Genital Herpes in Women

Genital herpes in women is a sexually transmitted infection of the genital tract caused by herpes simplex virus type 2 and, increasingly, type 1. It produces painful vesicles and ulcers and then lies latent in sacral nerve ganglia.

• First episodes are the most severe; recurrences are milder and shorter.
• Viral shedding occurs without symptoms and transmits infection.
• Infection raises the risk of acquiring HIV.

First episode: 2 to 12 days after exposure, grouped painful vesicles that burst into shallow ulcers on the vulva, vagina, cervix, perineum or buttocks.

• Dysuria, urinary retention, vaginal discharge, tender inguinal lymph nodes, fever, headache and malaise.
• Recurrences: tingling or burning prodrome, then a few ulcers lasting 5 to 7 days.
• Differential diagnosis: syphilis, chancroid, Behçet disease, trauma, candidiasis, fixed drug eruption, herpes zoster, lymphogranuloma venereum.
• Complications: urinary retention, aseptic meningitis, sacral radiculopathy, secondary infection, neonatal herpes, psychological distress.

Diagnosis is by swab for herpes simplex virus PCR or culture, and is made clinically where PCR is unavailable.

• Swab from the base of an ulcer or unroofed vesicle for HSV PCR or culture where available.
• HIV and syphilis tests; screen for other STIs.
• Pregnancy test.
• Urea and creatinine before high-dose treatment in severe disease.

Treat with an antiviral drug early, with episodic or suppressive therapy for recurrences.

• Supportive: salt-water sitz baths 3 times daily; cool compresses; petroleum jelly to the lesions; pass urine in water or a warm bath; wear loose cotton underwear; avoid intercourse until healed; condom use.
• Pharmacological: first episode: aciclovir 400 mg oral 8-hourly for 7 to 10 days, or valaciclovir 500 mg oral 12-hourly for 7 to 10 days. Episodic treatment of recurrence, started at the first symptom: aciclovir 800 mg oral 8-hourly for 2 days, or 400 mg oral 8-hourly for 5 days. Suppression (6 or more recurrences a year): aciclovir 400 mg oral 12-hourly for 6 to 12 months, then review. Severe disease, retention or meningitis: aciclovir 5 mg/kg IV 8-hourly for 5 to 7 days, then oral to complete 10 days. Analgesia with paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours) and lignocaine 2 percent gel applied to the ulcers 3 to 4 times daily.
• Procedures: urethral catheterisation for retention.
• Special groups: in pregnancy give aciclovir 400 mg oral 8-hourly for 7 to 10 days for a first episode; from 36 weeks give suppression with aciclovir 400 mg oral 8-hourly until delivery; offer caesarean delivery if a first episode occurs within 6 weeks of delivery or active lesions are present in labour. In HIV infection give aciclovir 400 mg oral 8-hourly for 7 to 10 days and suppression with 400 mg 8-hourly. In creatinine clearance below 10 mL/minute give aciclovir 200 mg oral 12-hourly, and ensure adequate hydration.
• Red flags: urinary retention, severe headache with neck stiffness, spread to the eye, ulcers lasting longer than 4 weeks in HIV, herpes in the last 6 weeks of pregnancy.
• Follow-up: review at 1 week; counselling on recurrence, asymptomatic shedding and partner testing; test of cure is not required.