Genital Herpes
BASHH Guidelines for the Management of Anogenital Herpes. Last Updated: Oct 2024.
NICE CKS Herpes Simplex – Genital. Last Revised: May 2024.
Definition
Genital herpes is an STI caused by herpes simplex virus infection of the anogenital area.
Aetiology
Herpes simplex virus (HSV) is a double-stranded DNA virus
Types of HSV:
- HSV-1 – most common cause of genital herpes nowadays (same as oral herpes)
- HSV-2 – historically the most common cause of genital herpes, and more likely to cause recurrent anogenital symptoms
Clinical Features
Only 1/3 of patients are symptomatic at the time of acquiring the infection, symptoms may appear years later.
Typical features:
- Multiple, painful genital blisters in groups
- Location: external genitalia / perineum / perianal region
- Blisters quickly burst to leave erosions and ulcers
- Tender bilateral inguinal lymphadenopathy
- Dysuria
- Vaginal / urethral discharge
- Systemic symptoms (headache, malaise and/or fever)
MSM may present with herpes proctitis.
Primary vs recurrent genital herpes
- In recurrent episodes, genital lesions are usually less severe and localised to the same dermatome during each episode
- In recurrent episodes, lesions usually heal within 6-12 days, while it could last up to 3 weeks in primary herpes
- Systemic symptoms are more common with primary herpes
- Prodromal tingling / burning pain in the genital area / lower back / buttocks / upper thighs may occur up to 48 hours before lesions appear in recurrent episodes
Investigation and Diagnosis
1st line: viral swab for viral detection by PCR
Management
Management of genital herpes in pregnancy is covered in a separate article – Genital Herpes in Pregnancy
Conservative Management – All Patients
General advice:
- Increase fluid intake
- Urinate in a bath or with water flowing over the area (can help reduce dysuria)
- Abstinence from sexual contact during lesion recurrences / prodromes
Self-care measures:
- Saline bathing
- Analgesia (paracetamol / ibuprofen)
- Topical petroleum jelly / anaesthetic agent (e.g. 5% lidocaine ointment)
Primary Herpes Infection
Ideally diagnosed and managed in a specialist GUM clinic / center
Antiviral therapy is generally indicated in primary infections. Specifically indicated in ANY of the following scenarios:
- <5 days of onset of first episode
- New lesions are forming
- Persistent systemic symptoms
Recommended 1st line oral antiviral regimens (either):
- Aciclovir 400mg TDS for 5 days
- Valaciclovir 500mg BD for 5 days
Recurrent Herpes Infection
Recurrences can be managed in primary care. However, referral should be considered in pregnancy / immunocompromise / presence of complications
Advise patients that recurrences are self-limiting and generally cause minor symptoms
- 1st line: conservative management (see above)
- 2nd line: consider antiviral therapy
- Infrequent episodes (<6 episodes/year) → episodic oral antiviral treatment
- Frequent episodes (≥6 episodes/year) → suppressive oral antiviral treatment
References