Infectious Disease Book

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Genital HerpesAka: Herpes Simplex Virus 2, Herpes Genitalis, HSV II

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  1. See Also
    1. Oral Herpes
    2. Neonatal Herpes Simplex Virus
  2. Epidemiology
    1. Most common cause of ulcerative STD in United States
    2. Affects 10-30% of sexually active
    3. U.S. Prevalence: 30-45 Million
    4. U.S. Incidence: 300,000 new symptomatic cases yearly
    5. Not reportable
  3. Pathophysiology
    1. Cause of genital herpes
      1. HSV II: 80-90%
      2. HSV I: 10-20%
    2. Associated with stressors
      1. Virus remains latent in spinal nerve roots
  4. Primary Infection
    1. Systemic symptoms (Prodrome precedes lesions)
      1. Fever
      2. Headache
      3. Malaise
      4. Myalgias
    2. Lesions
      1. Lesion development
        1. Starts as shallow Vesicle
        2. Umbilicates with central depression
        3. Ulcerate early in course
        4. Crusts and then re-epitheliazes without scarring
      2. Multiple, grouped lesions are common and may coalesce
      3. Very painful!
      4. Present for 4-15 days
    3. Adenopathy
      1. Starts during second or third week of disease
      2. Usually bilateral inguinal adenopathy
      3. Slightly enlarged, mildly tender
    4. Course
      1. Viral shedding: 15-16 days
      2. Complete lesion healing: 19-21 days
    5. Complications
      1. Aseptic Meningitis
        1. Occurs in 15% with primary genital herpes
      2. Sacral radiculopathy syndrome
        1. Sacral anesthesia, Urinary Retention
        2. May last up to 8 weeks
      3. Extragenital lesions
        1. Autoinoculation of buttocks, hands, eyes
      4. Transverse myelitis
  5. Non-Primary Infection
    1. Prodrome (occurs in 50%, hours to days before lesions)
      1. Tingling
      2. Dysesthesia
      3. Numbness
    2. Adenopathy: slight, mildly tender
    3. Vessicles ulcerate and then crust
      1. Solitary or 3-4
      2. Enlarges over 3-4 days
      3. Peaks at 4-8 days
    4. Course
      1. Viral shedding during first 3-4 days
    5. Recurrence
      1. 5-8 episodes per year
  6. Diagnosis
    1. Sample collection
      1. Lance vessicle and place viral swab into fluid
    2. Viral culture of vesicular fluid
      1. Culture requires 2-3 days minimum, as long as 10 days
      2. Test Sensitivity: 75% (90% in primary episode)
        1. Best during vesicular or early ulcerative stage
        2. Not useful in lesions beyond 5 days old
      3. Differentiates HSV I from HSV II
    3. Polymerase chain reaction (PCR for HSV II)
      1. Test Sensitivity: 95%
      2. Provides more rapid results than viral culture
      3. Used in HSV Encephalitis diagnosis for rapid results
    4. HSV II direct immunofluorescence antigen detection
      1. Test Sensitivity: 80-90% of viral culture positive
    5. HSV serology (Glycoprotein G-specific HSV serology)
      1. Incidence of positives
        1. HSV: 90% of adults are positive
        2. HSV II: 30% of adults positive
      2. Indications
        1. Confirm HSV where history is questionable
        2. Recurrent lesions, but negative culture
  7. Management (Not Pregnant)
    1. General measures
      1. Keep infected area clean and dry
        1. Avoid secondary bacterial infections
        2. Avoid spread to uninvolved skin (autoinoculation)
      2. Wear comfortable clothing
        1. Loose fit
        2. Cotton underwear
      3. Apply an ice pack or baking soda compress to area
    2. Primary Infection (Initial episode)
      1. Outpatient
        1. Acyclovir
          1. 400 mg PO three times daily for 10 days OR
          2. 200 mg PO five times daily for 10 days
        2. Famciclovir 250 mg 3 times daily for 10 days
        3. Valacyclovir 1g PO twice daily for 10 days
        4. Shortens duration of pain, viral shedding
      2. Inpatient (Severe cases, hepatitis, CNS, pneumonitis)
        1. Acyclovir 5-10 mg/kg IV q8h for 2 to 7 days
        2. Convert to oral Acyclovir when able
    3. Recurrent (Start within 24 hours of first symptoms):
      1. Acyclovir
        1. 200 mg PO five times daily for 5 days or
        2. 400 mg PO three times daily for 5 days or
        3. 800 mg PO twice daily for 5 days or
        4. 800 mg PO three times daily for 2 days
          1. Two day regimen as effective as 5 day
          2. Wald (2002) Clin Infect Dis 34:944
      2. Famciclovir
        1. 125 mg orally twice daily for 5 days or
        2. 1 gram orally twice daily for 1 day
      3. Valacyclovir
        1. 500 mg orally twice daily for 3 days or
        2. 1 gram orally daily for 5 days
    4. Suppression/Prophylaxis
      1. Indications for suppression
        1. More than 6 episodes per year
        2. Consider for disabling episodes less often
      2. Acyclovir 400 mg orally twice daily for 12 months (Appears safe for up to 6 years)
        1. Prophylactic at stress times
        2. Decreases episodes from 11.4 to 1.8 per year
          1. Kaplowitz (1991) JAMA 265:747
      3. Famciclovir 250 mg orally twice daily
      4. Valacyclovir 500 mg orally daily
        1. Reduces HSV-2 transmission to partner by 50%
        2. Corey (2004) N Engl J Med 350:11
    5. Topical (oral agents are preferred)
      1. Penciclovir 1% cream ($20 for 2g tube)
        1. Efficacy
          1. Significant shortens duration of pain, healing
          2. (1997) Med Lett Drugs Ther 39(Issue 1003):57
        2. Dosing
          1. Start at first prodromal symptom
          2. Continue every 2 hours while awake for 4 days
      2. Viscous Lidocaine
        1. Applied to genital lesions
        2. Can give significant relief
  8. Management: Pregnancy (> 36 weeks gestation)
    1. Treat primary HSV II infections on protocol above
    2. Culture Cervix and lesion q3-5 days until negative
    3. Acyclovir if indicated
      1. See below for prevention of Neonatal HSV transmission
    4. Cesarean Section indications
      1. HSV II Culture positive
      2. All women with active HSV II lesions
  9. Management: Investigational
    1. L-lysine 1000 mg PO three times daily
    2. Aspirin 125 mg PO daily
    3. Local licorice root gels applied three times daily
    4. Lemon balm applied four times daily
    5. Zinc applied daily
    6. Aloe vera 0.5% applied three times daily
  10. Complications: Vertical transmission
    1. Neonatal Herpes Simplex Virus
  11. Prevention: Neonatal Herpes Simplex Virus transmission
    1. Prevent transmission from HSV positive partner
      1. Abstinence or Condom use during pregnancy
      2. Consider vaccine below
      3. Antiviral prophylaxis for HSV positive partner
      4. Avoid oral-genital contact if Oral HSV in partner
    2. HSV-2 Glycoprotein-D-Adjuvant Vaccine Indications
      1. HSV I and II negative women with positive partner
      2. Stanberry (2002) N Engl J Med 347:1652
    3. Identify HSV II risks in all pregnant women
      1. Personal history of HSV II
      2. Partners with HSV II
      3. Screen at first Prenatal Visit and perinatally
    4. Cesarean section for all women with active lesions
    5. Acyclovir indications (see dosing above)
      1. Third trimester prophylaxis if frequent outbreaks
      2. Any primary genital herpes outbreak during pregnancy
      3. All women with near-term or perinatal HSV II outbreak
    6. References
      1. Sheffield (2003) Obstet Gynecol 102:1396
  12. Prevention
    1. Avoid sexual contact during prodrome or when lesions
    2. Inform sexual partners of genital herpes
      1. Transmission can occur even when asymptomatic
    3. Condom use prevents transmission to women (not to men)
      1. Condom must cover active lesions
      2. Wald (2001) JAMA 285:3100
  13. Course
    1. Recurrence rate: Four episodes per year
    2. Factors predictive of more frequent recurrences
      1. Severe primary outbreak
      2. Male gender
      3. More frequent initially, decrease over time
      4. Exposure to provocative factors
        1. Fever
        2. Trauma
        3. Stressful situations
        4. Heat or cold extreme exposure
        5. Immunocompromised
        6. Menses
  14. Resources
    1. Herpes Resource Center: (919) 361-8488
    2. Herpes Web
      1. http://www.herpesweb.net
    3. CDC Herpes site
      1. http://www.cdc.gov/std/herpes/stdfact-herpes.htm
  15. References
    1. Beauman (2005) Am Fam Physician 72(8):1527
    2. Nadelman (2000) Postgrad Med 107(3):189

