History
A 29-year-old woman presents to the emergency department having been unable to pass urine for 8 h. For the last 3 days she has been feeling unwell with a fever, shivering and a reduced appetite. She has pain in her groins specifically but says that her whole body aches. Yesterday she began to feel pain on passing urine, and today this has became very severe such that now she cannot micturate at all. She has never experienced any episodes like this before. She has no previous medical or gynaecology history and has regular men-strual cycles. She recently ended a long-term relationship and has been with a new partner for a few months, with whom she uses condoms.
Examination
The woman is obviously in significant discomfort. Her temperature is 37.4°C, heart rate 102/min and blood pressure 118/80 mmHg. Bilateral tender inguinal lymphadenopathy is noted and axillary lymph nodes are also palpable. The bladder is palpable midway to the umbilicus. The vulva is generally reddened and there is a cluster of ulcerated lesions of approximately 2–5 mm on the left side of the labia minora. Speculum examination shows the cervix is inflamed with a profuse exudate.
Questions
• What is the diagnosis?
• How would you further investigate and manage this patient?
Medicine
The woman is demonstrating a classic presentation of primary herpes simplex virus infec-tion. Prodromal ‘flu type symptoms and generalized lymphadenopathy usually occur most significantly with primary infection, and any subsequent attacks are more likely to pre-sent with vulval soreness as the only noticeable feature.
The woman probably acquired the infection from her new partner – condoms do not effect-ively prevent spread as the organism can spread from the perineum. In this case there is also evidence of herpes cervicitis from spread of virus particles into the vagina. Further investigation Vulval viral swab should be sent to confirm the diagnosis. This requires firm rubbing of the swab onto an ulcer and is very painful, but as the diagnosis has such profound social implications, confirmation of the diagnosis is imperative.
Management
• Immediate management:
• the woman should have an indwelling (preferably suprapubic) urinary catheter inserted immediately and be given analgesia and paracetamol
• local anaesthetic gel often relieves the pain and can be used until symptoms settle
• oral aciclovir started within 24 h of an attack reduces the severity and duration of the episode.
• Further management:
• referral to a health counsellor should be made to discuss the diagnosis and its implications
• some women have many recurrent attacks, whereas others never experience a fur-ther episode. For recurrent attacks aciclovir may be given again if commenced within 24 h of becoming unwell.
KEY POINTS
• Genital herpes simplex infection has a major psychosexual and social impact o sufferers.
• The first attack is generally severe and associated with primarily systemic features.
• Recurrent episodes may be hardly noticed; transmission may occur prior to the appearance of blisters and condoms do not prevent spread of disease and so it is difficult to limit.
• Aciclovir does not cure the disease but is effective at reducing the duration and severity of an episode.
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