GUD — Key Facts & Diagnosis

Clinical description

• Main symptoms: single or multiple sores, ulcers or blisters on any part of penis, vulva, vagina and surrounding skin.
• Most common causes in Malawi: Herpes simplex virus type 2, syphilis, chancroid (Haemophilus ducreyi).
• Less common: lymphogranuloma venereum, granuloma inguinale, Schistosoma haematobium (not sexually transmitted).
• Clinical picture varies greatly (number/shape of ulcers, pain, duration). Underlying cause cannot be reliably diagnosed from clinical picture alone.
• Syphilis rapid tests have no value for confirming/excluding syphilis in GUD patients — they do not influence treatment decisions.

Treatment

Treat if genital sores/ulcers are confirmed on examination. Always prescribe a complete treatment course. Consider adding empirical treatment of genital schistosomiasis for women with vaginal sores and potential exposure (praziquantel 40 mg/kg oral stat).

Standard syndromic treatment for GUD

• Benzathine penicillin 2.4 mega units IM stat.
• Ciprofloxacin 500 mg oral BD for 3 days.
• Acyclovir 800 mg oral TDS for 2 days.

First or severe episode of genital herpes requires an extended course: acyclovir 400 mg oral TDS for 10 days. Ciprofloxacin and doxycycline should be avoided in PBFW and children. If other STI syndromes are also present, add the standard treatment but do not duplicate the dose of antibiotics used for both.

3–5 day review

• Ulcers healed: no need to return.
• Ulcers improved: no further treatment; ask to return if not healed after 7 days.
• Ulcers not improved: treat for LGV and granuloma inguinale; refer for further investigation.

Partner treatment

Partner treatment (asymptomatic)

• Uncomplicated GUD: benzathine penicillin 2.4 mega units IM stat + azithromycin 1000 mg oral stat.
• Treatment-resistant GUD: azithromycin 1000 mg oral stat + doxycycline 100 mg oral BD for 21 days.

At every visit

HIV & ART status

• Ascertain HIV + ART status from health passport or self-report.
• Offer new HIV test for all unless previously diagnosed. Do not use coercion.
• New positive: active referral for ART initiation.
• New negative: refer/offer PrEP, VMMC, consistent condom use.
• Known positive: reinforce ART adherence or refer for re-initiation.

Hepatitis B

• Offer HBV rapid test for all patients born before 2002.
• HBsAg negative: refer for HBV vaccination unless previously completed 3 doses.
• HBsAg positive: refer for clinical and treatment assessment.

Syphilis screening

• Offer syphilis rapid test for concurrent asymptomatic syphilis (except in GUD/ARI where it does not influence treatment decisions).

Risk reduction & condoms

• Risk reduction counselling. Promote and dispense condoms.
• Promote VMMC for all non-circumcised men. Schedule appointment in 2 weeks.