Genital Herpes

Microbiology

  • Herpes simplex virus (Mainly type 2 (anogenital type)- although Type 1 now becoming more predominant as a cause for genital herpes)
  • Usually sexually transmitted and symptoms classically occur 1 week post-exposure
    • Can be transmitted by oral sex, autoinnoculation,

Clinical picture

  • Multiple small painful ulcers on genitalia (begin as small irritable vesicles which rupture)
    • These are usually painful and may cause dysuria, urethral or vaginal discharge or anal/perianal/rectal pain
  • The primary infection may also have flu-like symptoms but can also be completely asymptomatic
  • First episode tens to heal within 2-4 weeks without treatment
  • Virus can lie dormant for long periods of time in the sacral ganglion
  • Recurrence is common, and are usually decreasing in  frequency and may not be as severe (particularly of type 2 infection)
  • Rarely, complications such as urinary retention (due to autonomic neuropathy) and aseptic meningitis can occur

Diagnosis

  • Swab of deroofed vesicles/ulcers for HSV PCR
  • NOT blood test (likely to be false positive in most individuals)

Management

  • Aciclovir orally (200mg 5x/day)
  • Lidocaine gel topically (for pain management)
  • Discuss asymptomatic shedding with patients- even in bouts without symptoms the individual can still be infective
  • Discuss risks in pregnancy- particularly primary infection during pregnancy as there will not be any maternal antibody present yet.

Management in Pregnancy

  • In general- any episode in pregnancy should be treated with antivirals
  • Vaginal delivery is ok for women who are asymptomatic in the third trimester/late pregnancy but caesarean section should be considered if there is a recurrence close to labour (>34 weeks)

Chancroid

  • Chancroid is the most common cause of genital ulceration worldwide
  • H ducreyi is an organism responsible
  • Presents as an erythematous papular lesion which breaks down into a painful bleeding ulcer with a necrotic base and ragged edge
  • Diagnosis is with lesion culture and PCR, which, in most cases, identifies H ducreyi
  • Treatment is with either
    • Azithromycin 1g oral single dose
    • Ceftriaxone 250mg IM single dose
    • Ciprofloxacin 500mg oral single dose or 500mg oral BD for 3 days
    • Erythromycin 500mg oral QDS for 7 days (recommended also for patients with HIV)
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