Presentations of genital herpes

See Also - Issues in genital Herpes
     Clinical Photographs

1 True primary (initial) genital herpes

True primary genital herpes (a first episode without prior HSV-1 or HSV-2 antibodies) with a classical presentation is usually straightforward to diagnose.

The episode is usually severe and may include the following clinical features¹:

• Multiple bilateral lesions, fluid filled blisters, lasting an average of 19 days (if not treated)
• Severe pain, particularly on urinating, and itching
• Systemic symptoms: fever, malaise, headache and myalgia
• Tender inguinal adenopathies
• Pharyngitis, cervicitis, and urethritis

Potential complications include development of extra-genital lesions (most frequently on the buttocks, groin and thigh), secondary yeast infections and aseptic meningitis (rarely).

2 Non-primary initial genital herpes

This is defined as a first outbreak of genital herpes in people who have previously been exposed to HSV and have antibodies to HSV-1 or HSV-2. An example of this is an individual who has had a cold sore in the past, and is now infected with genital herpes through sexual contact. Non-primary initial genital herpes manifests with similar symptoms to true primary (initial) genital herpes. However, symptoms are usually less severe in non-primary cases.

3 Recurrent genital herpes

Recurrent outbreaks of HSV infection tend to be less severe than the initial episode, although this will vary from patient to patient. There are markedly fewer lesions and the duration of the outbreak is shorter.

Recurrences typically include the following clinical features:

• Trigger factors, including stress, fatigue, menstruation, trauma, intercourse, altered immune system
• Prodromal symptoms, including sacral neuralgia, tingling, itching, burning
• Less severe signs and symptoms than the initial outbreak; localised unilateral lesions and less severe pain
• Outbreak duration of 5-10 days (if not treated).

4 Atypical presentations

It is critical to know that many patients do not present with classical symptoms. The severity of symptoms varies widely, and presentations that were previously viewed as atypical have become more common.

Atypical presentations of genital herpes include:

• Fissuring
• Furuncles
• Excoriations
• Non-specific vulval erythema
• Linear fissure of the prepuce
• Macules and papules on the glans penis

This diversity in presentation means that a genital HSV infection may go unrecognised. It is vital that a diagnosis of genital herpes should still be considered even in the absence of classical symptoms.

5 Asymptomatic disease

Many patients considered to have unrecognised genitourinary disease may, in fact, have asymptomatic or subclinical HSV infection. Further, many patients with suspected asymptomatic genital HSV infection, and who are seropositive for HSV-2, on further evaluation have symptomatic disease. ¹ The figure below suggests that up to 80 per cent of HSV-2 seropositive individuals have symptomatic genital HSV disease.

Corey investigated the issue of asymptomatic genital herpes at the University of Washington Family Medical Center.¹ Patients who were seropositive for HSV-2 but who reported no history of past or current genital lesions of ulceration attended a counselling session describing the signs and symptoms of genital herpes. On follow-up, nearly 75% had clinical or viral culture evidence of genital herpes. The authors concluded that most patients who are seropositive for HSV-2 have symptoms and simply need to be educated about their disease.

See transmission and asymptomatic shedding for the implications of unrecognised or asymptomatic infection on the transmission of genital herpes.

References:

1. Corey L. The current trend in genital herpes. Progress in prevention. Sex Transm Dis 1994; 21: S38-S44.