The combination of HSV and candidiasis seems to commonly affect diabetic women and may cause serious problems. Complications of acute genital herpes at distant sites include autoinoculation which frequently affects the fingers (i.e. herpetic whitlow). Dissemination rarely occurs except in the immunocompromised individual or during pregnancy where mild immunosuppression occurs. Neurological symptoms (e.g. headache, neck stiffness, photophobia) frequently occur in primary genital herpes but encephalitis and transverse myelitis are rare.
History
A detailed history including a sexual history should be obtained. The physician should ask particularly about partners, sexual practices and use of recreational drugs (including alcohol) which will influence use of safe sex practices. Obtaining a good patient history is highly predictive of diagnosis of genital herpes with a specificity of more than 90%.
Laboratory confirmation of diagnosis
A clinical diagnosis of genital herpes should be confirmed by laboratory techniques. A positive culture for HSV is still the best test to confirm a clinical diagnosis of genital herpes at first presentation. Culture has the advantage that typing and, if necessary, acyclovir sensitivity testing can also be performed. Specimens for culture should be taken from several sites. If the culture result is negative a second culture should be performed. Alternatively, some antigen detection tests may also be useful if culture is not available. Serological testing, including use of the Western blot assay, is not the method of choice for diagnosis of first-episode genital herpes.
Differential diagnosis
Worldwide, HSV is the most common infective cause of genital ulceration. The old rule that ‘genital ulceration is due to syphilis unless proven otherwise’ could now be replaced by the statement: ‘genital ulceration is due to herpes unless proven otherwise’.
In the long-term, the consequences for the individual with genital herpes can be severe. They include psychological and social morbidity, and the potential for neonatal transmission, transmission to partners and recurrences.
‘Atypical’ genital herpes
Extragenital lesions occur commonly in 16% of patients with primary genital herpes, 8% of non-primary genital herpes and 4% of cases of recurrent genital herpes. Extragenital lesions commonly affect the buttock, groin or thigh and are more frequent in females than in males. Cutaneous extragenital lesions recur as frequently as genital lesions. Diagnosis of an ‘atypical’ case of genital herpes may be easier if a good patient history is taken. A history of recurrences at the same site, with healing taking 4-7 days suggests genital herpes.
Management of Genital Herpes
First presentation
Management of the patient with first-episode genital herpes should include both the clinical symptoms and the psychological impact of the diagnosis of genital herpes on the patient. Optimal management of the patient with genital herpes is not simply a prescription for an antiviral drug, but should also address the patient’s clinical and emotional issues. Such management is time-intensive.
The patient should be asked to return for a second visit during the following week. Some patients may need to be admitted to hospital for a short period at the first episode.
Management at first presentation is critical to the patient’s subsequent recovery and adjustment to the disease. Good management will help the patient to cope well with the diagnosis, whereas poor management may lead to subsequent stigmatization. The physician should show a caring attitude, ask the patient open, non-judgmental questions and develop the patient’s trust to be able to ask about other STDs including HIV.
Clinical management: The first stage is diagnosis of genital herpes. To the experienced physician the combination of signs and symptoms leading to a diagnosis of genital herpes is straightforward.
The patient should be reassured that recurrences of genital herpes are usually less severe than the primary episode (except when the first episode is actually a recurrence). The physician should explain clearly, in language that the patient can understand, that the virus becomes latent and may recur.
The physician should give the patient sufficient information such that he/she can decide on the appropriate management of their disease. Antiviral therapy will alleviate the symptoms in first-episode genital herpes. Many studies have shown that acyclovir is effective in the treatment of primary and non-primary episodes of genital herpes. Treatment of first-episode genital herpes should include counseling on emotional issues.
Specific symptoms should be addressed. Hospitalization may be necessary for treatment with intravenous antiviral or to treat acute urinary retention or pain.
Psychological management: Management of the patient with genital herpes requires considerable time. Some physicians find that an experienced nurse practitioner, physician assistant or nurse can help in the psycho social management of the patient with genital herpes.
If the patient is referred to a specialist centres for counseling, the diagnosing physician should still address the acute issues at the first presentation.
Not all patients will want to take up the offer of counseling and support, nevertheless it should be offered to all.
The following guidelines should be considered:
Counseling should take place in a comfortable setting The patient should be dressed Interruptions should be minimized The session should be kept confidential The physician/counselor should stop taking notes (notes can be written up later) Terms that are pejorative or prejudiced should be avoided Listen to the patient The physician/counselor should show that he/she cares for and understands the patient The patient should be given the necessary time Give the patient information to take away and read The patient should be encouraged to return with a list of questions
The education process may include answering questions about the natural history of the disease including the likely triggers for reactivation. Little solid data exist, but patient experience suggests that stress appears to be associated with outbreaks in some patients. Advice on how to manage stress and lead a healthy lifestyle (exercise, good diet etc) should be given with care. Too much advice on lifestyle may be stressful for the patient, heighten feelings of guilt and the belief that the disease is self-inflicted.
