Herpes genitalis refers to infection with the herpes simplex virus (HSV)—most commonly HSV-2. The patient may present with a symptomatic primary infection (PI), a first-episode nonprimary infection, or a recurrent episode. The majority of individuals with HSV, however, are unaware of their infection.
PI refers to the initial transfer of the virus. The patient may remain asymptomatic at this time, and may later present with a first-episode nonprimary infection. Patients who develop symptoms with the PI may experience a prodromal viral syndrome consisting of a low-grade fever and myalgias that start 1 to 3 days prior to the onset of the characteristic rash of genital herpes. This rash consists of multiple groups of small vesicles that quickly ulcerate into shallow, painful ulcers on an erythematous base. The ulcers may coalesce and form larger ulcers, especially in women. The lesions are typically intensely painful, last up to 3 weeks, and heal without scarring. Women may also experience urinary retention due to sacral autonomic dysfunction. Although the majority of PIs are relatively mild and self-limited, more serious infections can occur, especially in the immunosuppressed. Up to 10% of patients develop aseptic meningitis. Disseminated infections can also result in a diffuse rash, pneumonitis, hepatitis, and encephalitis.
Primary Genital Herpes—Female. Multiple coalescing superficial ulcerations of primary genital herpes. (Photo contributor: Lawrence B. Stack, MD.)
The clinical presentation of first-episode nonprimary genital herpes and recurrent genital herpes is less dramatic. Systemic symptoms are usually absent and patients typically have only a single to a few painful lesions. First-episode nonprimary outbreaks resolve within 1 to 2 weeks, whereas recurrent episodes generally last less than a week. Recurrences of genital herpes are often heralded by a warning prodrome of tingling or numbness in the perineal area.
Management and Disposition
Counseling of patients with genital herpes that this is a sexually transmitted infection with a chronic and recurrent course is imperative. Evaluate all patients for other possible infections and recommend evaluation and appropriate treatment for all sexual partners. Definitive diagnostic testing includes cell culture, HSV polymerase chain reaction, and serologic testing.
Advise patients that treatment with antiviral agents can decrease the length and severity of symptoms but cannot completely eradicate the infection from the body. Antivirals may also be used for suppressive treatment for patients with frequent recurrences or immunosuppression, and decrease episodes by 70% to 80%.
Treat primary genital herpes with acyclovir, 400 mg orally three times daily, or 200 mg orally five times daily, for 7 to 10 days or until symptoms resolve. Alternatives include famciclovir 250 mg orally three times daily or valacyclovir 1 g orally twice daily for 7 to 10 days.
Herpetic Ulcerations—Female. Multiple coalescing vesicles and ulcers causing a deep ulcer. (Photo contributor: Lawrence B. Stack, MD.)
For recurrent genital herpes, treatment must be started within 1 day of the onset of symptoms in order to be effective. Multiple antiviral treatment regimens are appropriate. Five-day oral courses include acyclovir 400 mg three times daily, acyclovir 800 mg twice daily, famciclovir 125 mg twice daily, or valacyclovir 1 g once daily. Shorter courses include acyclovir 800 mg three times daily for 2 days, famciclovir 1000 mg PO twice daily for 1 day, or valacyclovir 500 mg twice daily for 3 days.
Admit patients with disseminated herpes infections and other complications for treatment with intravenous antiviral medications.
Primary Lesions—Male. Multiple genital vesicles of primary genital herpes. (Photo contributor: H. Hunter Handsfield, MD. From Handsfield HH (ed): Atlas of Sexually Transmitted Diseases, 3rd ed. New York: McGraw-Hill; 2011.)
Primary Lesions—Male. Confluence of ulcerations on an erythematous base in a patient with primary herpes simplex type II. (Photo contributor: David Effron, MD.)
Perinatal transmission of genital herpes is associated with high rates of infant morbidity and mortality. Infected women must be counseled to inform their obstetrician of their history of herpes when they become pregnant.
Genital herpes is the most common cause of ulcerating genital lesions in the developed world.
Topical antiviral agents are not effective against genital herpes.
Recurrent Lesions—Female. Few, small, minimally painful lesions of recurrent genital herpes. (Photo contributor: Hope Haefner, MD.)
Herpes Simplex Virus—Cervix. Erosive ulcerations of the cervix in a patient with genital herpes infection. This patient may be completely asymptomatic and may transmit the disease. (Reproduced with permission from Wisdom A. A Colour Atlas of Sexually Transmitted Diseases. London: Mosby-Wolfe Ltd; 1992. Copyright © Elsevier.)