Primary genital herpes can be caused by both HSV-1 and HSV-2. HSV-2 has been more associated with genital infections.
Most genital herpes infections are due to oral-to-genital transmission through oral sex, as opposed to genital-to-genital transmission through sexual intercourse. The incubation period of primary genital herpes is typically 3-7 days. The clinical features and course of primary genital herpes caused by both HSV-1 and HSV-2 are indistinguishable, but recurrences are more common with HSV-2.Constitutional symptoms include fever, headache, malaise, and myalgia are prominent in the first 3-4 days. Local symptoms include pain, itching, dysuria, vaginal and urethral discharge, and tender lymphadenopathy.
In women, herpetic vesicles appear on the external genitalia, labia majora, labia minora, vaginal vestibule, and introitus. In moist areas, the vesicles rupture, leaving tender ulcers. Ulcers are seen more commonly than vesicles at the time of presentation because of the frailty and thin walls of the vesicles. The ulcerative lesions persist from 4-15 days until encrusting and reepithelialization occur. The median duration of viral shedding is about 12 days. The clinical course depends on the age and immune status of the patient, the anatomic site , and the virus type. Primary HSV infections are accompanied by systemic signs, longer duration of symptoms, and higher rate of complications. Recurrent infections are typically milder and shorter. HSV infections in immunocompromised host tend to be more severe, prolonged, and widespread and are more likely to recur than HSV infections in immunocompetent individuals. Preexisting antibodies to HSV-1 have an ameliorating effect on disease severity caused by HSV-2. Prior orolabial HSV-1 infection appears to protect against or may lower genital HSV-1 infection risk. Symptoms of primary genital herpes are more severe in women. Most primary genital HSV infections are asymptomatic, with 70%-80% of seropositive individuals having no history of known genital herpes. However, upon education regarding the varied clinical manifestations, many patients recognize the symptoms of genital herpes.
Recurrent genital herpes is preceded by a prodrome of tenderness, pain, and burning at the site of eruption that may last from 2 hours to 2 days. In some patients, severe ipsilateral sacral neuralgia occurs. The major morbidity of genital herpes is due to its frequent reactivation rate. The duration of symptoms is usually shorter in recurrent infection than in primary infection.
HSV polymerase chain reaction (PCR) is the test of choice if direct swabbing is not possible and has a very high sensitivity especially in earlier stage lesions. PCR testing is faster and has a higher sensitivity that viral culture.
The antivirals are well established treatments for both HSV-1 and HSV-2.
When antivirals are taken within 72 hours of lesion appearance, they are very effective.. Appropriate wound care is needed, and treatment for secondary bacterial skin infections may be required. No preventive vaccine exists for HSV-1 or -2.
Genital herpes and pregnancy
A primary outbreak in the first trimester of pregnancy has been associated with neonatal chorioretinitis, microcephaly, and skin lesions in some cases. Women with a primary or nonprimary first-episode outbreak in pregnancy, as well as women with a clinical history of genital herpes, should be offered suppressive therapy beginning at 36 weeks of gestation. Alternatively, for primary outbreaks that occur in the third trimester, continuing antiviral therapy until delivery may be considered. Cesarean delivery is indicated in women with active genital lesions.
There are no documented increases in adverse fetal or neonatal effects because of acyclovir exposure.