Genital herpes
Definition
Sexually transmitted infection with HSV-1/2
causing oral, genital and ocular ulcers
Epidemiology
Pathophysiology
Transmission
Mucosal surfaces or breaks in skin
Ulcers or asymptomatic shedding (commonest)
Sexual contact (vaginal, anal, oral sex)
Oral (kissing, sharing cutlery etc.)
Vertical (mother to child)
Primary infection
Primary infection: arises ~7d after infection, can last 3wk
Agent
Herpes simplex virus 1 or 2
HSV-1 usually causes oral
HSV-1 and 2 equal contribution to genital herpes
HSV-2 typically more severe genital disease
Commonest ulcerative STI
70% HSV-1 and 30% HSV-2 Ab +ve
Young adults (15-24y)
Mostly heterosexual
Clinical
presentation
Asymptomatic
80% patients
Risk factors
Previous STIs
Recent new/multiple sexual partners
Young adults
UPSI
Early age first intercourse
HIV+
Immunocompromised
MSM
Recurrent infection
Tirggers: local trauma, UV light, smoking, alcohol,
tight clothing, stress
Reactivation with symptomatic lesions or asymptomatic infectious viral shedding
Symptomatic often less severe than primary and lasts 4-7d
Diagnosis
Management
Complications
Prognosis
Autoinnoculation
Fingers (herpetic whitlow),
adjacent skin (thighs)
Autonomic neuropathy
Urinary retention
Superinfection
Strep, candida
Aseptic meningitis
Primary infection, recurrent
Neonatal HSV
Third trimester infection/recurrence
Chronic condition
Variable recurrence
Some asymptomatic, others frequent;
average 4/yr following symptomatic first episode,
but usually declines over time
HIV risk
Increases risk of HIV infection
(mucosal breaks)
Genital
Examination
Investigations
History
Medical
Conservative
PMH
Previous episodes, known HSV
Other STIs, previous cold sores
DH
Current meds, allergies
PC/HPC
Painful, itchy lesions, discharge,
dysuria, fever, malaise
Reproductive history
Gynae: menses, bleeding, contraception, smears
Obs: gravity/parity, delivery, complications (neonatal HSV)
SxH
Partners (regular/casual, gender, age)
Type of sex (vaginal, oral, rectal, receptive/passive)
Contraception (UPSI, barrier)
BBV risk (partner status, partners from abroad, prev HIV tests, IVDU, sex work, blood transfusions abroad)
SH
Occupation (sex work), living arrangements,
smoking, alcohol, drugs
External female/male genitalia
Bilateral erythema, blistering, ulceration,
inguinal LNs
PR examination
Erythema, blistering, ulcers
Speculum examination
Internal ulcers in vagina/cervix, discharge
Bedside
Obs (mild fever)
Swabs
Lesion swab (PCR for HSV/syphilis)
Genital swabs/FPU (NG/CT NAAT)
Bloods
BBV (HIV, HCV, HBV)
Urine
Dipstick, pregnancy test
Systemic
Antivirals
Indication: first episode <5d/new lesions still forming;
recurrent episode; prophylactic for frequent attacks (>6/y)
E.g. aciclovir PO 5-10d (primary/recurrent),
aciclovir PO BD (prophylaxis; regular review)
Self care
Salt water bathing (promote healing, prevent secondary infection)
Topical anasthetic if needed (dysuria etc.)
High fluid intake
Avoid tight clothes, towel sharing
Referral
Referral to GUM for diagnosis, management, FU
Analgesia
Indication: pain
E.g. paracetamol, ibuprofen
Information, advice, support
Explaination of herpes, cause, transmission, complications
Explain that -ve swab doesn't mean not have herpes
Explain first attack doesn't mean recent infection
No cure at present, explain possible recurrences
Transmission can occur when asymptomatic (use condoms),
high risk with lesions (avoid SI/close skin contact/sharing towels)
Abstain from SI until healed
FU ~1wk (symptoms, test results, STI screen, questions, advice)
Headache
Dysuria
Malaise
Tender LNs
Fever
Discharge
Vaginal/urethral
Pain
Tingling/burning in genitals, lower back, buttocks, legs
Ulcers
Site (external/internal genitals, anus), painful, bilateral/multiple, blistering, ulcerated, itchy
Latent infection
Dormant in local sensory ganglia
Asymptomatic