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Year : 1992  |  Volume : 58  |  Issue : 4  |  Page : 246-251

A microbiological study of penile ulcers with clinical correlation

Correspondence Address:
K D'souza

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A microbiological study was conducted on 100 men with penile ulcers. Thirty eight cases with infection due to H ducreyi, 12 cases with Treponemal infection, 3 with Herpes and 2 with Calymmatobacterium granulomatis were detected. N. gonorrhoeae was isolated from 2 cases with ulcer confluent with the urinary meatus. Mixed infections were identified in 17 cases. No cause of ulceration could be found in 26 cases. A polymicrobial flora was identified in the ulcers of all patients. A past history of penile ulcers was more common in patients who were HIV antibody positive.

Keywords: Penile ulcers, Microbiological study

How to cite this article:
D'souza K, Deodhar L P, Tendulkar U M. A microbiological study of penile ulcers with clinical correlation. Indian J Dermatol Venereol Leprol 1992;58:246-51

How to cite this URL:
D'souza K, Deodhar L P, Tendulkar U M. A microbiological study of penile ulcers with clinical correlation. Indian J Dermatol Venereol Leprol [serial online] 1992 [cited 2020 Dec 5];58:246-51. Available from:

  Introduction Top

Sexually acquired penile ulceration is very common in our country. Reports on penile ulcers from most countries besides India do not include the other organisms besides the established pathogens [1],[2],[3],[4] and most of them are based on clinical diagnosis rather than microbiological aspects. [5],[6] Both these data are however sparse in Indian literature and therefore the present study was undertaken.

  Material and Methods Top

One hundred men (age 16-48 years, mean 24.9) with penile ulcers were selected. Patients were excluded if they were using topical or oral antimicrobials for the current problem: Selection of controls was based on absence of symptoms or signs of venereal disease and abstinence from sexual intercourse for more than 1 week.

The ulcer of each patient was cleansed with gauze-piece soaked in saline and the following samples were collected. (1) Two smears were prepared to be stained by Gram's and Giemsa method. (2) Wet preparation was made from the exudate of the ulcer and observed under dark-ground illumination. (3) A piece of granulation tissue was taken from the ulcer and crushed between 2 slides so as to get impression smears for Giemsa staining. (4) Three saline soaked swab scrapings were inserted into Stuart's transport medium and one scraping taken separately for culture. (5) 5 ml blood was drawn into a sterile test tube and allowed to clot for culture and serology.

In the case of controls, swabs were taken from those regions where ulcers are frequently encountered (glans, prepuce, shaft, coronal sulcus).

Culture media used were Blood agar, MacConkey agar, Thayer-Martin medium, Ureaplasma broth, Sabouraud's dextrose agar, clotted blood, Mueller-Hinton blood agar (MHBA) and Brain-Heart infusion blood agar (BHIBA). Mueller-Hinton agar supplemented with Hemin, L-glutamine, defibrinated rabbit's blood, vancomycin. Brain-Heart infusion agar supplemented with Hemin, defibrinated rabbit's blood, yeast extract, vancomycin [8] and clotted blood [9] were used to culture H ducreyi. Thayer-Martin medium and clotted blood were incubated at 37°C in a candle-jar, MHBA and BHIBA plates were incubated at 35° C in a candle jar with humid conditions for a week. Isolation of anaerobes was not attempted. After the required period of incubation, colonies on various media were subjected to standard biochemical tests for identification. Subculture on to MHBA and gram-stained smears were prepared from clotted blood. Gram-stained smears were examined for typical `railroad tract' arrangement of H ducreyi.

Biochemical tests used for identification of H. ducreyi were oxidase, catalase, nitrate reduction, [10] X and V factor requirement test [11] and the carbohydrate fermentation test. [12]

A portion of the serum was screened for anti-HIV by ELISA test (vironostika) and V D R L test.

