Genital Infection

Genital herpes is the major clinical presentation of HSV-2 infection, but it may also
result from HSV-1 in 10 to 40 percent
of the cases, primarily ones following oralgenital contact. Because of their
epidemiology, acquisition of HSV-1 in a
person with prior HSV-2 infection is unusual, but HSV-2 acquisition in the presence
of previous HSV-1 infection is
common, and infection of the genital tract with both HSV-1 and HSV-2 has been
described. Patients with previously
known HSV-1 genital infection who develop frequent genital herpes recurrences
should be tested for HSV-2 infection. 24
The clinical courses of acute first-episode genital herpes among patients with HSV-1
and HSV-2 infections are similar.
These infections are associated with extensive genital lesions in different stages of
evolution, including vesicles,
pustules, and erythematous ulcers that may require 2 to 3 weeks to resolve ( Fig.
214-3). In males, lesions commonly
occur on the glans penis or the penile shaft; in females, lesions may involve the
vulva, perineum, buttocks, vagina, or
cervix. There is accompanying pain, itching, dysuria, vaginal and urethral discharge,
and tender inguinal
lymphadenopathy. Systemic signs and symptoms are common and include fever,
headache, malaise, and myalgias.
Herpetic sacral radiculomyelitis, with urinary retention, neuralgias, and constipation,
can occur. HSV cervicitis occurs in
more than 80 percent of women with primary infection. It can present as purulent or
bloody vaginal discharge, and
examination reveal areas of diffuse or focal friability and redness, extensive
ulcerative lesions of the exocervix, or, rarely,
necrotic cervicitis. Cervical discharge is usually mucoid, but it is occasionally
mucopurulent.
FIGURE 214-3 A. Primary genital herpes with vesicles. B. Primary herpetic vulvitis. (
Courtesy of Clyde S. Crumpacker,
MD.)
The rates of recurrence for genital HSV-2 infections vary greatly among individuals
and over time within the same
individual. Infections caused by HSV-2 reactivate approximately 16 times more
frequently than HSV-1 genital infections,
and average 3 to 4 times per year, but may appear virtually weekly. 6 Recurrences
tend to be more frequent in the first
months to years after first infection. 6 The classical clinical manifestations of recurrent
HSV-2 infection include multiple
small but grouped vesicular lesions in the genital area. They may ulcerate promptly
in women, some days later in men.
The recurrence of genital lesions is usually heralded by a prodrome of tenderness,
itching, burning, or tingling. Without
treatment, the lesions usually heal in 6 to 10 days. Herpetic cervicitis is less common
in recurrent disease, occurring in
12 percent of the patients. It may present without external lesions. Signs and
symptoms that are less classical for genital

HSV infection and which may divert one from the correct diagnosis include small
erythematous lesions, fissures, pruritus,
and urinary symptoms. HSV can cause urethritis, usually manifested only as a clear
mucoid discharge, dysuria, and
frequency. Occasionally, HSV can be associated with endometritis, salpingitis, or
prostatitis. Symptomatic or
asymptomatic rectal and perianal infections are common. Herpetic proctitis presents
with anorectal pain, anorectal
discharge, tenesmus, and constipation, with ulcerative lesions of the distal
rectal mucosa.