GPAtlas🧭 When to suspect
Genital herpes is a common, lifelong sexually transmitted infection (STI) caused by the herpes simplex virus (HSV) – the same family of virus responsible for oro-labial cold sores. There are two types: HSV type 1 (HSV-1), the usual cause of cold sores and now the commonest cause of genital herpes in the UK, and HSV type 2 (HSV-2), which causes more frequent anogenital recurrences. After the first infection the virus becomes latent in local sensory nerve ganglia and reactivates periodically, causing recurrent lesions or silent (asymptomatic) but infectious viral shedding.
The practical task in primary care is threefold: recognise the clinical picture and confirm it by swabbing a lesion, treat early and by episode type, and counsel sensitively – this last point matters as much as the prescription. Most of the management evidence comes from the British Association for Sexual Health and HIV (BASHH).
| Feature | First (initial) episode | Recurrent episode |
|---|---|---|
| Typical severity | Often more severe and prolonged | Usually milder and shorter |
| Systemic symptoms (fever, headache, myalgia) | Common, especially in primary infection | Uncommon |
| Lesions | Often bilateral and extensive, with tender bilateral inguinal nodes | Usually unilateral, confined to one favoured site |
| Prodrome (tingling, burning, itching) | May be absent | Often precedes the lesions |
| Duration | Up to 2–3 weeks | Often self-limiting within about 7–10 days |
Suspect genital herpes in anyone with painful genital, perianal, or buttock blisters, sores, or ulcers, particularly with a preceding prodrome. Risk is higher with a new or multiple sexual partners, unprotected sex, a partner with known genital or oro-labial herpes, immunosuppression (for example HIV), or other STIs. Note that symptoms can appear months or years after infection, and there is no screening test – diagnosis rests on swabbing a lesion while one is present.
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🧠 Clinical pearl In the UK, HSV-1 – the cold-sore virus – has overtaken HSV-2 as the commonest cause of genital herpes, particularly in younger adults. This matters prognostically: genital HSV-1 recurs far less often than genital HSV-2 (a median of roughly one recurrence a year versus around four). Always type the virus from the swab – it lets you give a realistic picture of likely recurrences rather than a one-size-fits-all warning. |
Source: BASHH 2024
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