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Genital Herpes

Essentials

Genital herpes should be kept in mind as a differential diagnostic alternative in a patient with recurrent indeterminate symptoms in the genital area.
Antivirals are effective in relieving the symptoms and preventing transmission Antiviral Treatment for Genital Herpes.

Aetiology

In most cases genital herpes is a chronic sexually transmitted infection caused by the Herpes simplex virus 2 (HSV-2). However, more than one third of the infections are nowadays caused by HSV-1. After infection the virus always remains latent in the body.

Epidemiology

About 13% (estimate) of the world's population aged 15-49 years were living with HSV-2 infection in 2016 http://www.who.int/bulletin/volumes/98/5/19-237149.pdf.
The virus is particularly contagious in the symptomatic phase; however, asymptomatic virus shedding is also known to occur. Partners who are unaware of carrying the virus transmit the virus in about half of the cases.
Herpes infection in the oral region Viral Infections of the Oral Mucosa may be transmitted to the partner's genitals through oral sex.
The risk of infection is greater from man to woman than from woman to man.

Symptoms

The clinical picture of genital herpes is often typical and easy to diagnose.
Problems arise when the manifestations are atypical, such as intermittent itching in the genital area, fissures and erythema. In order to provide adequate care and prevent the patient from spreading the disease it is essential to recognize these as symptoms of herpes.

Primary herpes

The symptoms appear 4-14 days after infection.
General symptoms include
- fever
- headache
- myalgia.
Genital symptoms include
- vesicles and ulcers (picture 1)
- stinging pain
- dysuria
- inguinal lymphadenopathy
- ulcerating cervicitis.
The lesions are bilateral.
The symptoms persist for 2-3 weeks.
Primary herpes infection may also be asymptomatic.
Virus secretion continues for about 2 weeks.
During pregnancy the risk of foetal infection is 50% in primary herpes, but less than 5% in recurrent herpes.

Recurrent herpes

Lesions are unilateral.
Lesions and symptoms are usually limited to the genitals (picture 2); in females to the external genitals, and less frequently the cervix. Herpes may also occur in the urethra.
General symptoms are rare.
The frequency of recurrences varies individually.
The infection may recur after physical or mental stress, in females frequently during menstrual period.
The duration of symptoms is about 7 days.

Diagnosis

Herpes simplex virus can be isolated from the lesion either by viral culture http://www.dynamed.com/condition/genital-herpes#VIRAL_CULTURE_AND_ANTIGEN_DETECTION or by nucleic acid detection test http://www.dynamed.com/condition/genital-herpes#POLYMERASE_CHAIN_REACTION_PCR_. Both methods can differentiate HSV types 1 and 2. Antigen detection may also be used in the diagnostics.
The sample is taken from the lesion with a cotton swab by rubbing.
Antibody tests detect HSV-1 and HSV-2 seropositivity, i.e. carrier status, but not the location of the infection.
Nucleic acid detection test is especially well applicable for the diagnosis of neonatal herpes from the spinal fluid.

Treatment

In primary herpes oral medication shortens viral shedding, accelerates healing and reduces pain. Mere clinical suspicion is a cause for starting medication: acyclovir 200 mg × 5 or 400 mg × 3 Antiviral Treatment for the First Episode of Genital Herpes, valaciclovir 500 mg × 2 or famciclovir 250 mg × 3; treatment duration for all three drugs is 5-10 days. Indications for intravenous administration are
- severe clinical manifestations
- meningeal irritation causing a headache
- neonatal herpes.
In recurring herpes oral antiviral medication http://www.dynamed.com/condition/genital-herpes#RECURRENT_INFECTIONS_EPISODIC_THERAPY_ relieves the symptoms and shortens the duration of the symptomatic phase Antiviral Treatment for Genital Herpes:
- acyclovir 200 mg × 5 or 400 mg × 3 for 5 days (or 800 mg × 3 for 2 days)
- valaciclovir 500 mg × 2 for 3-5 days, or
- famciclovir 125 mg × 2 for 5 days (or 1 g × 2 for 1 day).
Short-term prophylaxis can be used in a targeted manner, for example, during holidays.
In frequent and difficult recurrence long-term prophylactic medication http://www.dynamed.com/condition/genital-herpes#CHRONIC_SUPPRESSIVE_THERAPY can be employed (6 months-) Antiviral Maintenance Treatment in Recurrent Genital Herpes: acyclovir 400 × 2, valaciclovir 500 mg × 1 or famciclovir 250 mg × 2.
Prophylactic medication can reduce viral secretion considerably. Transmission is, however, still possible.
At present there is no drug for eradication of the virus from neural sensory ganglions.
To identify early symptoms and thus reduce the risk of transmission, the patient needs information on the natural course of the infection and infectivity.

References

Patel R, Kennedy OJ, Clarke E, et al. 2017 European guidelines for the management of genital herpes. Int J STD AIDS 2017;28(14):1366-1379. [PubMed]
Kortekangas-Savolainen O, Orhanen E, Puodinketo T et al. Epidemiology of genital herpes simplex virus type 1 and 2 infections in southwestern Finland during a 10-year period (2003-2012). Sex Transm Dis 2014;41(4):268-71. [PubMed]

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Information

Editors

Genital Herpes

Essentials

Aetiology

Epidemiology

Symptoms

Primary herpes

Recurrent herpes

Diagnosis

Treatment

References