Penile ulcers
Written 3rd May 2020 - Last Update 30th August 2026
Penile ulcers
STIs: herpes simplex virus (HSV); syphilis; lymphogranuloma venereum (LGV); donovanosis; chancroid.
Other conditions: fixed drug eruptions; aphthous ulcers; trauma; carcinoma.
Diagnosis
| Infection | Site/specimen | Test |
|---|---|---|
| Herpes | Swab of base of ulcer or de-roofed vesicle | NAAT |
| Syphilis | Swab of base of ulcer; blood | NAAT; serology. If clinical suspicion of syphilis, refer to the syphilis guideline. |
| Donovanosis | Dry swab or punch biopsy of lesions | Histology has low-to-moderate sensitivity but is highly specific — requires an experienced histopathologist, as classic Donovan bodies may be sparse. NAAT is highly sensitive and specific but only available in research laboratories. |
| Lymphogranuloma venereum (LGV) | Swab from ulcer | NAAT (chlamydia) |
| Chancroid | — | If chancroid is suspected, seek specialist advice |
Management
| Infection | Recommended | Alternative |
|---|---|---|
| Herpes* | Initial episode: valaciclovir 500mg PO BD for 5–10 days. Recurrence — episodic: valaciclovir 500mg PO BD for 3 days; suppressive: valaciclovir 500mg PO daily for 6 months. | Initial episode: aciclovir 400mg PO TDS for 5–10 days. Recurrence — episodic: famciclovir 1g PO BD for 1 day OR aciclovir 800mg PO TDS for 2 days; suppressive: famciclovir 250mg PO BD for 6 months OR aciclovir 400mg PO BD. |
| Syphilis# | Benzathine benzylpenicillin 2.4 MU (1.8g) IMI stat, given as 2 injections of 1.2 MU (0.9g) | Discuss with specialist |
| Donovanosis | Azithromycin 500mg PO daily for 7 days, OR azithromycin 1g PO once weekly for at least 4 weeks until complete resolution of lesions | Doxycycline 100mg PO BD for a minimum of 4 weeks, until complete resolution of lesions |
| Lymphogranuloma venereum (LGV) | Doxycycline 100mg PO BD for 21 days | Alternative regimens are not recommended due to lack of efficacy data — seek specialist advice if needed |
| Chancroid | Azithromycin 1g PO stat, OR ceftriaxone 500mg in 2mL of 1% lignocaine IMI stat, OR ciprofloxacin 500mg PO BD for 3 days | Alternative regimens are not recommended |
Contact tracing
- Contact tracing is a high priority for syphilis, donovanosis, LGV and chancroid, and should be performed in all patients with confirmed infection.
- If a contact of syphilis is confirmed (i.e. the named contact names the index case), treat even if serology is negative — provided the contact was within the last 3 months.
- Contact tracing for herpes is not recommended.
*Limited evidence comparing aciclovir/famciclovir with valaciclovir suggests all are therapeutically equivalent for herpes; choice can follow dosing frequency the patient can adhere to. Initial episodes may need the longer end of the 5–10 day range.
#There is an ongoing Australian shortage of benzathine benzylpenicillin (Bicillin L-A) prefilled syringes as at mid-2026 (both strengths, into 2027) — check current TGA guidance and discuss alternatives with a specialist if supply can’t be obtained. Doxycycline can be used for non-pregnant patients unable to access penicillin (100mg PO BD for 14 days in early syphilis, 28 days in late/unknown-duration syphilis) after a penicillin-allergy assessment (e.g. PEN-FAST).