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Tuesday, August 12, 2025

Genital herpes


Definition

Genital herpes is a sexually transmitted infection (STI) caused by herpes simplex virus (HSV), primarily HSV-2 and increasingly HSV-1. It is a chronic, lifelong viral infection characterized by recurrent episodes of genital ulcerations and asymptomatic viral shedding.

Etiology and Virology

  • HSV-1: Traditionally associated with orolabial herpes but increasingly responsible for primary genital herpes, especially in developed countries

  • HSV-2: Most common cause of recurrent genital herpes worldwide

  • Transmission occurs via direct mucocutaneous contact with infected secretions during sexual activity (vaginal, anal, oral)

  • Virus enters through breaks in skin or mucosa, infects epithelial cells, and travels via sensory nerves to dorsal root ganglia, where it establishes latency

Epidemiology

  • One of the most prevalent STIs globally

  • High seroprevalence in sexually active adults

  • HSV-2 prevalence is higher in women and in individuals with multiple sexual partners

  • Asymptomatic shedding contributes to most transmissions

Risk Factors

  • Multiple sexual partners

  • Unprotected sex

  • Early onset of sexual activity

  • History of other STIs

  • Immunosuppression (e.g., HIV infection)

Pathophysiology

After primary infection:

  1. Primary infection phase – viral replication in epithelial cells, immune activation, and acute symptoms

  2. Latency – viral genome persists in dorsal root ganglia in a dormant state

  3. Reactivation – triggered by stress, illness, immunosuppression, menstruation; virus travels along sensory nerves to skin/mucosa, causing recurrent lesions

Clinical Presentation

Primary Genital Herpes

  • Incubation period: 2–12 days post-exposure

  • Symptoms more severe than recurrent episodes

  • Multiple painful vesicles → ulcers on genital, perineal, or anal areas

  • Dysuria, vaginal/urethral discharge

  • Tender inguinal lymphadenopathy

  • Systemic symptoms: fever, malaise, myalgia

  • Lesions heal in 2–4 weeks without scarring

Recurrent Genital Herpes

  • Milder, shorter duration (heals in 7–10 days)

  • Fewer lesions

  • Localized tingling, itching, or burning (prodrome) precedes lesions by hours to days

Asymptomatic Shedding

  • Occurs intermittently, even without visible lesions

  • Important in transmission

Complications

  • Neurological: Aseptic meningitis, radiculopathy

  • Autoinoculation: Herpetic whitlow, ocular herpes

  • Neonatal herpes: Severe, potentially fatal infection if transmitted during delivery

  • Psychological impact: Anxiety, depression due to stigma and recurrent nature

Diagnosis

  • Clinical diagnosis: Based on typical vesicular/ulcerative lesions

  • Laboratory confirmation:

    • PCR testing (gold standard) from lesion swab – highly sensitive and specific

    • Viral culture – less sensitive, especially for recurrent lesions

    • Type-specific serology – detects HSV-1 and HSV-2 antibodies; useful for atypical cases or when lesions are absent

Management

Management goals: shorten symptom duration, reduce severity, prevent complications, and minimize transmission.

1. General Measures

  • Analgesia: paracetamol or NSAIDs

  • Saline bathing for comfort

  • Avoid sexual contact during symptomatic episodes and for a few days after healing

  • Counsel regarding chronic nature and transmission risk

2. Antiviral Therapy

Antivirals inhibit viral replication but do not eradicate latent virus.

Primary episode treatment – initiate as soon as possible:

  • Acyclovir: 400 mg orally three times daily for 7–10 days or 200 mg orally five times daily for 7–10 days

  • Valacyclovir: 1 g orally twice daily for 7–10 days

  • Famciclovir: 250 mg orally three times daily for 7–10 days

Recurrent episode treatment – start within 24 hours of onset or during prodrome:

  • Acyclovir: 800 mg orally three times daily for 2 days or 800 mg twice daily for 5 days

  • Valacyclovir: 500 mg orally twice daily for 3 days or 1 g once daily for 5 days

  • Famciclovir: 1 g orally twice daily for 1 day or 125 mg twice daily for 5 days

Suppressive therapy – for frequent recurrences (≥6/year) or to reduce transmission:

  • Acyclovir: 400 mg orally twice daily

  • Valacyclovir: 500 mg orally once daily (for ≤9 recurrences/year) or 1 g once daily (for >9/year)

  • Famciclovir: 250 mg orally twice daily

  • Reassess need annually

Severe disease or complications (e.g., disseminated infection, CNS involvement):

  • Acyclovir IV: 5–10 mg/kg every 8 hours for 2–7 days, followed by oral therapy to complete at least 10 days

3. Pregnancy Considerations

  • HSV infection in late pregnancy increases neonatal herpes risk

  • Suppressive therapy from 36 weeks gestation:

    • Acyclovir: 400 mg orally three times daily

    • Valacyclovir: 500 mg orally twice daily

  • Caesarean delivery recommended if active lesions or prodrome present at labour

Prevention

  • Consistent condom use (reduces but does not eliminate risk)

  • Abstain from sexual activity during outbreaks

  • Suppressive antiviral therapy for serodiscordant couples to reduce transmission risk

  • Routine HSV screening not recommended in asymptomatic individuals

Prognosis

  • Chronic condition with variable recurrence frequency

  • Recurrences often decrease over time

  • Antiviral therapy effectively controls symptoms and reduces transmission risk, but no cure exists




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