( To view figures please refer to the Herpes Gallery page ).
Acute genital herpes is an extremely painful condition. The patients initially present with intense dysuria over several days. They then develop pain, blisters, discharge and female patients can go into urinary retention. (Figs. 1 to 6) The urinary retention is a direct consequence of the extreme pain and is not thought to be neurological, so relief of pain can overcome this. It is caused by Herpes Simplex Type 1 or Type 2, and can develop in a perfectly stable monogamous relationship, so although sexually transmissible, is not always sexually transmitted and suspicion of partner infidelity can add distress, as this is often unfounded.
Diagnosis is by history and appearance. There are multiple shallow ulcers that are intensely painful. There is usually inguinal adenopathy. The patient is often feverish with muscle aches and pains, typical of any systemic viral illness. If there is a possibility of doing a viral swab from one of the ulcers, that should be done, but treatment should not be delayed whilst this is being organised. Most units use viral culture and this requires live virus from the base of a fresh ulcer. If the patient has applied any topical cream this needs to be wiped off first. A fresh blister is also a good source of virus but care needs to be taken when bursting the blister that none of the vesicle fluid sprays on the swab taker (Figs 7, 8a, 8b). It is usually unnecessary and too painful to insert a speculum to view the cervix. However if there is uncertainty about the diagnosis and minimal lesions at the vulva, typical ulcers may be seen on the cervix (Fig 9).
The sooner anti-viral drugs are taken, the better. There is no advantage of intravenous over oral, so oral Acyclovir, Valiciclovir or Famciclovir should be initiated as soon as possible. Most cases presenting to A&E and Gynaecology are at the severe end of the spectrum and in this situation it is best to double up the standard dose. This will slowly stop the virus multiplying over about twelve hours. In women there is usually extreme discomfort passing urine and EMLA or Lignocaine gel can be applied to the area a few minutes prior to passing water, in the hope of relieving this. Having a pee in the bath or an upturned shower is also helpful, as it immediately dilutes and dissipates the urine away from the painful ulcerated areas. Sometimes intramuscular Pethidine is needed.
CATHETERISATION OR NOT
This is a grey area. Traditionally a suprapubic catheter was put in, but this is a cumbersome procedure, not without its consequences. A urethral catheter in theory may push the virus up the urethra into the bladder. However, most clinicians agree that if the patient has already taken some anti viral medication at least half an hour beforehand, then with lots of local anaesthetic a urethral Jaques or in/out rigid catheter, just to drain the bladder once, can be used. Hopefully, by the time the bladder has refilled the situation will have resolved enough to allow the patient to urinate spontaneously a few hours later.
Severe acute genital herpes in pregnancy can cause enough systemic illness to even induce a spontaneous abortion, so it is appropriate to treat severe cases with oral medication during pregnancy. Obviously, all drugs are avoided whenever possible in the first trimester and Acyclovir has been around for over 20 years now with no evidence of teratogenicity in any trimester. Indeed, many units use Acyclovir in the last month of pregnancy in women who have frequent recurrences in the hope of avoiding the presence of recurrences around the time of delivery.
CHRONIC OR RECURRENT HERPES
Some unfortunate patients get frequent recurrences. This is largely dependent on the ability of their immune system to suppress the viruses and is genetic. Many patients however describe factors that they consider a trigger and some of these factors can be modified. Ultraviolet light, whether from sunshine or sun beds is a recognised irritant and patients should be told of this – especially if there is evidence of sun bed use (Fig 10)
Episodic treatment, where patients treat themselves with anti herpes medication as soon as they feel a recurrence coming on, suits some but others are so distressed by any recurrences they need maintenance therapy with low dose medication on a continuing basis.
Recurrences are usually small and in the same location each time but new sites are not uncommon .i.e buttock (Fig 11).