A 67-year-old woman presented with a painful genital ulcer. She denied new sex partners and previous genital lesions. William Keenan, MD, of Williamsport, Pa, noted the ulcer with notching in the labia, which suggested an infiltrative process. An excisional biopsy of the ulcer revealed vulvar intraepithelial neoplasia. The cause of this vulvar cancer is uncertain, although human papillomavirus is known to play a key role in its development.1 The diagnosis is confirmed with biopsy. Treatment consists of surgical excision. Although the biopsy margins were generous, the lesion extended to these margins and a partial vulvectomy was required. This patient’s condition illustrates that not all genital ulcers result from sexually transmitted diseases.