  Results Top

Seventy patients were unmarried and belonged to low socio-economic status. Ninety eight patients reported to have acquired infection from sex-workers. Seventy one of these had more than a single exposure. Thirty eight had previous history of penile ulcers. The incubation period (calculated as the time interval from the most recent sexual contact to the appearance of the ulcer) varied from 1 day to more than a month. Fifty nine patients had ulcers accompanied with inguinal lymph node involvement, of these 32 showed bilateral and 27 showed unilateral enlargement. Suppuration and rupture of a fluctuant lymph node was noted in 1 case. Fifty six patients had multiple ulcers.

The clinical correlation with microbiological findings is given in [Table - 1]. The number of ulcers ranged from 1 to more than 6. The common sites where ulcers were encountered were prepuce (38 cases), mixed sites (19), glans (17), coronal sulcus (11), intrameatal (7), shaft (5) and frenulum (4).

Sole pathogen could be identified in 57 cases as shown in [Table - 2]. Mixed aetiologic agents were identified in 17 cases as shown in [Table - 3]. In 26 cases no pathogen could be identified. Chlamydial inclusion bodies were identified in 3 cases with other pathogens.

In 52 cases clinical diagnosis did not agree with microbiological findings [Table - 4].

In the control group which comprised of 31 subjects, no established pathogens of penile ulcers were identified. The penile microflora of patients with ulcers reflected the flora of normal counterparts as depicted in [Table - 5].

Twenty seven patients were reactive for V D R L (27%) as against 4 among the controls (12.9%). Nine patients were positive for anti - HIV on 2 occasions, 8 of these gave a past history of penile ulcers (88.8%). Thirty of the 91 seronegative patients (32%) gave a past history of penile ulcers. No HIV antibody was detected among the controls.

  Comments Top

Maximum number of patients in this study were from the sexually active age group. As expected, more number of patients diagnosed as syphilis had single ulcer and more number of patients diagnosed as chancroid, donovanosis, and mixed infection showed multiple ulcers. The absence of inguinal lymph node involvement in any of the diagnosed cases of donovanosis is typical of the condition.

Chancroid was the commonest cause of ulcers (55% proven on culture). Datta [13] and Kumar et at [1] reported that H ducreyi was the cause of 15% and 23.14% of genital ulcers (using only smears for diagnosis) respectively. Sehgal et a t [13] found chancroid to be the cause of 44.9% of ulcers. Chancroid was identified in 62% genital ulcers in Kenya [14], 1-2% in the USA, [15] and 28% in England. [2]

We encountered 21 cases of syphilis (21%), in comparison using the dark-field technique Kumar et at report 14.84% and 41.4% by Datta. In the USA syphilis accounted for 17% ulcers and 22% in Gambia. [3]

We diagnosed 5 cases of genital herpes as against 21.02% by Kumar et al using Tzanck preparation. Clinically Datta found Herpes in 4.4% ulcers and 12.4% by Vijayaiakshmi. [6]

Climatic conditions influence the prevalence of donovanosis, most cases are reported among the coloured races. In India, it is more prevalent along the eastern Sea-Coast. [16] Donovanosis was the fourth commonest cause of penile ulcers accounting for 7%. Kumar et at reports donovanosis in 11.48% ulcers, 1.4% by Datta, and 3% of all STDs by Jeyasingh et al. [4] Clinically Vijalakshmi diagnosed the infection in 4.47% of ulcers.

Mixed infections were noted in 17% cases. Coexisting infections have also been reported by other workers. [12],[14] The cause of 26 cases of ulcers could not be established, as by Kumar et al in 12.89% and by Datta in 8%. No definitive diagnosis., could be made by Kinghorn et al in 13%, 23% by Nsanze et al, 40% by Barile et al. [8]

Like other workers, [14],[17] we found that clinical diagnosis has to be corroborated with microbiological findings. Apart from the established pathogens of penile ulcerations, a polymicrobial flora was identified in the ulcers of patients which reflected the normal flora of the genital area.

