Although individuals with vulvar ulcers who are sexually active can have noninfectious causes of their lesions, they are most likely secondary to sexually transmitted infections with herpes and syphilis being most common depending on the population and location [3]. Table 16.2 represents the sexually transmitted infections that should be considered when seeing a patient with vulvar ulcers and their usual clinical manifestations. National data between 2007 and 2008 suggests prevalence rates of herpes simplex virus (HSV) type 2 of 16.5% among 15–49-year-old men and women in the United States, while prevalence rates of syphilis are much lower (0.08% of 18–49-year-olds from 2001 to 2004) [4]. These prevalence rates are driven by the lifelong latency of HSV as opposed to the definitive treatment of syphilis with antibiotics. Since 1988 there has been a decreasing trend of seroprevalence of HSV-2 [5]. Industrialized countries have also seen a decrease in HSV-1 at sexual debut prompting concern for increased numbers of adolescents who will be infected with HSV-1 genitally [6].

Both HSV-1 and HSV-2 can cause genital herpes and thus vulvar ulcers [7, 8]. Development of clinical signs and symptoms due to HSV genital infection begins after a brief incubation period (averaging just under a week but can be as long as 2 weeks). The virus replicates at the site of infection and travels via nerve fibers to the dorsal root ganglia where latency is established. Reactivation of the latent virus travels back along nerve fibers to the initial sites of infection [7]. While primary genital infection with HSV-1 is less likely to be symptomatic than HSV-2, the majority of primary genital HSV infections are asymptomatic. It is important to note, however, that asymptomatically infected individuals are potentially contagious and can transmit the virus to susceptible sexual partners [8, 9]. When symptoms are present, they can include local irritation (burning or itching) and vesicular lesions that can be unilateral but are more often bilateral and are in different stages (papules, vesicles, ulcerations, crusting, and eventual resolution). While the vesicles generally heal within 10 days, new vesicles can occur over 1 or 2 weeks, so it can take up to 3–4 weeks for complete resolution of all HSV lesions. The lesions are painful and can involve any part of the genitoanal area. The presence of the lesions can contribute to dysuria and subsequent urinary retention. Other symptoms that are reported in those with symptomatic primary infection include inguinal lymphadenopathy, fever, malaise, and headache. More serious complications include meningitis, neuralgias, and transverse myelitis [7–10]. There is evidence that primary genital infection with HSV is more likely symptomatic in persons without antibodies to either HSV-1 or HSV-2 [8]. Recurrent HSV can be asymptomatic (causing only viral shedding and risk of sexual transmission) or symptomatic (usually unilateral genital lesions are preceded by a prodrome of tingling or genital irritation). These lesions are generally less severe, do not necessarily look like classic herpes lesions, and can be mistaken for other genital lesions; thus, if a diagnosis of genital herpes has not yet been established, testing should be done.

There is a high index of suspicion for primary genital herpes in the young woman in this case. While this is not a new sexual partner, they recently stopped using condoms, which provide some protection against genital herpes [11, 12]; he could have had a new partner (and thus new infection, which could have been asymptomatic) since going to college, and she had unprotected sex with him within the last week. While she reports that when she and her partner started having sex he “got tested for everything,” this rarely involves testing for HSV since screening without symptoms is not recommended. Additionally, the constellations of symptoms and signs that she presents with (flu-like illness, bilateral vulvar ulcerations, inguinal lymphadenopathy) are suggestive of primary genital herpes infection. Syphilis is unlikely given that it is more common in men who have sex with men and is associated with a single localized lesion or chancre. The lesions of primary syphilis are also less likely to be painful. The other possible sexually transmitted infections are less likely in an adolescent with one sexual partner but merit consideration. Chancroid is much more common in regions of Africa and the Caribbean, and the adenopathy is suppurative. Chancroid should be considered if there is no evidence of either HSV or syphilis on testing [3]. Similarly, granuloma inguinale is rarely seen in the United States, and the lesions are painless. The clinical hallmark of lymphogranuloma venereum is the tender lymphadenopathy rather than the genital lesions [3].

Nonsexually transmitted infections should be considered given that the patient’s boyfriend was not feeling well. Reactive genital lesions caused by various nonsexually transmitted pathogens are referred to as Lipschutz lesions, particularly those associated with Epstein-Barr virus (EBV) [1, 13]. EBV is commonly seen in the college population. Genital ulcers may occur in 10–30% of individuals who have EBV and do not have to necessarily occur with more classic symptoms of EBV such as fever, rash, or pharyngitis [13]. However, her boyfriend does not have any symptoms suggesting EBV.

In considering noninfectious etiologies, autoimmune diseases are important to consider given the patient’s mother’s recent diagnosis of systemic lupus erythematosus. Bechet’s disease, a systemic and multisystem vasculitis, must be considered. While genital lesions can be the initial presentation of the disease and are the second most common finding seen, this patient has no other clinical manifestations of Bechet’s (recurrent oral ulcerations, recurrent genital lesions, eye lesions, and positive pathergy test), and the patient would need to be followed for this diagnosis over time [13]. Crohn’s disease should also always be considered in an adolescent with genital ulcers. This chronicinflammatory bowel disease can have genital ulcers as an extraintestinal manifestation when gastrointestinal symptoms (diarrhea, blood in stool, weight loss) are absent; however, it is more common to see these genital lesions in patients with colonic involvement. This includes not only bloody stool and abdominal pain but also perianal lesions [1, 13]. This patient does not have any of these associated findings. The patient denies any trauma, medications that would cause vulvar ulcers, or lesions that would be consistent with aphthosis (recurrent ulcers, present orally and genitally).