Genital Herpes

Definition/diagnostic criteria Genital herpes is a common, chronic sexually transmitted infection (STI) caused primarily by herpes simplex virus type 2 (HSV-2) and, less frequently, by herpes simplex virus type 1 (HSV-1). Diagnosis is typically made based on clinical findings and confirmed through laboratory tests. It is characterised by the presence of recurrent, painful genital ulcers, with a primary episode potentially presenting more severe symptoms.

Epidemiology Genital herpes is one of the most prevalent STIs globally and in the UK. The exact prevalence is challenging to estimate due to the asymptomatic nature of many infections. However, HSV-2 seroprevalence in the UK is estimated to be lower than in global estimates, with a significant number of genital herpes cases caused by HSV-1, often transmitted through oral-genital contact.

Diagnosis
Clinical features: Clinically, genital herpes presents as painful blisters or ulcers at the site of infection, typically the genitals, rectum, or mouth.

• Primary episodes may be accompanied by systemic symptoms such as fever, malaise and inguinal lymphadenopathy.
• Recurrences are usually milder and shorter in duration.
• Atypical presentations, especially in recurrent infections, are common, making clinical diagnosis challenging without laboratory confirmation.

Investigations: Diagnostic confirmation is obtained through viral culture or, more commonly, polymerase chain reaction (PCR) testing of the lesion swab. Serological tests can identify type-specific HSV antibodies, but are less useful in acute diagnosis.

Treatment Patients should ideally be referred to a sexual health clinic to confirm the diagnosis, initiate treatment, screen for other STIs and help with contact tracing. Treatment aims to alleviate symptoms and reduce the frequency of recurrences.

• Antiviral medications such as aciclovir, valaciclovir and famciclovir are the mainstay of treatment.
• For initial episodes, oral antiviral treatment is recommended for 5 to 10 days.
• In recurrent episodes, episodic treatment should be initiated within 24 hours of symptom onset, or suppressive therapy can be considered in individuals with frequent recurrences (more than six episodes per year).

Prognosis While there is no cure for genital herpes, the prognosis is generally good. Symptoms tend to be most severe during the first outbreak and typically lessen in severity and frequency over time. Psychological and emotional impacts are common, necessitating a supportive and informative approach to management. Education on the chronic nature of the disease, potential for transmission and methods to reduce the risk of spread is crucial. Individuals with genital herpes are at increased risk of HIV acquisition and transmission, and this should be part of the education and management plan.