Clinical Approach

Genital herpes is a recurrent sexually transmitted disease that currently has no cure. The two types are HSV-1 and HSV-2. HSV-1 usually affects the epithelium in the oral or facial region (above the waist), whereas HSV-2 usually affects the genital region (below the waist). However, up to one third of the time, the "above-the-waist versus below-the-waist" rule does not hold true. HSV is the most common cause of infectious vulvar ulcers in the United States.

Primary genital infection has both local and systemic effects. It usually affects people between the ages of 15 and 35 years. After an incubation period of 2 to 7 days, the herpes infection usually induces paresthesias of vulvar skin then formation of vesicles, which become shallow ulcers. Often, the vagina, cervix, and perineal area may be involved. The ulcers of the primary infection may persist for 2 to 6 weeks, and viral shedding generally continues for 2 to 3 weeks after lesions appear. Local symptoms include pruritus, inguinal adenopathy, vulvar pain, and discharge. Approximately three fourths of affected patients will have systemic symptoms, which include malaise, myalgias, and fever. Rarely, the virus causes central nervous system infection (herpes encephalitis), with a mortality rate of 50%.

After the primary infection, the herpes virus lies dormant in the dorsal root ganglia, typically in the sacral (S2-4) region. Triggers for reactivation include sunlight, fever, menses, emotional stress, and local trauma. Recurrent disease is mostly local and unilateral, and symptoms are much less severe, lasting approximately 1 week. Often, a prodromal phase, with symptoms of vulvar burning, tenderness, and pruritus, occurs a few hours to 5 days before an outbreak. Viral shedding typically lasts for only 5 days.

The diagnosis of HSV infection is first suspected by clinical clues. The history may include vulvar burning, tingling, or pain. The lesions, which are shallow and eroded on an erythematous base, are painful to the touch. The "gold standard" diagnostic test is isolation of the virus by a cell culture or PCR. A specimen should be obtained by swabbing at the base of an open vesicle. Overt lesions that are not ulcerative should be unroofed and the fluid sampled. The cultures generally become positive 2 to 4 days after inoculation. Newer methods include polymerase chain reaction (PCR) and DNA hybridization, which have equivalent accuracy. Cultures for other sexually transmitted diseases should be obtained on examination. Women should be advised to abstain from sexual intercourse from the time of the prodromal symptoms or when lesions appear until they have re-epithelialized.

In the pregnant woman, practitioners usually allow a vaginal delivery if, at the time of labor, there are no lesions (ulcers or vesicles) noted in the cervix, vagina, or vulva, and the patient denies prodromal symptoms. Cesarean delivery should be performed if primary or recurrent lesions are present near the time of labor, when the membranes are ruptured, or if there are prodromal symptoms.

The nucleoside analogues acyclovir, valacvclovir and famciclovir inhibit viral DNA replication. The latter two have increased bioavailability, allowing for less frequent dosing to achieve the same therapeutic benefits. Although each is available in oral, topical, and intravenous preparations, the topical preparation generally is not recommended because it is less effective and may lead to inoculation of other sites. Oral agents are most commonly used to decrease the duration of primary infection or suppress recurrent episodes. Severe infection requiring hospitalization or affecting immunocompromised women, such as with HIV infection, may require intravenous acyclovir.

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