Genital Herpes

Comments from Expert Advisory Group

1. Genital Herpes can be caused by either herpes simplex virus (HSV) 1 or 2. HSV-1 is now the most common form of genital herpes in Ireland.
2. Following direct inoculation to the genital area, individuals can experience a prodromal viral illness, genital itch, vesicles and / or painful ulceration with painful regional lymphadenopathy within seven days of infection. The genital ulceration will spontaneously clear and thereafter the virus remains dormant in local sensory ganglia and can reactivate periodically resulting in symptomatic lesions or asymptomatic, but infectious, viral shedding.
3. The likelihood of recurrence is greater with HSV-2 than HSV-1 and the likelihood of recurrences and asymptomatic viral shedding reduces over time.
4. The diagnosis can be suspected clinically but should be confirmed with a HSV NAAT swab of the lesions to determine if HSV-1 or HSV-2. HSV NAAT swabs are available to order from the NVRL
5. Treatment should be started on the basis of reasonable clinical suspicion.
   • Topical antiviral medication is not as effective as oral antiviral medication.
   • Simple oral analgesia and local anaesthetic cream (e.g. Instillagel^®, EMLA^® cream)
   • Advise micturition into bath water to relieve dysuria
   • Hospitalisation may be required for urinary retention, meningism or severe constitutional symptoms.
6. Advise patients about minimising transmission of infection to others:
   • Advise to abstain from sexual activity (including non-penetrative and oro-genital sex) if lesions are present, until follow-up or until lesions have cleared.
   • Patients diagnosed with HSV-2 should be advised to avoid sexual contact when they have symptoms of genital herpes unless it is known that their sexual partner has already been exposed to HSV-2.
   • Advise that transmission is possible when there are no symptoms ('asymptomatic shedding'), but more likely when a person is symptomatic.
7. Some patients experience great difficulty adjusting to a genital herpes diagnosis.  The Herpes Viruses Association in the UK is an excellent resource for additional patient support.
8. Individuals diagnosed with genital herpes should be offered testing for other STIs including HIV, hepatitis B, syphilis, chlamydia and gonorrhoea. It is reasonable to do a vulvovaginal swab for chlamydia / gonorrhoea  at initial presentation if the patient can tolerate same.  A speculum exam at time of acute infection is rarely indicated and should be deferred.
9. Hepatitis C (HCV) testing should be considered part of routine sexual health screening in the following circumstances: gay, bisexual or other men who have sex with men (gbMSM); people living with HIV; commercial sex workers; people who inject drugs (PWID). Partners of the above should also be considered for HCV testing.
10. Pregnant patients with a history of genital herpes should inform their obstetrician of this history and have a referral to a GUM clinic for management, particularly if the patient is experiencing frequent recurrences.
11. Patients presenting with genital herpes for the first time in pregnancy should have the diagnosis confirmed, treatment started and be referred to a GUM clinic. The obstetric team should be made aware of a person presenting with a first episode of genital herpes in the third trimester to discuss their birth plan.
12. Patients presenting with frequent recurrences (≥ one per month) should be offered suppressive therapy and may be best managed at a GUM clinic.
13. Genital Herpes Simplex is a notifiable disease. The complete list of notifiable diseases and information on the notification process is available at HPSC

Treatment

Antiviral treatment should be initiated as soon as possible following symptom onset.

Patient information

• Genital herpes patient information leaflet
• Patient information on STIs and genital conditions is available at the HSE Sexual Health and Crisis Pregnancy website
• Herpes Viruses Association in UK
• Information on the free HSE home STI testing service

Safe Prescribing

Visit the safe prescribing page

• Doses are oral and for adults unless otherwise stated
• Renal impairment dosing table
• Safety in Pregnancy and Lactation
• Drug interactions tables
• Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).

Reviewed May 2024