A young woman returns for a vulval swab result for “cold sore virus.” She was seen a week ago complaining of being sore “down below” and pain on passing urine for one week. A urine dipstick test was negative, but on examination she had two 1 mm red spots on her labia minora and a 0.5 cm linear fissure (“scratch”). There were no vesicles, ulcers, or inguinal glands. After she had been told that this could be due to cold sore virus infection, the lesions were swabbed and sent for culture in viral transport medium. The laboratory report confirmed herpes simplex virus type 1.
What issues you should cover
Sexual history—Has she had these symptoms before? Has she got other symptoms? When did she last have sexual intercourse? How long has she had a sexual relationship with her partner? Has he got symptoms? Has she had sex with anyone else in the past six months?
Implications of genital herpes—Explain that genital herpes is a sexually transmitted infection caused by the cold sore virus. It is common and relatively harmless. As it often causes few symptoms she may have become infected some time ago. (Both herpes type 1 and 2 can cause genital ulceration; type 1 also causes facial cold sores.)
Key points
As genital herpes is an incurable, emotive infection, diagnosis must be confirmed by culture
All general practices should have supplies of viral transport medium, genitourinary clinic leaflets, and patient information leaflets on genital herpes
To reduce risk of transmission patients should be advised to use barrier methods and to avoid sexual intercourse when symptomatic
Patients with genital herpes should be screened for other sexually transmitted infections, especially chlamydia
Partners should be notified
Patients may need psychological support—for example, from the Herpes Viruses Association's helpline (tel 020 7609 9061; www.herpes.org.uk)
Partner notification—Advise her to be open with her partner about herpes. Often it is passed on by someone unaware of being infected. Both should be checked for other infections.
Screening for sexually transmitted infection—Screening is probably best done in a genitourinary clinic, where experts provide a thorough check up, treatment is free and confidential, and health advisers offer information and support.
Reducing risk of transmission—Explain that she can have sex unless she has active sores or feels an outbreak coming on, when she should avoid sexual contact until the sores have healed. However, even when she is well a small risk of transmission remains. This can be reduced by consistent condom use. (Female to male infection rate is less than 5% a year.) Condoms also protect against other infections.
Treatment—Many infections are mild, and symptomatic treatment usually suffices. Primary herpes may be severe, classically presenting up to seven days after sexual contact with multiple, painful genital ulcers, often with inguinal lymphadenopathy. For the first acute episode genitourinary referral is recommended, especially if tropical travel suggests other possible causes of ulcers. Aciclovir 200 mg five times daily for five days (cost £6) reduces pain, duration, and viral shedding. It is most effective if started within six days of onset. Later treatment or topical aciclovir has little effect.
Useful reading
Health Education Authority. Genital herpes. London: HEA, 1997.
McCormack S. The diagnosis and management of genital ulceration. In: Barton SE, Hay PE, eds. Handbook of genitourinary medicine. London: Arnold, 1999:97-121.
Drake S, Taylor S, Brown D, Pillay D. Improving the care of patients with genital herpes. BMJ 2000;321:619-23.
Update on drugs for herpes zoster and genital herpes. Drug Ther Bull 1998;36:77-9.
Recurrences—Many patients never notice a recurrence. (Recurrences are more likely with type 2 or if the first episode is severe.) Symptoms are generally milder, and no specific treatment is needed. If she has six or more recurrences a year consider referral for suppressive treatment. This prevents symptomatic recurrences in up to 80% of patients but is expensive.
Pregnancy—Herpes is rarely a problem unless the first ever episode is during pregnancy. She should be checked for signs of infection at the onset of labour. Risk of neonatal herpes in the United Kingdom is less than 2 per 100 000 live births.
What you should do
Advise dilute salt baths and paracetamol, with no sex until completely better.
Refer her to the genitourinary clinic for partner notification and an infection screen. Alternatively, take endocervical swabs for chlamydia and gonorrhoea and ask her to advise her partner to get checked.
Offer her a genital herpes leaflet and the telephone number of the local genitourinary clinic health advisers.
This is part of a series of occasional articles on common problems in primary care
Footnotes
The series is edited by Ann McPherson and Deborah Waller
The BMJ welcomes contributions from general practitioners to the series