colchicine or immunosuppressive drugs. In refractory cases, biologic therapies, which target specific inflammatory pathways, may be used to achieve healing and prevent recurrence. General management for all ulcers includes proper hygiene and pain control.