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Ten top tips on genital herpes

Dr Phil Hammond gives GPs a guide to diagnosis and management

Dr Phil Hammond gives GPs a guide to diagnosis and management

1

Be aware that loose talk can damage relationships. HSV is commonly caught through oral sex and most people catch genital herpe from a partner who doesn't know they are infected. Three-quarters of those who are HSV positive are unaware of their status, having only mild or non-existent symptoms.

Asymptomatic carriers may experience their first symptoms years after initial infection so transmission between partners may occur at any time in established relationships. Suggesting that a third party may be involved is unhelpful and often untrue. But there will often be uncertainty as the partner is unlikely to be diagnosed unless clear symptoms are present.

2

‘Herpes' is a condition that has been subjected to unnecessary hype and is now highly stigmatised. Many patients aren't unduly affected by physical symptoms but are psychologically devastated when diagnosed. Referring to the condition as ‘cold sores on the genitals' and explaining the parallel with chicken pox (herpes varicella) allows the patient to put the condition in context and helps to contain stigma.

3

Be alert to the possibility of non-genital symptoms. Facial recurrences may occasionally affect the eye or the brain. Genital reactivation from the sacral ganglion may cause symptoms in the anogenital region and even down the back of the leg, sometimes accompanied by ‘sciatica' or other types of neuralgia – burning skin, itching, aching or jabbing sensations.

4

Herpes simplex types 1 and 2 are clinically indistinguishable. Patients will present reporting malaise, followed by localised pain or itching. Signs include small vesicles or fissuring. Look under the foreskin or in the folds of the labia as lesions may be small and easily missed.

Swabs are best taken from the base of a freshly pierced blister and PCR-based methods are preferable to viral culture. Typing should be done as a type 1 result may be reassuring to the patient since the majority of future contacts will already carry type 1 antibodies. Dysuria may cause women to attribute primary symptoms to cystitis, but cystitis is characterised by frequent urination, whereas genital herpes affects the urethra and stifles the desire to urinate.

In rare cases, catheterisation may be required. In patients with recurrences that do not respond to antivirals, consider an additional or differential diagnosis. These include Behcet's syndrome, eczema, pemphigus vulgaris and lichen sclerosus.

5

If the infection is severe enough to treat, prescribe a five-day course of aciclovir even if diagnosis is still uncertain. It's a cheap, safe treatment and will have helped the patient if HSV is confirmed. British Association for Sexual Health and HIV (BASHH) treatment guidelines are summarised in the box on the left. Lidocaine 5% ointment can ease discomfort and may speed healing. There is no place for topical aciclovir in primary infection.

6

Look out for neuralgia in the affected dermatome. This can be treated with analgesics and/or systemic aciclovir.

7

Refer patient to GUM clinic immediately if symptoms are not clear. When diagnosis is obvious, suggest patient visits a clinic for a full screening in a few weeks, when symptoms of herpes simplex have resolved.

8

Reassure patients the condition may be painful and is stigmatised but is seldom medically serious. Most patients do not suffer frequent recurrences but these are more likely with HSV2. C-sections are no longer routine when the patient has a recurrence at term and the risks of vaginal delivery for the fetus are small and must be set against risks to the mother of the operation.

Advice on pregnancy, transmission, relationships and stigma is available from the Herpes Viruses Association website and helpline. HVA patient cards to hand out are available free on request.

9

Offer prophylactic aciclovir to patients who are having frequent recurrences – more than six a year – or if symptoms are perceived to be a problem by the patient. Latest BASHH prescribing advice is summarised in the box below.

10

Offer type-specific antibody test to partner if required. The results could reduce stress and recurrences if both partners are found to have the same type.

Dr Phil Hammond is a GP in Bristol and patron of the Herpes Viruses Association

Competing interests: None declared

Patients can contact the HVA at info@herpes.org.uk or on the helpline 0845 123 2305

Prescribing recommendations

First episode (all for five days)
• Aciclovir 200mg five times daily
• Aciclovir 400mg three times daily
• Valaciclovir 500mg twice daily
• Famciclovir 250mg three times daily
Episodic treatment (all for five days)
• Aciclovir 200mg five times daily
• Aciclovir 400mg three times daily for three to five days
• Valaciclovir 500mg twice daily
• Famciclovir 125mg twice daily
Prophylactic treatment
• Aciclovir 400mg twice daily
• Aciclovir 200mg four times daily
• Famciclovir 250mg twice daily
• Valaciclovir 500mg once daily

Genital herpes

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