Genital Herpes Simplex

CHAPTER 80

Genital Herpes Simplex

Presentation

The patient may be distraught with severe genital pain, with subsequent outbreak of painful vesicles on the external genitalia that may ulcerate or erode. Alternatively, he may just be concerned about paresthesias and subtle genital lesions. He may want pain relief during a recurrence, or he may be suffering complications, such as superinfection or urinary retention. Often, with primary infection, there are associated systemic symptoms, such as fever, malaise, myalgias, and headache.

Instead of the classic grouped vesicles on an erythematous base, herpes in the genitals usually appears as groupings of 2- to 3-mm ulcers, representing the bases of abraded vesicles (Figures 80-1 and 80-3). Resolving lesions are also less likely to crust on the genitals. Lesions can be tender and should be examined with gloves on, because they shed infectious viral particles. Inguinal lymph nodes may be painful, are usually involved bilaterally, and are not confluent.

Figure 80-1 Herpes genitalis in a male patient. (Adapted from White GM, Cox NH: Diseases of the skin, ed 2. St Louis, 2006, Mosby.)

Figure 80-2 Primary genital herpes in a male patient. (Adapted from Bolognia J, Jorizzo J, Rapini R: Dermatology, St Louis, 2003, Mosby.)

Figure 80-3 Primary genital herpes in a female patient. (Adapted from Bolognia J, Jorizzo J, Rapini R: Dermatology, St Louis, 2003, Mosby.)

What To Do:

If necessary for the diagnosis, perform a Tzanck preparation by scraping the base of the vesicle (this hurts!), spreading the cells on a slide, drying, and staining with Wright or Giemsa stain. The presence of multinucleate giant cells with nuclear molding provides suggestive evidence of herpes infection. This method does not distinguish herpes simplex virus (HSV) from varicella-zoster virus infection. Confirmation of HSV infection should be obtained by viral culture of a freshly opened lesion or glycoprotein G testing of healing lesions.

Send a serologic test for syphilis, and culture any cervical or urethral discharge in search of other infections requiring different therapy.

For the immunocompetent patient, prescribe acyclovir (Zovirax), 400 mg tid for 7 to 10 days. Alternative treatment regimens include famciclovir (Famvir), 250 mg tid for 7 to 10 days, and valacyclovir (Valtrex), 1000 mg bid for 7 to 10 days.

For recurrent infections, prescribe any of the following choices: acyclovir, 400 mg tid for 5 days, or 800 mg bid for 5 days or 800 mg tid for 2 days; famciclovir, 125 mg bid or 1000 mg bid for 1 day or 500 mg once, followed by 250 mg bid for 2 days; or valacyclovir, 1000 mg qd for 5 days or 500 mg bid for 3 days. If there are no contraindications, prescribe adequate anti-inflammatory or narcotic analgesics for pain. Try sitz baths for comfort.

Warn the patient of the following:

Lesions and pain can be expected to last 2 to 3 weeks during the initial attack (usually less in recurrences).

Although acyclovir reduces viral shedding, the patient should assume he is contagious whenever there are open lesions (and can potentially transmit the virus at other times as well). Men with HSV infection should be counseled and advised to use barrier contraceptive methods during intercourse.

The patient should be careful about touching lesions and washing hands, because other skin can be inoculated.

Recurrences can be triggered by any sort of local or systemic stress and will not be helped by topical acyclovir.

Suppressive therapy should be considered for patients who have more than six episodes per year or to reduce transmission in couples where one partner is HSV-2 positive. This therapy can reduce the frequency of recurrences by 70% to 80%. Prescribe acyclovir, 400 mg bid; famciclovir, 250 mg bid; or valacyclovir, 500 mg to 1 g qd. Because the number of recurrences decreases over time, it is wise to discuss discontinuation of suppressive therapy annually with patients.

What Not To Do:

Do not confuse these lesions with the painless, raised genital ulcer of syphilis or the erosive lesions of Stevens-Johnson syndrome, which will also involve at least one other mucous membrane, such as oral mucosa, pharynx, larynx, lips, or conjunctiva.

Do not delay starting treatment pending culture results. Treatment is more effective if started earlier in the course of the infection.

Discussion

Infection is transmitted by direct contact with infected mucosa or secretions, and the incubation period is 2 to 20 days.

In men, lesions occur on the penile shaft, glans, and prepuce. Men who practice receptive anal intercourse can develop HSV proctitis with pain, tenesmus, and rectal discharge. In women, lesions may be seen on the external or internal genitalia.

Lesions heal over a 3-week period, although latent infection is established in dorsal root ganglia indefinitely and recurrent infection is common. Within 12 months of the initial herpes simplex virus type 2 (HSV-2) episode, 90% of patients have had at least one recurrence, and approximately 40% have had six or more recurrences. Fortunately, recurrences tend to decrease over time. These infections are generally milder in terms of duration, extent of lesions, and pain and may be associated with a prodrome of itching or burning pain.

HSV-2 is the cause of approximately 80% of genital ulcer disease in the United States. Diagnosis of herpes infection can be made largely on clinical grounds with a typical history and physical examination, although typical symptoms and signs are absent in many infected patients. Also, HSV serotyping may influence prognosis, treatment, and counseling, and, therefore, definitive diagnosis should be performed. Confirmation of HSV infection is best performed by culture of an intact vesicle obtained within 7 days of the initial outbreak or within 2 days of subsequent infections. During active infection, culture sensitivity is approximately 95% from vesicular lesions, whereas it is only 70% from ulcerative lesions and 30% from crusted lesions.

Type-specific serologic testing for HSV may be useful for diagnosis in patients who have symptomatic disease in the healing stages or in recurrent infections when cultures of lesions are less likely to yield the virus. The Centers for Disease Control and Prevention (CDC) recommends glycoprotein G tests, which have a high sensitivity (80% to 98%) and specificity (>96%). Those tests include POCkit HSV-2 (Diagnology, Research Triangle Park, Durham, N.C.) and HerpeSelect-1 and 2 ELISA and HerpeSelect 1 and 2 Immunoblot (Focus Technologies, Cypress, Calif.).

All the acyclic nucleoside analogue antiviral agents (acyclovir, valacyclovir, famciclovir) are equally effective in the treatment of an acute first episode of genital herpes infection and in the episodic treatment of recurrent herpes. Acyclovir is the least expensive regimen but is less convenient and must be taken more often than valacyclovir and famciclovir.

Counseling is an important part of the management of genital herpes infection. Key points to make when counseling patients should include the potential for recurrences and the effectiveness of antiviral medication for the treatment of recurrences. Because HSV infection may initially be asymptomatic, a symptomatic episode does not necessarily mean that the patient’s current partner is not monogamous. Patients should be counseled regarding the possibility of transmission during periods of asymptomatic viral shedding and the need to abstain from sexual activity with uninfected partners when lesions or prodromal symptoms are present. They should also be encouraged to use condoms. They should be advised that the risk for HSV transmission to an uninfected partner is not completely eliminated by taking these precautions and that genital ulcer disease increases the risk for transmission of human immunodeficiency virus (HIV).

The diagnosis of genital herpes can be emotionally devastating to a young man or woman who is infected. Although it is advisable for patients to inform future sexual partners about their infection, it is also understandable that discussing this with a future partner can be difficult. It is very important for the physician caring for these patients to provide appropriate psychological as well as medical support.