Primary care

Genital herpes

Pippa Oakeshott, senior lecturer ^a, Phillip Hay, senior lecturer ^b. 

^a Department of General Practice, St George's Hospital Medical School, London SW17 0RE, ^b Department of Genitourinary Medicine, St George's Hospital Medical School

Correspondence to: P Oakeshott oakeshot{at}sghms.ac.uk

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

Top What issues you should... What you should do

Sexual historyHas 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 herpesExplain 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.)

Partner notificationAdvise 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 infectionScreening 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 transmissionExplain 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.

TreatmentMany 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.

RecurrencesMany 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.

PregnancyHerpes 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

Top What issues you should... 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.

	Footnotes

The series is edited by Ann McPherson and Deborah Waller

The BMJ welcomes contributions from general practitioners to the series