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Genital herpes
Background
Overview
Definition
Genital herpes is a sexually transmitted viral infection characterized by primary and recurrent genital inflammation and lesions.
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Pathophysiology
Genital herpes is mostly caused by HSV-2 and HSV-1 transmitted through sexual contact.
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Epidemiology
The incidence of genital herpes in North America is estimated to range from 5,000 to 24,000 per 100,000 people per year.
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Disease course
Clinical manifestations include lesions of mucous membrane presenting as bilateral clusters of macules, papules, followed by vesicles, pustules, and ulcers on the external genitalia with symptoms of pain, itching, burning, dysuria, lymphadenopathy, fever, cervicitis (women), and proctitis (homosexual men). Complications in women include aseptic meningitis and urinary retention. Recurrent episodes may show prodromal symptoms of paresthesia and pains in the area of lumbosacral dermatomes. Asymptomatic genital shedding without any clinical symptoms is quite frequent. The disease increases psychological stress with frequent recurrences.
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Prognosis and risk of recurrence
Untreated pregnancy-related genital herpes is associated with a mortality of 0.062 per 1,000 births in neonates.
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of genital herpes are prepared by our editorial team based on guidelines from the British Association for Sexual Health and HIV (BASHH/RCOG 2025), the European Association of Urology (EAU 2025), the U.S. Department of Health and Human Services (DHHS 2025), the American Academy of Family Physicians (AAFP 2024), the U.S. Preventive ...
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Screening and diagnosis
Diagnostic investigations
Initial assessment: as per EAU 2025 guidelines, elicit a comprehensive medical history, including a history of previous sexual contacts, from all patients presenting with genital ulcers potentially related to HSV.
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Laboratory testing
Medical management
Management of first episode: as per EAU 2025 guidelines, administer any of the following regimens for the management of a first clinical episode of genital HSV infection:
aciclovir: 400 mg PO TID for 10 days, or; 200 mg PO 5 times daily for 10 days
valaciclovir: 500 mg PO BID for 10 days.
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Management of recurrent episode
Specific circumstances
Pregnant patients, evaluation: as per BASHH/RCOG 2025 guidelines, obtain PCR testing from ulcers, including type-specific HSV, VZV, and Treponema pallidum for syphilis. Consider obtaining enterovirus PCR testing where available, and Mpox and lymphogranuloma venereum PCR, depending on risk factors, in addition to testing for other tropical ulcerative diseases.
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Pregnant patients (antiviral therapy)
Pregnant patients (symptomatic management)
Pregnant patients (suppressive therapy)
Pregnant patients (considerations for delivery)
Neonates
Patients with HIV (primary prevention)
Patients with HIV (secondary prevention)
Patients with HIV (antiviral therapy)
Patients with HIV (pregnant patients)
Patients with HIV (pediatric patients)