Sexual Health
A 19 year old man presents to the Emergency Department with a 2 day history of penile ulcers. You suspect genital herpes. You redirect him to the GUM clinic, what treatment is he likely to receive there?
Answer:
- Ideally, all people with suspected genital herpes should be referred to a specialist in genito-urinary medicine for diagnosis, treatment, screening for STIs, counselling, and follow-up.
- For initial episodes, treatment with oral aciclovir (200 mg five times a day) should be started within 5 days of the start of the episode or while new lesions are forming. This should be continued for 5-10 days, or longer if new lesions are still forming while on treatment.
Genital Herpes
Sexual Health
Last Updated: 12th February 2021
Genital herpes is infection with herpes simplex virus HSV-1 or HSV-2, which can cause oral, genital and ocular ulcers. Following primary infection, the virus becomes latent in local sensory ganglia. Recurrent genital herpes occurs due to reactivation of pre-existent HSV infection after a latent period. It may cause symptomatic lesions, or asymptomatic, but infectious, viral shedding.
Transmission
Herpes simplex virus (HSV) is acquired at mucosal surfaces, or at breaks in the skin by direct contact with infected secretions or mucosal surfaces. This is normally through sexual contact, where HSV-2 is transmitted during vaginal or anal intercourse and HSV-1 through orogenital intercourse. Genital herpes can also be acquired from contact with lesions at other anatomical sites, such as the eyes, and other non-mucosal surfaces (such as herpetic whitlow on fingers or skin lesions). Transmission is most likely to occur when lesions are present (for example vesicles, or ulcers), however, it may also occur when the virus is shed asymptomatically.
Clinical features
- First episode of genital herpes:
- Usually presents with multiple painful blisters, which quickly burst to leave erosions and ulcers, on the external genitalia (as well as on the cervix, rectum, thighs, and buttocks).
- Lesions are usually bilateral and develop 4–7 days after exposure to herpes simplex virus (HSV) infection.
- Around 50% of people with symptomatic lesions report headache, fever, malaise, dysuria, or tender inguinal lymphadenopathy.
- A primary episode can last up to 20 days, and is often more severe than a recurrent episode.
- Other symptoms include:
- Vaginal or urethral discharge.
- Local oedema.
- Tingling/neuropathic pain in the genital area, lower back, buttocks or legs.
- Recurrent genital herpes:
- Recurrent infections usually occur in the same area and may be preceded by localised prodromal tingling and burning symptoms up to 48 hours before the appearance of lesions.
- Recurrences are less severe than initial episodes and last from 6 to 48 hours.
- Systemic symptoms such as fever and malaise are less common.
- Lesions crust and heal in around 10 days.
Ideally, the diagnosis of genital herpes should be carried out by a specialist in genito-urinary medicine (GUM), as confirmation of genital herpes requires identification of the type of herpes simplex virus. A swab should be taken from the base of a lesion (pop blister if necessary) for viral culture, or polymerase chain reaction (PCR), depending on local arrangements.
Differential diagnosis
- Syphilis (single, non-tender ulcer).
- Chancroid (a single deep, painful ulcer)
- Aphthous ulcers (fewer and larger lesions, with no preceding vesicles)
- Lymphogranuloma venereum (single or few ulcers and unilateral lymphadenopathy, with lack of vesicles)
- Granuloma inguinale (painless, slowly progressive ulcerative genital lesions which are highly vascular and bleed)
- Other infections — for example, herpes zoster, scabies or candida
- Skin disorders — for example, dermatitis, psoriasis, folliculitis, lichen sclerosus.
- Other systemic conditions - for example, Behçet's syndrome, Crohn's disease, and malignancy.
- Fixed drug eruptions — improves on withdrawal of the causative drug.
Management
- Ideally, all people with suspected genital herpes should be referred to a specialist in genito-urinary medicine for diagnosis, treatment, screening for STIs, counselling, and follow-up.
- For initial episodes, treatment with oral aciclovir (200 mg five times a day) should be started within 5 days of the start of the episode or while new lesions are forming. This should be continued for 5-10 days, or longer if new lesions are still forming while on treatment.
- Self-care measures may be helpful if appropriate, including:
- Cleaning the affected area with plain or salt water to help prevent secondary infection and promote healing of lesions.
- Applying vaseline or a topical anaesthetic to the lesions to help with painful micturation.
- Increasing fluid intake to produce dilute urine which is less painful to void.
- Urinating in a bath or with water flowing over the area to reduce stinging.
- Avoiding wearing tight clothing which may irritate lesions.
- Taking adequate pain relief.
- Avoid sharing towels or flannels.
- Abstaining from sexual contact until follow-up or until lesions have cleared.
- Management of recurrent episodes may involve:
- Self-care measures - these alone may be helpful for some people.
- Episodic antiviral treatment (for example, oral aciclovir 200 mg five times a day for 5 days). This is an option if attacks are infrequent (less than six attacks per year). Self-initiated treatment should be considered, so antiviral medication can be started early in the next attack.
- Suppressive antiviral treatment (for example, oral aciclovir 400 mg twice a day for 6–12 months). This is an option if attacks are frequent (six or more attacks per year), causing psychological distress, or affecting the person's social life.
Complications
- Superinfection of lesions with Candida, or Streptococci.
- Autoinoculation to fingers and adjacent skin sites, such as the thighs.
- Autonomic neuropathy resulting in urinary retention.
- Aseptic meningitis — this may occur during primary infection or may be recurrent over months to years.
- Neonatal herpes simplex virus (HSV) — risk is highest if the mother acquires HSV in the third trimester.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
