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Primary syphilis is characterized by the development of a chancre, a painless ulceration that usually begins as a papule at the site of inoculation. The ulcer has a smooth base and firm, raised borders with no exudate or inflammation. Spirochetes are present in the lesion, which is highly infectious. The chancre appears wherever the inoculum occurred; common sites include the external genitalia, cervix, mouth, perianal area, and anal canal. Lesions may become secondarily infected, especially in the oral and perianal region. Painless regional lymphadenopathy is often present.

Because of its painless nature, the chancre may go unnoticed, resulting in lack of diagnosis and continued transmission. Furthermore, lesions are frequently atypical or absent in primary syphilis, especially with a low inoculum, intercurrent antibiotics, or previous syphilis infection. Multiple chancres may also occur, particularly in patients with HIV. Chancres typically heal within 2 to 8 weeks. In immunocompromised patients, such as those with HIV, however, chancres may take longer to heal and are often present when manifestations of secondary syphilis begin.

The lesions of primary syphilis must be distinguished from genital ulcers caused by herpes simplex and Haemophilis ducreyi (chancroid), which are most often painful. Other potential mimickers of primary syphilis include lymphogranuloma venereum, granuloma inguinale, trauma, malignancies, and atypical non-venereal infections such as tularemia.


Men's Health