Case 4

82-year-old man presents with a small non-healing ulcer on the frenulum of his penis; the lesion apparently appeared after minimal trauma.

History

Do you have any other problems?

Yes, I have a swelling in my left groin, but it isn't painful.

Search for other findings which fit with the clinical problem.

Have you have unprotected sex recently?

No, I was at a Thai massage parlor 2 months ago but only had oral sex there.

Most often this disease is transmitted by unprotected genital sexual contact.

Have you had any other sexual contact?

Yes, I had intercourse with my regular partner about a week ago.

Always repeat the questionoften the first answer is not complete.

Are you married or do you have a regular sexual partner?

I have been married for 61 years but I have always had something on the side.

Search for source of infection, as well as for those who could have become infected.

Have you had multiple sexual partners?

I have had sex with 4 different women in the past 6 months but I had unprotected sexual contact only with my wife.

Important for determining risk-taking behavior.

Have you ever had a venereal disease?

Yes, I got shots for syphilis about 35 years ago.

Important for determining risk-taking behavior.

Have you ever had a HIV or syphilis blood test?

I have had a syphilis test, but never an HIV test. I didn't think it was needed.

These two important diseases are usually sexually transmitted.

Lesion

Choose the right efflorescences:

Ulcer

Erosion / Excoriation

No efflorescence

Pustule

Papule (nodule and also plaques)

Diagnosis

Choose the right diagnosis:

Lymphogranuloma venereum (LGV)

Gonorrhoea

Chancroid

Syphilis

Therapy

Choose the right therapy(ies):

1 g azithromycin p.o.

None needed; the disease is harmless.

Darkfield examination, syphilis serology. Then 2.4 million units benzathine penicillin i.m. Examination and treatment of partners, arrange for followup

Darkfield examination and systemic antibiotics.

Urethral smear, Gram stain and culture or PCR.Then ceftriaxone 250 mg i.m. or azithromycin 1.0 g p.o. Check sexual partners and arrange for follow-up.