Syphilis presents with an easily overlooked ﬁrst stage and, if left untreated, can slowly progress to a disabling disease noted for central nervous system, cardiac, and musculoskeletal involvement. The primary lesion of syphilis, though readily noted by the male, is not infrequently overlooked by the female. It appears most commonly on the labia majora, mons veneris, clitoris, fourchette, and vaginal mucosa but can also be seen on the anus, rectum, pharynx, tongue, lips, ﬁngers, or the skin of almost any part of the body. The initial lesions ﬁrst appear 10 to 60 days (average, 21 days) after infection as a ﬁssure, abrasion, or nodule with slight erosion and may then develop the characteristics of a hunterian chancre; an orange-red, granular ulcer, round or oval in shape, 1 or 2 cm in diameter, with sharp margins, and an indurated base. Multiple chancres are sometimes seen, particularly within the labial folds.
Inguinal lymphadenopathy begins slowly, and by the sixth week after infection is usually well delineated. It appears as ﬁrm, painless, nonsuppurating nodes, from the size of a cherry to that of a walnut. Histologically, the chancre shows edema, congestion, and inﬁltration with lymphocytes, plasma cells, epithelioid, and giant cells. The initial lesions heal and may be associated with progression to a low-grade fever, headache, malaise, sore throat, anorexia, generalized lymphadenopathy, and a diffuse, symmetric, asymptomatic maculopapular rash over the palm and soles (“money palms”), mucous patches, and condyloma lata.
The Venereal Disease Research Laboratory (VDRL) and rapid plasma reagin (RPR) tests are nonspeciﬁc tests that are good screening tests because they are rapid and inexpensive. The ﬂuorescent treponemal antibody absorption or microhemagglutination Treponema pallidum tests are speciﬁc treponemal antibody tests that are conﬁrmatory or diagnostic and are generally not used for routine screening. Rather, they are useful to rule out a false-positive screening test, though reductions in the cost of these tests may change this role to one of screening as well. False-positive screening results may occur in patients with lupus, hepatitis, sarcoidosis, recent immunization, drug abuse, or during pregnancy. These test results may be falsely negative in the second stage of the disease as a result of high levels of anticardiolipin antibody that interferes with the test (prozone phenomenon). Up to 30% of patients with a primary lesion have negative test results. (Approximately 15% to 25% of patients treated during the primary stage revert to being serologically nonreactive after 2 to 3 years.) If neurosyphilis is suspected, a lumbar puncture with a VDRL performed on the spinal ﬂuid is required. (Unless clinical signs or symptoms of neurologic or ophthalmic involvement are present, cerebrospinal ﬂuid (CSF) analysis is not recommended for routine evaluation of patients who have primary or secondary syphilis.) Screenin for HIV infection should also be strongly considered.
The moisture, warmth, and irritation of the opposing surfaces of the vulva tend to modify the papules of secondary syphilis, which appear in this region. Through coalescence, hypertrophy, maceration, and ulceration, the typical condylomata (moist papules, syphilitic warts) are produced. These appear as multiple, slightly elevated, disc-shaped, round or oval lesions, of sizes varying up to that of a dime. They are often conﬂuent or in clusters, with a moist, slightly depressed, necrotic surface.
Condylomata lata may cover the vulva, perineum, perianal region, inner thighs, and buttocks and grow during pregnancy. The lesions are highly infectious.
Ulcerated and hypertrophic gummas of the vulva, as manifestations of tertiary syphilis, are rare. They are ﬁrm, massive growths, which may extend deeply into underlying tissues or may appear as multinodular ulcerated tumors involving part or most of the vulva. Secondary infections are common.