Correct management of acute genital herpes is time-intensive. The likely impact of the disease on the patient and how well they are coping should be assessed. Psychological issues and concerns should start to be addressed at the first session. Many patients will be worried about the risk of having acquired HIV or other STDs, that they are seen to be promiscuous and may be worried about the doctor’s opinion of them. In all cases (whether primary, non-primary or first symptomatic reactivation) the emotional consequences of the disease need to be addressed. The diagnosis of genital herpes will provoke a shock reaction in many patients and cause feelings such as guilt, anger, confusion and a sense of isolation.
Patients with genital herpes are usually very concerned about the diagnosis of the disease, its potential impact on their lives and how they will be viewed by their family and friends. Common concerns of patients relate to the social stigma of the disease, transmitting the disease, fear of telling potential sexual partners who may then reject them and how it will affect both their sex life and their social activities. Patients should be reassured that they are not alone in having genital herpes. The physician or counselor could offer information about local genital herpes support groups.
First recurrence
Patients should be asked to return to see the physician at the first recurrence.
At the first recurrence it may be useful to suggest that the patient keeps a symptom diary. This helps to educate the patient about their disease. If patients are treated with episodic antiviral therapy, recognition of the prodrome preceding an outbreak of genital herpes will allow the patient to start the drug immediately. The first recurrence may be the best time to tell the patient about local support groups.
Long-term management
Patients with few recurrences may be best managed with episodic antiviral therapy or no therapy, whereas those with more frequent recurrences may find suppressive therapy more beneficial. Medical indicators considered when evaluating the potential suitability for suppressive therapy are the frequency, duration, severity and psychological impact of recurrences. Psychological factors considered are whether the patient is psychologically affected by genital herpes, if the patient is withdrawn, frightened, unable to function and whether the patient’s sex life is affected by recurrences (e.g. in new relationships the patient may feel a greater need to use therapy than in an established relationship). In some cases suppressive therapy may be indicated if the psychological impact of genital herpes on the patient is great. The patient should be made to feel empowered to use antiviral therapy.
Involving the Partner in Treatment Programs
The diagnosing physician should establish whether the patient with genital herpes has a partner, and if they do, the partner should also be invited to attend the clinic. The partner should be seen individually at first and then, if the couple agree, the patient and his/her partner should be seen together. Counseling of patients and their partners requires different skills from counseling individual patients and should only be tackled by those with appropriate skills and experience. In this case, referral to an appropriate counselor might be considered or specific training in couples counseling undertaken.
Counseling the patient and partner
As mentioned above, counseling of couples is best approached only by those experienced in this area. The physician/counselor should acknowledge at the first visit that the partner’s decision to be included in the treatment program is to be commended and is a positive sign, since many partners do not wish to be involved in the treatment and counseling for genital herpes.
PRESS RELEASE
IHMF Meets to Address the Increase in Genital Herpes
21 November 1997
A major international meeting to address the public health problems caused by the dramatic increase in genital herpes world-wide, highlighted by recent new data in the New England Journal of Medicine, takes place on 23-24 November 1997 in Cannes, France.
Genital herpes is caused by herpes simplex virus (HSV), with most cases attributable to the type 2 strain (HSV-2). It is estimated that 107 million people in western countries are now HSV-2 seropositive. A recent US survey showed that HSV-2 seropositivity increased by 32% from 1978 to 1990 and in the UK the number of new cases recorded in 1995 was 62% higher than in 1988. The authors of the New England Journal of Medicine paper argue that improvements in the prevention of genital herpes infection are urgently needed, particularly as genital ulcers have been implicated in aiding the transmission of HIV.
The meeting of the independent group of clinicians, the International Herpes Management Forum (IHMF), will bring together over 450 delegates to discuss the implementation of IHMF guidelines for the management of genital herpes, published in June 1997. The guidelines highlight the following disturbing findings:
60% of HSV seropositive patients have signs or symptoms of genital herpes infection which remain unrecognised. Only 20% of HSV seropositive patients have recognized symptoms. Of the patients who consult a physician, only 27% receive antiviral treatment.
“The increase in the incidence of genital herpes and the increasing number of cases that are undiagnosed and untreated is of major concern to us” commented IHMF spokesperson, Professor Richard Whitley of the University of Alabama, Birmingham, USA. “We are hoping that this meeting will identify how we can ensure patients get effective trea