Case 32: Genital lesion

Opening scenario

Eva Woods, a 17-year-old female, comes to the physician's office because of a genital lesion.

Vital signs

• Temperature: 97.7°F (36.5°C)
• Blood pressure: 115/80 mm Hg
• Heart rate: 68/min
• Respirations: 16/min

Examinee tasks

• Take a focused history.
• The patient's parents gave consent to perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

Patient instructions

• You are not aware of the meanings of medical terms (e.g., HPV vaccine) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: Ask “Will you tell my parents about this? I do not want them to find out!”

Hovering over the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form will not interrupt your progress.

History of present illness

• Chief complaint
• There is something on the skin in my genital area.
  • Describe skin change
  • I do not really know, I did not look closely.
  • Painful lesion
  • No.
• Onset
• It started 5 days ago.
• Constant/intermittent
• It is there all the time.
• Precipitating events
• I cannot think of anything.
• Progression
• No.
• Previous episodes
• None.
• Alleviating factors
• None.
• Aggravating factors
• None.
• Associated symptoms
• It has also felt weird when I pee for the past 5 days.
  • Frequency
  • Every time I have to pee.
  • Other urinary symptoms (e.g., bloody urine)
  • No.

Review of systems specific to genital lesions and dysuria

• Recent travel
• No, I have not been anywhere recently.
• Fever/chills
• No.
• Rash/skin changes
• No.
• Bowel problems
• No.
• Appetite
• Normal.
• Weight changes
• No.
• Recent infections
• I had two urinary tract infections in the past year, when peeing was pretty painful. But this time it feels different.
• Swelling in groin
• No.
• Pain in groin
• No.

Past medical history, family history, and social history

• Past medical history
• None.
• Allergies
• I am allergic to latex. I had to wear latex gloves in our biology lab and I got a horrible rash.
• Medications
• I take a birth control pill.
• Hospitalizations
• Only for the removal of my appendix.
• Ill contacts
• No.
• Past surgical history
• My appendix was removed when I was 10 years old.
• Family history
• My father has hypertension and diabetes.
• Work
• I work as a waitress.
• Home
• I live by myself in an apartment.
• Alcohol
• Maybe a beer every other day.
• Recreational drugs
• Never.
• Tobacco
• No I do not smoke.
  • Ever used tobacco
  • I stopped smoking 3 months ago. Before that I smoked a pack a day for 2 years.

Do not forget to ask a patient who claims that he/she is not currently smoking if he/she has used tobacco products in the past!

Sexual history, OB/Gyn

• Sexually active
• Yes.
• With whom
• I had multiple partners.
• Men or women
• Only men.
• Number of partners over the past year
• I had 8 different partners over the past year, often one-night stands.
• Protection
• I am on the birth control pill. I cannot use condoms because of my latex allergy.
  • History of sexually transmitted infections
  • No.
• Last menstrual period
• 1 week ago.
• Menarche
• I had my first menstrual period when I was 13.
• Duration of period
• About 4 days.
• Period regular
• Yes.
• How many tampons per day
• About 3 of the small ones per day.
• Vaginal discharge
• Sometimes I have a little bit of discharge. I had more than usual the past 4 days.
  • Appearance of vaginal discharge
  • Mostly it is white, but I also had some greenish discharge for the past 4 days.
  • Smell of vaginal discharge
  • It does not smell.
• Vaginal itching
• Yes, my whole genital area has been itchy for the past couple of days.
• Vaginal dryness
• No.
• Pregnancies
• No, thank god. I make sure to take my birth control pills every day.
• Abortions/miscarriages
• No.
• Vaccination against HPV
• Yes, I received a shot against the virus that causes cervical cancer.
  • Completed vaccination series
  • No, unfortunately I forgot to go to my doctor again.

You do not have to ask this minor about her last pap smear, as women in the US are only screened starting at age 21.

• Washed hands
• Used respectful draping
• Head, eyes, ears, nose, and throat examination
  • Inspection of the oropharynx
• Neck examination
  • Palpation of the lymph nodes of the head and neck
• Back examination
  • Examination for costovertebral angle tenderness
  Abdominal examination
  • Inspection of the abdomen
  • Auscultation of the abdomen
  • Percussion of the abdomen
  • Palpation of the abdomen
  • Palpation of the inguinal lymph nodes
• Skin examination

Make sure to use respectful draping when examining the inguinal area. A full abdominal examination should also be performed to assess for signs of pelvic inflammatory disease.

