Case 95

This 15-year-old girl had noticed a blister on her genitals. She scratched it and it broke but was not painful. No bleeding was noted. She had been having her menstrual periods for over a year and denied sexual contact. She has not noticed other blisters ‘down there’. She had no other history of diseases, although sometimes she had ulcers in her mouth. She asked you to examine her private parts and you noted a non-tender, ulcerated lesion on her left labia majora shown (Image 95). There was no vaginal discharge or vesicles present. There was no palpable inguinal lymph-adenopathy. No ulcerations were noted in her mouth or pharynx. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig95.jpg"/>

What does the image show?

Is this caused by sexual contact?

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The image shows an ulcer on the non-mucosal labial skin. There is no vesicle fluid present and there is no induration or signs of bacterial infection. This ulceration is not specific for sexually transmitted disease; while herpes viruses such as herpes simplex types 1 and 2 can cause painful vesicles, their presentation varies based on location. ¹ Tests appropriate for this situation include viral culture as well as screening for additional sexually transmitted infections.

Non-sexual causes for this type of lesion are common. In one series, ² extensive workup failed to reveal a specific infectious or autoimmune aetiology in all but one patient, who was diagnosed with acute mycoplasma pneumonia. Acute genital ulcers in young girls who are not sexually active likely represent a form of idiopathic vulvar aphthosis. When present with other ulcerations this has been called Behçet’s disease, which is characterized as a triad of symptoms that include recurring mouth ulcers (aphthous ulcers, canker sores), genital ulcers and inflammation of a specialized area around the pupil of the eye termed uveitis. The cause is not known. Both inherited and environmental factors are suspected to contribute to its development, but it is not contagious. The disease is relatively rare but is more frequent and severe in patients from Eastern Mediterranean countries and Asia than in those of European descent. Evaluation of a first episode of acute genital ulcers with mild prodromal symptoms should be limited. Treatment consists primarily of supportive care and symptom relief.