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9-04: Genital Herpes

Suzanne Dooley-Hash; Nicholas W.C. Herrman

Clinical Summary

Genital herpes is caused by both herpes simplex virus (HSV) type 1 and 2. Primary infections are often asymptomatic but may present with a prodrome of fever, headache, myalgias, and dysuria followed by development of an eruption within a few days. The typical eruption consists of clusters of small vesicles that ulcerate into shallow painful ulcers with an erythematous base. The eruption can last for several weeks. Most primary infections are self-limited, but complications may include acute urinary retention, aseptic meningitis, encephalitis, hepatitis, and pneumonitis. Nonprimary infections occur when patients with preexisting antibodies to one HSV type are infected by the other type. Recurrent episodes are common. Both nonprimary first and recurrent episodes tend to have a milder course than primary infections. Immunocompromised patients are at risk for disseminated herpes and other complications. Perinatal transmission of genital herpes is associated with high rates of infant morbidity and mortality.

FIGURE 9.20

Herpetic Ulcerations—Female. Multiple coalescing vesicles and ulcers causing a deep ulcer. (Photo contributor: Lawrence B. Stack, MD.)

Herpetic Ulcerations presenting as multiple ulcers clustered at the base of the vulva and one very large, discolored ulcer at the bottom right.
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FIGURE 9.21

Primary Genital Herpes—Female. Multiple superficial ulcerations of primary genital herpes. (Photo contributor: Lawrence B. Stack, MD.)

Primary genital herpes in females presenting as several superficial ulcerations all over the female genitalia.
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Management and Disposition

Diagnosis of primary or nonprimary first infection is confirmed by viral culture from lesions or serum polymerase chain reaction testing. Recurrent episodes are diagnosed clinically.

Antiviral agents can decrease length and duration of symptoms and may be used for suppressive therapy, but no curative treatment is available. Treat primary genital herpes with oral acyclovir 400 mg three times daily or 200 mg five times daily for 7 to 10 days. Alternatives include famciclovir 250 mg three times daily or valacyclovir 1000 mg twice daily for 7 to 10 days.

FIGURE 9.22

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, NY: McGraw Hill; 2011.)

Primary lesions in males presenting as multiple raised genital vesicles and redness in the groin area.
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FIGURE 9.23

Primary Lesions—Male. Confluence of ulcerations on an erythematous base in a patient with primary herpes simplex type II. (Photo contributor: David Effron, MD.)

Primary lesions in males shows a confluence of raw ulcerations on the head and base of the penis.
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FIGURE 9.24

Recurrent Genital Herpes Type 2—Male. Multiple umbilicated vesicles on an erythematous base adjacent to genital warts on the mons pubis of a male who typically wears condoms during sex. (Photo contributor: Lawrence B. Stack, MD).

Recurrent Genital Herpes Type 2 in a man shows raised genital warts and redness on the mons pubis.
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For recurrent genital herpes, treatment is most effective if started within 24 hours of symptom onset. Multiple antiviral treatment regimens are appropriate, with the most commonly used being 3- to 5-day courses of oral acyclovir 400 ...

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