Very nervous about chancre-like ulcer on penis head

[gnozt777]

Hi Doc, hope you can help.

Exposure:

Received protected oral sex from masseuse in Thailand. Didn't check condom, looked fine. She may have licked my scrotum. When removing condom, her saliva may have came into contact with my penis. I'm uncircumcized.

Symptoms:

Seven weeks later, discovered a lesion on the side of my penis head. About 1/3 inch in size, oval-shaped, dark brown/reddish in color. The lesion did not appear raised, did not seem to have any blisters either. I first discovered it whilst masturbating and after I ejaculated, experienced intense pain in the lesion. The pain subsided after that, but the lesion remained tender. A day later, after the doctor prescribed biotine cream and acyclovir, the lesion turned into an ulcer. Ulcer had a whitish/yellowish inside - could be due to the cream. Still not raised, but I could be wrong. But it just looked like an open wound.

Diagnosis:

Got tested at 7-week mark for everything: Chlamydia (Urine), Syphilis (RPR), Gonorrhea (Urine), Herpes (TSST blood test & tzanck culture test). All came back negative. Doctor didn't think it looked like a chancre; said it could be herpes. When the nurse scrapped the lesion for the herpes test culture, the lesion hadn't turned into an ulcer yet. The lesion scabbed a few days after I started the medication. A week later, the scab fell off, probably due to rubbing against my boxer shorts. Now, the area where the lesion was has lost its color - probably quite natural. As I was very nervous, I went for a Syphilis rapid test at 8-week and it was also negative.

Questions:
1) Could you tell me if this sounds like either syphilis or herpes to you?
2) I've tested at 7 weeks for both. Given that symptoms are present, when do you think I should test until results are conclusive?
3) Are there any other tests you'd recommend I take?
4) Any other advice you can dish out would not fall on deaf ears....

Thank you.

[ohnojustmyluck]

Wow, I'm going through a very similar situation.  However, I have three sores.  I've been tested and everything came back negative.  I too self diagnosed as Balanitis (of course, prior to the test coming back negative, I thought I had all sorts of things). Nevertheless, I am going to see a dermatologist.  The sores are slowly clearing, but I've had them since the end of January and it's freaking me out.

[Edward W Hook, MD]

Sorry, looking at a picture on the web site is not the same as an examination. Balanitis could be contributing to your problem.  Talk to your doctor about it.  EWH

[gnozt777]

I think I managed to self-diagnose my condition. I reckon it's balanitis...!

Found the following picture on the web and the far left dark red lesion is IDENTICAL to the one I had in the early stages (same location too!)

http://www.dermis.net/dermisroot/tr/15307/image.htm

Don't suppose you could have a look and see if it looks remotely like syphilis/herpes?

Bless...

[Edward W Hook, MD]

You're correct. I was just going too fast.  No change in my advice however.  EWH

[gnozt777]

By the way, the TSST (Type-Specific Serology Test) is for herpes, not syphilis. I've only taken RPR and one Rapid ELISA test for Syphilis.

[Edward W Hook, MD]

While the concern about a prozone is reasonable for the RPR test, it is not a problem for the treponemal tests like the TSST.  Thus you do not have syphilis.  As I said, I do not doubt that you have a lesion and that it is of concern to you.  It is not an STD.  You need to get this sorted out with a clinician, preferrably a dermatologist.  EWH

[gnozt777]

Hi Dr EWH,

First of all i owe you an apology - I'm sorry if my request for Dr. Handsfield is seen as inappropriate. From your magnanimous response, I know you didn't take anything to heart. You are an excellent doctor and one with a big heart as well.

I wish to inform you also that my doctor made me take the 3-months RPR and TSST for syphilis and herpes respectively. As you have predicted, both were negative.

I'd be lying if I tell you that alls fine and well in my head now. The cause of my lesion is baffling and a worry, especially at a time when I'm trying for a baby with my partner (I have sworn to cut out my philandering way by the way). It has never happened to me and this develops after the one time I strayed. Coincidence?

My ONE outstanding question is this notion of 'prozone' which I have read time and again in the archives. Is there a way I can rule myself out of such exception? Is there an outer testing limit beyond 3-months for people like me who develop chancre-like lesions?

Thank you. This, I promise is my final entry. I thank you once again for helping me through what has been an unbelievably difficult time in my life.

Best wishes.

[Edward W Hook, MD]

Sorry, Dr. Handsfield and I both just take the tests as we come to them.  You got me.  for your information however, Dr. Handsfield and I have never disagreed on a management answer.  You still do not have syphilis.  If you still have lesions, you need to see a dermatologist.  EWH

[Edward W Hook, MD]

Sorry, Dr. Handsfield and I both just take the tests as we come to them.  You got me.  for your information however, Dr. Handsfield and I have never disagreed on a management answer.  You still do not have syphilis.  If you still have lesions, you need to see a dermatologist.  EWH

[gnozt777]

I'm extremely anxious as you can see. I wonder if you could be so kind to look over my posting and spare me your thoughts...? Please...?