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the patient).
• Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
• Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
• Examinee discussed initial diagnostic impressions with the patient.
• Examinee explained the management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated the patient's agreement with the next diagnostic steps.
  • Examinee asked for consent to perform HIV test.
• Examinee asked about concerns or questions.

Counseling and challenge

• Examinee offered counseling on safer sex practices.
  • Examinee counseled the patient on the use of latex-free condoms.
  • Examinee recommended completion of HPV vaccination series.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: “Eva, I can understand your concern. While I would encourage you to share as much information with your parents as you feel comfortable, I am not allowed to share any information regarding contraception, pregnancy, and sexually transmitted diseases with your parents without your consent. So everything that you tell me about your current symptoms will be kept confidential, and I promise I will not speak with your parents unless you want me to do so. Do you have any other questions?”

If a minor is seeking medical care that is related to sex (contraception, pregnancy care, or STIs) or addiction, parental consent is not required and the information has to be kept confidential. However, the minor should be encouraged to discuss their issues with their parents. See also informed consent in minors.

Patient note

Differential diagnoses

1. Human papillomavirus (HPV) infection: HPV infection is the most common STI in the United States. Human papillomavirus, particularly types 6 and 11, cause condylomata acuminata , painless lesions on the vulvar, cervix, urethra (rare), and/or anal region that can also lead to pruritus and tenderness. The condition can be prevented by using condoms and completing the 2- or 3-shot series of the HPV vaccination. However, the condition is not typically associated with dysuria and vaginal discharge, making a coinfection likely in this case.
2. Syphilis: A chancre is caused by infection with Treponema pallidum, a bacteria that is transmitted through unprotected sexual intercourse. The condition manifests as a single red, round, and raised painless ulcer with an elevated edge on the vulva or cervix. However, the condition is often associated with inguinal lymphadenopathy, and vaginal discharge and pruritus are not typical features. An HPV infection is more likely to explain this patient's genital lesion.
3. Chlamydia trachomatis infection: Several serotypes of Chlamydia cause chlamydial genitourinary infections, one of the most common STIs. It can also manifest as urethritis and vaginal infection that present with (muco)purulent vaginal discharge and dysuria, as seen in this patient. Specific serotypes of Chlamydia can also cause lymphogranuloma venereum, a painless genital lesion that manifests as a transient small papule or ulcer on the posterior vaginal wall, cervix, and/or vulva. Lymphogranuloma venereum is seen primarily in tropical and subtropical countries, although the incidence is increasing among men who have sex with men (MSM) in the US. While it is likely that this patient has a chlamydial genitourinary infection, her genital lesion is unlikely to be caused by Chlamydia.

Always consider coinfection with multiple sexual transmitted infections, which can lead to various constellations of symptoms. It is also possible that patients may also have an asymptomatic coinfection that can only be diagnosed with appropriate testing.

Diagnostic studies

• Pelvic examination: to inspect the genital lesion and vaginal discharge and examine for signs of pelvic inflammatory disease.
• Rectal examination: to assess for lesions in the rectal area (e.g., often the cases in HPV infection).
• HIV test: should be performed in all high-risk patients; consent must be obtained before the test is performed.
• Rapid plasma reagin test: to test for syphilis.
• Dark field microscopy: definitive tests for detecting primary and secondary syphilis when a specimen can be obtained (e.g., exudative chancre, condyloma).
• Nucleic acid amplification tests for chlamydia and gonorrhea: to test for Chlamydia trachomatis and Neisseria gonorrhoeae infection.
• Urine dipstick, urinalysis: to assess for a UTI.
• Wet mount preparation with KOH test: to assess for different forms of vulvovaginitis (e.g., vulvovaginal candidiasis ).

Other differential diagnoses to consider

• Granuloma inguinale
• Gonococcal infection
• Vulvovaginal candidiasis
• Urinary tract infection
• See also genital lesions.

PAINLESS genital lesions include condylomata acuminata, granuloma inguinale, lymphogranuloma venereum, and chancre. PAINFUL genital lesions include genital herpes and chancroid.