PassFinals
Sexual Health

Genital herpes

Genital herpes is a lifelong HSV infection with latent virus in sensory ganglia, causing painful first episodes and usually milder recurrences; diagnosis, partner counselling, antiviral treatment and pregnancy planning are the core UK pathway.

In a nutshell

HSV establishes lifelong latency in sensory ganglia, causing painful first episodes and usually milder recurrences. Swab a fresh lesion for NAAT/PCR, offer timely antiviral and supportive treatment, test for other STIs, counsel on asymptomatic shedding and sexual transmission, and involve GUM, obstetric and neonatal teams for infection near delivery or severe disease.

Classic presentation

Painful grouped genital or perianal vesicles and ulcers with dysuria and tender inguinal nodes during a first episode; recurrences are shorter and milder and may follow tingling or burning.

Key points

  • HSV remains latent in sensory ganglia: antivirals shorten episodes but do not eradicate infection.
  • A first recognised episode may be primary, non-primary or a previously unnoticed recurrence; serology cannot date infection.
  • NAAT/PCR from a fresh vesicle or ulcer is the preferred diagnostic test; also screen for other STIs and HIV.
  • Supportive care and prompt oral aciclovir or valaciclovir help first episodes; use the current BNF for regimen and renal adjustment.
  • Suppressive therapy is a shared decision for frequent, severe or distressing recurrences or when reducing transmission is important.
  • Avoid sex from prodrome until lesions heal; condoms reduce but do not remove risk because asymptomatic shedding occurs.
  • First primary or non-primary infection late in pregnancy needs urgent joint planning; recurrent disease usually supports vaginal birth unless lesions, prodrome or obstetric factors change the plan.
  • Urinary retention, meningitis, hepatitis, disseminated disease, immunocompromise and neonatal illness require urgent specialist escalation.

First-line investigation

NAAT/PCR swab from a fresh vesicle or ulcer plus a full sexual-health screen and HIV testing according to risk.

Management

Test and treat the first episode

  • Swab a fresh lesion for NAAT/PCR, start prompt oral aciclovir or valaciclovir using the current BNF and provide analgesia and local care; assess hydration and urinary retention.1,6,2

Screen and classify

  • Offer a full STI and HIV screen, distinguish primary or non-primary infection from recurrence where it changes counselling, and use type-specific serology only for a defined clinical or pregnancy question.1,5,3

Manage recurrences and wellbeing

  • Offer supportive care or patient-initiated episodic treatment for troublesome recurrences, discuss suppressive therapy for frequent or distressing disease, and address sexual, psychological and partner concerns.1,2,6

Escalate pregnancy and severe disease

  • Arrange urgent GUM, obstetric and neonatal planning for infection near delivery, and involve virology or infectious diseases for retention, meningitis, hepatitis, disseminated, immunocompromised or neonatal disease.3,4,6

Prevent transmission and safety-net

  • Advise avoiding sex from prodrome until lesions heal, discuss barriers and disclosure without blame, explain asymptomatic shedding, and give urgent return advice for urinary retention, neurological or systemic illness and neonatal symptoms.1,2,3

Exam traps

  • A negative swab from a healing lesion does not safely exclude HSV.
  • Do not call a first recognised episode primary without considering prior HSV exposure; serology cannot date infection.
  • Antivirals reduce episode severity and duration but do not cure latency.
  • Recurrent genital herpes is not an automatic indication for caesarean birth; timing and infection type matter.
  • Suppressive treatment reduces recurrences and transmission risk but does not eliminate asymptomatic shedding.
  • A sick neonate or a pregnant patient with disseminated features needs urgent neonatal, obstetric, virology and infectious-disease input.

Illustrations

Genital herpes lesionsClustered vesicles and shallow ulcers of genital herpes simplex infection.NaNo327, Wikimedia Commons · CC-BY-SA-3.0
Grouped vesicles and erosions in genital herpesClinical photograph of grouped vesicles, pustules and shallow erosions on vulval mucosa in genital herpes infection.SOA-AIDS Amsterdam, Wikimedia Commons · CC-BY-SA-3.0

Key sources

  1. BASHH: UK national guideline for the management of anogenital herpes, 2024 (Current UK adult guideline for lesion PCR, first episodes, recurrences, suppressive treatment, transmission counselling, proctitis and patient-centred care.)
  2. NHS: Genital herpes (Current NHS advice on symptoms, lesion swabbing, self-care, recurrence, transmission, HIV and pregnancy safety-netting.)
  3. Joint BASHH/RCOG: UK guideline for HSV in pregnancy and the neonate, 2024 (Current UK pregnancy and neonatal guideline for maternal infection timing, serology, antiviral suppression, mode of birth, neonatal risk stratification, breastfeeding and specialist MDT planning.)
  4. RCOG: Management of genital herpes in pregnancy (Current RCOG landing page confirming the joint BASHH/RCOG pregnancy guideline, its replacement of the archived Green-top guideline and the stronger support for vaginal birth in recurrent infection.)
  5. BASHH: Summary guidance on testing for sexually transmitted infections, 2023 (UK STI-testing guidance supporting a full sexual-health screen and risk-based HIV, syphilis, chlamydia and gonorrhoea testing.)
  6. BNF online: aciclovir, valaciclovir and current antiviral prescribing information (Use the current BNF and specialist protocol for regimen, renal adjustment, pregnancy, immunocompromise, intravenous treatment, interactions and monitoring; no fixed dose is reproduced in rapid-revision text.)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.