A high prevalence of past history of penile ulcer in HIV positive patients indicates that penile ulcers increase the risk for acquiring HIV, a finding in support to other studies. [18]

  References Top

1.Kumar B, Sharma V K, Malhotra S, Bakaya V. Pattern of Sexually transmitted diseases in Chandigarh. Ind J Dermatol Venereol Leprol, 1987; 53: 286-91.  Back to cited text no. 1    
2.Kinghorn G R, Hafiz S, McEntegart M G. Pathogenic microbial flora of genital ulcers in Sheffield with particular reference to herpes simplex virus and Haemophilus ducreyi. Br J Vener Dis, 1982; 58 : 377-80.  Back to cited text no. 2    
3.Mabey D C W, Wall R A, Bello C S S. Aetiology of genital ulceration in the Gambia. Genitourin Med, 1987; 63 : 312-5.  Back to cited text no. 3    
4.Jeyasingh P, Ramanaiah T B B S V, Fernandes S D. Pattern of sexually transmitted diseases in Madurai, India. Genitourin Med, 1985; 61 399-403.  Back to cited text no. 4    
5.Ganguli D D, Sundharam J A, Bhargava N C, Dey M M, Ravi S, Sharma V K. A study of behavioural aspects of sexually transmitted diseases. Ind J Dermatol Venereol Leprol, 1983; 49 : 11-6.  Back to cited text no. 5    
6.Vijayalakshmi K. Analytical study of 1,054 genital lesions. Ind J Dermatol Venereol Leprol 1972;38:125-31.  Back to cited text no. 6    
7.Vanden Berghe D A. Selenium and the growth of Haemophilus ducreyi. J Clin Pathol 1987; 40: 1174-7.  Back to cited text no. 7    
8.Barile M F, Blumberg J M, Kraul C W, Yaguchi R. Penile lesions among U S armed forces personnel in Japan. Arch Dermatol 1962; 86 273-81.  Back to cited text no. 8    
9.Borchardt K A, Hoke A W. Simplified laboratory technique for the diagnosis of chancroid. Arch Dermatol 1970; 102 : 188-92.  Back to cited text no. 9    
10.Oberhofer T R, Back A E. Isolation and cultivation of Haemophilus ducreyi. J Clin Microbiol 1982; 15 : 625-9.  Back to cited text no. 10    
11.Baker F J, Breach M R. Haemophilus and Bordetella. In : Medical Microbiological Techniques, 1st edn. Boston : Butterworths, 1980; 110.  Back to cited text no. 11    
12.Sng E H, Lim A L, Rajan V S, Goh A J. Characteristics of Haemophilus ducreyi. Br J Vener Dis 1982; 58 : 239-42.  Back to cited text no. 12    
13.DattaA K. Genital ulcers in male. IndJ Dermatol Venereol Leprol 1978; 44: 204-5.  Back to cited text no. 13    
14.Nsanze H, Fast M V, D'costa L J, Tukei P, Curran J, Ronald A. Genital ulcers in Kenya­clinical and laboratory study. Br J Vener Dis 1981; 57 : 378-81.  Back to cited text no. 14    
15.Chapel T, Brown W J, Jeffries C, Stewart J A. The microbiological flora of penile ulcerations. J Infect Dis 1978; 137 : 50-6.  Back to cited text no. 15    
16.Sowmini C N, Nair G M, Vasantha M N. Climatic influence on the prevalence of donovanosis in India. Ind J Dermatol Venereol Leprol 1971; 37: 111-4.  Back to cited text no. 16    
17.Khare A K, Bansal N K. Pseudogranuloma inguinale. IndJ Dermatol Venereol Leprol 1985;, 51 : 219-20­  Back to cited text no. 17    
18.Cameron D W, Simonsen J N, D'costa L J, et al. Female to male transmission of human immunodeficiency virus type 1 : risk factors for seroconversion in men. Lancet 1989; ii :403-8.  Back to cited text no. 18    


[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]

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