2.5.10 Genital herpes simplex

Grading & Level of Importance: A

Review:
2021

W. Burgdorf, Munich; A. Salam, J. McGrath, London;
Revised by A. Salava, E. Hiltunen-Back, A. Ranki, Helsinki

Synonyms

None.

Epidemiology

One of the most frequent sexually transmitted infections in Europe. Seroprevalence 15-20 % but varies substantially between countries. Incidence in Europe ranges from 5 to 24 per 100 persons per year. 1 in 5 adults have evidence of HSV-2 infection.

Definition

Primary infection or recurrence of the genital mucosa or adjacent skin by human herpes simplex virus (HSV) type 2 (or less commonly type 1).

Aetiology & Pathogenesis

Causative pathogens are HSV type mostly type 2, which both belong to the most common human viral infections worldwide. Clinical symptoms can be caused by primary infection or recurrences. After the primary infection, HSV remains latent in regional neuronal ganglia from where the virus spreads to the mucous membrane or skin epithelial cells via sensory neurons. HSV infection can recur spontaneously on different stimuli.

Signs & Symptoms

Primary infection


In males the most common clinical features are grouped vesicles and erosions on the glans /corona glandis penis and the shaft. The erosions are painful and, if untreated, can last 2-3 weeks. The inguinal lymph nodes can be tender and patients can have flu-like symptoms with fever and myalgia.
In females, the lesions tend to be more erosive and ulcerative. Typical sites are the vulvar area and the mucosae of the vagina and cervix. Many patients have dysuria and pelvic pain. Although infection may be asymptomatic in some cases, fever may occur and the disease course may be more severe in females.

 

Recurrence


Symptoms are usually milder and of shorter duration than in the primary infection; Can occur spontaneously or be triggered individual provoking factors: minor trauma (e.g. after sexual intercourse), genital infections (e.g. Candida-vaginitis), menstrual cycle (especially before menstrual bleeding), immunocompromised patients and emotional stress.

Localisation

See symptoms. Anal intercourse can also lead to perianal and rectal HSV infection.

Classification

Based on causative agent HSV2 or less commonly HSV1 or on suspected clinical course as primary infection or a recurrence.

Laboratory & other workups

HSV can be detected from the skin and mucosal lesions of the skin by viral culture, HSV antigen test (direct immunofluorescence) or nucleic acid amplification tests. Serological tests are not helpful.

Dermatopathology

Usually not necessary.

Course

See symptoms.

Complications

In rare cases chronic neurogenic pain in the pelvic and genital areas. In pregnancy, genital herpes simplex can lead to infection of the fetus and should be managed by doctors of the maternity care or the obstetrician. Genital herpes increases the risk of HIV-transmission. Severe ulcerative and disseminated herpes infection possible in immunocompromised patients.

Diagnosis

Based on typical clinical features and optional confirmatory microbiological tests. Additional HIV testing and screening for other STI should be undertaken.

Differential diagnosis

Trauma-induced ulcers (e.g. during sexual intercourse), genital aphthae, herpes zoster (shingles), syphilis (primary chancre), ulcerative candida-infections, streptococci and weeping irritant and allergic contact dermatitis. In travel-related cases, chancroid (ulcus molle) and granuloma inguinale.

Prevention & Therapy

Barrier contraception may prevent the transmission of the infection.
Systemic anti-viral medicaments shorten symptomatic period and may decrease pain and itching caused by the infection. Antivirals should be started early when symptoms occur. Patients with frequent recurrences and high disease burden may profit from repeated courses or continuous antiviral medication.


Primary infection (course duration 3-10 days): acyclovir 400 mg t.i.d. or 200 mg q5h; valaciclovir 500 mg b.i.d.; famciclovir 250 mg t.i.d.

Recurrences (course duration 5 days): aciclovir 400 mg t.i.d. or 200 mg q5h; valaciclovir 500 mg b.i.d.; famciclovir 125 mg b.i.d.

Immunosuppressed patients may require initial administration of aciclovir intravenously 10 mg/kg body weight t.i.d.


Sexual activity should not take place until all lesions have healed.

Special

 Not applicable.

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