Genital herpes is a STI caused by the herpes simplex viruses (HSV) that are transferred through sexual contact. It results in the formation of herpetic sores, which are painful blisters that have the potential to rupture and release fluid. It is a chronic viral infection that is characterized by periods of inactivity and subsequent reactivation.
HSV can be classified into two distinct types:
• HSV-1: Primarily results in the formation of cold sores but can also lead to the development of genital herpes.
• HSV-2 primarily results in genital herpes, however it can also manifest as cold sores.
Cause or origin of a disease or condition.
HSV-1 is commonly acquired throughout childhood and typically appears as cold sores on or around the mouth. Following childhood, the chances of acquiring symptomatic primary infection with HSV-1 are equally probable in the vaginal or oral regions.
HSV-2 is commonly transmitted through sexual contact and mostly affects the genitals. The incidence of genital infection with HSV-2 progressively rises from adolescence and continues to grow with age. HSV-1 is responsible for the majority of primary and early genital herpes infections in adults in the UK.
Transmission and recurrence
• Transmission: Occurs through direct contact with the virus, which can be released through oral, anorectal, external genitalia, cervix, or urethra shedding. Transmission is most pronounced during the viral prodrome (if it is present) or when there are visible lesions. Asymptomatic shedding is also highly influential.
• Recurrence: HSV-2 has a higher frequency of recurrences compared to HSV-1. Following an initial episode with symptoms, the monthly rate of recurrence for HSV-2 is roughly 0.34 (equivalent to around 4 recurrences per year). The frequency of recurrence often decreases over time.
Manifestations of the medical condition
Symptoms:
- Frequently lacking noticeable symptoms.
- Painful lesions or sores.
- Painful or difficult urination.
- Discharge from the vagina or urethra.
- Primary HSV infections are characterized by a higher prevalence of systemic symptoms such as myalgia and fever.
Indications:
- Presence of blisters and ulcers on the external genitalia, potentially affecting the cervix and rectum.
• Inguinal lymphadenitis characterized by tenderness, typically affecting both sides during first bouts and only one side during subsequent occurrences.
• In recurring occurrences, the lesions may be tiny and have a resemblance to fissures or nonspecific erythema.
Medical assessment
The diagnosis should be made from the history, clinical appearance and the following investigations.
Identification and categorization of viruses - Confirming the diagnosis requires directly detecting HSV in genital lesions.
- Distinguishing between the herpes simplex virus types 1 and 2 by typing is helpful for providing counselling and managing the infection.
- It is recommended to collect specimens from the bottom of an ulcer or vesicle.
The recommended diagnostic method is nucleic acid amplification testing (NAAT), such as polymerase chain reaction (PCR), because it has greater detection rates compared to herpes simplex virus (HSV) culture.
Herpes serology - Herpes serology has a limited impact on the overall therapy of herpes.
- Not generally suggested for persons without symptoms.
- This test can be used to detect seroconversion in pregnant women or to monitor patients with recurrent genital illness of unclear origin.
Additional diagnostic techniques - Dark field microscopy may be suitable for some clinical scenarios.
Complexities - Urinary retention may occur because of intense pain or autonomic neuropathy.
- Aseptic Meningitis.
- Superinfection refers to the occurrence of additional infections in lesions caused by organisms such as candida or streptococcal species.
- Autoinoculation refers to the transmission of a virus from one part of the body to another, specifically in this case, from the fingers to the neighboring skin. This can result in a condition known as herpetic whitlow.
Administration
Initial episode
- The initial episode of genital herpes can be managed with general measures such as saline bathing, suitable pain relief, and potentially the use of topical anaesthetic.
- Antiviral medications, such as aciclovir, valaciclovir, and famciclovir, can be used orally to lessen the severity and duration of episodes. If new vesicles continue to develop, it may be necessary to undergo an extended period of therapy.
- Hospitalization may be necessary for conditions such as urinary retention, meningism, or severe systemic symptoms.
Recurrent Genital Herpes - Supportive Therapy: Used for brief, sporadic recurrences that result in minimal discomfort.
- Episodic antiviral therapy is recommended for individuals experiencing severe and/or prolonged recurrences of the condition. Provision of pre-emptive supplies for patient-initiated treatment is possible.
- Suppressive Antiviral Therapy: Recommended for those experiencing repeated recurrences of the virus. Aciclovir has the most comprehensive safety and resistance data available.
- Asymptomatic viral shedding is a phenomenon that occurs with both kinds of HSV (Herpes Simplex Virus) and can be minimized by antiviral medications. These medicines are crucial for preventing the spread of the virus to others.
Minimizing the spread of infection - Refrain from engaging in sexual activity while experiencing symptoms recurrences.
- Male condoms can provide some level of protection against the transmission of HSV.
- Instruct patients on how to identify symptoms of recurrences.
- Antiviral drugs have the ability to inhibit the release of viruses from infected cells.
Notification of a partner - Including the individual’s existing sexual partners in counselling can help reduce anxiety and provide support.
- Verifying the partner’s HSV status can assist in managing the situation.
- Support and counselling services are available to help patients cope with the significant emotional distress caused by the diagnosis. It is crucial to seek a referral to a sexual health advisor in order to obtain necessary help and knowledge.
- Counselling should encompass the progression of the illness, the occurrence of asymptomatic shedding, the risks of transmission, and the impact of infection during pregnancy.
- Disseminate information through written and verbal means, including providing contact information for support groups such as the Herpes Viruses Association.
Herpes in pregnancy
- Managing genital herpes in pregnant individuals should involve collaboration between obstetric and neonatal teams.
- The highest risk of newborn herpes occurs when new infections occur during the third trimester of pregnancy.
HIV infection and immunodeficiency
- HIV infection is a condition that leads to immunodeficiency.
- HSV stimulates HIV replication and maybe aids in the spread of HIV to others.
- Genital herpes is prevalent among patients who are HIV-positive.
- Untreated HIV-infected patients may experience severe and long-lasting primary HSV infection.
Resistance to antiviral drugs
Aciclovir resistance is more prevalent in patients who are co-infected with HIV.
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