Do you also feel that I don't warrant further testing despite the outbreak of my penis ulcer - which I might add resemble the textbook appearance of a syphilitic chancre?

I would be extremely grateful for any comments. I appreciate your kindness and all that you do for people like me - really.

(Dr. HHH, my initial question was meant for you but Dr. Hook answered it, which I'm thankful for, but honestly, I was hoping you could have advised me. I'm thankful to Dr. EWH, but because I've been following so many of your posts, I was hoping for your wise words deep down)

Gratefully yours.

[Edward W Hook, MD]

The sore was unlikely to be either herpes or syphilis to start with.  You now have test results which prove that it is not.  You do not need further testing.  If the ulcer reappears, you need to see a dermatologist.  This is not an STD.  EWH

[gnozt777]

I've just received my results from my 10.5 week test for both syphilis and herpes - both were negative. I know you advised against testing for syphilis but my doctor insisted on a 3-month confirmation mark, which I'm still 2.5 weeks short. In view of my penile ulcer at 7 weeks, my symptom warrant further testing? Thank you. P/S- i wish to be as close to 100% confirmation as my partner and i are trying for a baby.

[Edward W Hook, MD]

The lesion you describe would be unusual for herpes and timewise it would be quite late. Nonetheless, it  is reasonable to get tested for herpes.  As far as cultures, the earlier you are  tested, the better the test result.  A culture is a better test than just the Tzanck test.  Please let us know the outcome of your tests.  I suspect they will be negative. EWH

[gnozt777]

Dr. I've just discovered new lesions around my penis urethra today. This is abt 22 days after I first discovered my other lesion. The lesion is dark brown in colour, can't really determine if there are small blisters or not. The lesion looks like wrinkly skin. It generally doesn't hurt, but it irritates a little when I rub it against my boxer shorts. Is it evidence that it is most likely genital herpes despite my 7 week negative result? Also, I plan to go to the doctor tomorrow to have it checked out and do another herpes test which will be 10.5 weeks. The lesion is still not an ulcer (yet), is it too early to do a tzanck culture test? Should I wait until it turns ulcerative? Thanks for your advice. I'm very scared at the moment.

[Edward W Hook, MD]

The RPR does not detect chancroid but chancroid is very rare and very painful.  This is not chancroid.

Seven weeks after exposure, not symptoms.

EWH

[gnozt777]

Is that 7 weeks after exposure, or, 7 weeks after the onset of symptoms (i.e. ulcer)? Does it make a difference?

[gnozt777]

Sorry Dr. Hook, one FINAL question... I promise, this is the last...
How about chancroid? Will I be able to rule that out too? Does the RPR detect that as well? Thanks.

[gnozt777]

Thanks Doctor for your generous advice. I will re-test for HSV and will only post again if it's a positive result.

[Edward W Hook, MD]

1.  At 7 weeks all syphilis tests and about 95% of HSV blood test would be positive (half of HSV blood tests are positive at 21 days).  The yield of further testing in such a low risk situation is tiny.  If you do get re-tested, I would not bother with syphilis only HSV.

2.  Sorry, trying to make such a guess would not be fair to you and improper of me.  The list of dermatological problems (infectious and otherwise ) which can casue genital lesions is huge.  Again, should it recur, before you do anything for it and ASAP, seek the opinion of a dermatologist(although personally I doubt that it will recur).  EWH

[gnozt777]

Thanks, Dr. Hook. Your comments are like gold dust...

Few follow-up questions if I may...

1. Could the late outbreak have delayed the seroconversion process such that 7 weeks is too early for me to test positive? Am considering re-testing at 13 weeks. Think there's a chance I might seroconvert by then?

2. Have you come across cases like mine, where patients have chancre-like ulcers and test negative for both syphilis and herpes? If so, any suggestions what it could be? Being an experienced masturbator, I very much doubt it was abrasion. Definitely some kind of viral/bacterial infection.

Thanks once again Dr Hook. All best.  

[Edward W Hook, MD]

While the lesion you describe could have been herpes or syphilis by description, the fact that your herpes and syphilis tests are negative prove that you do not have them.  By and large the tests are far better than observation. Taken as a whole, your tests are conclusive at this time.


What could it have come from, perhaps from the trauma/unintended abrasion which may have occurred during masturbation.  

Other tests- none.  If the lesion recurs see a physician, possibly a dermatologist if possible, as quickly as possible. My guess however is that it will not recur.  Therefore, you should just work to put this behind you.  

Hope this helps.  EWH

[gnozt777]

Also, I have tested for genital herpes in the past and results have always been negative.
Thought I'd mention that.