genital herpes (C0019342)

Definition (MSH)Infection of the genitals (GENITALIA) with HERPES SIMPLEX VIRUS in either the males or the females.
Definition (CSP)infection caused by herpes simplex virus type 2 (HSV-2) that is usually transmitted by sexual contact; marked by recurrent attacks of painful eruptions on the skin and mucous membranes of the genital area.
Definition (NCI)Herpes simplex infection on the genitals, most commonly caused by the herpes simplex-1 virus.
ConceptsDisease or Syndrome (T047)
ICD9054.1, 054.10
MSHD006558
EnglishGenital herpes, Genital Herpes Simplex, Genital herpes unspecified, HERPES GENITALIA, Herpes Genitalis, HERPES SIMPLEX VIRUS GENITAL INFECT, Herpes Simplex Virus Genital Infection, venereal herpes
Spanishherpes genital, herpes genital no especificado, herpes simple genital, herpes simplex genital
Parent ConceptsHerpesviridae Infections (C0019372), Herpes Simplex Infections (C0019348), Sexually Transmitted Diseases (C0036916), reproductive system infection (C1171315), genital herpes (C0019342), Female Genital Diseases (C0017411), Genital Diseases, Male (C0017412), Sexually Transmitted Diseases, Viral (C0036918), Virus Diseases (C0042769), Viral infection by site (C0729529), Genital infection (C0729552), Duplicate concept (C1274013)
SourcesAOD, COSTAR, CSP, ICD9CM, LCH, MEDLINEPLUS, MSH, MTH, NCI, NDFRT, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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