What is the presentation of primary genital herpes simplex virus (HSV) infections?

Updated: Feb 27, 2019
  • Author: J Michael Klatte, MD; Chief Editor: Russell W Steele, MD  more...
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Primary infection occurs in the absence of preexisting antibodies to herpes simplex virus, either HSV-1 or HSV-2. First episode nonprimary infections occur in the absence of any previous signs or symptoms of genital herpes but in the presence of preexisting heterologous antibodies. Formerly, HSV-2 accounted for 80-90% of herpes genitalis, however, HSV-1 has been associated with an increasing prevalence of genital outbreaks. [48]  

Primary infection

Primary, symptomatic, first-episode genital infections are characterized by severe constitutional symptoms, including fever, malaise, and myalgias. [2] Itching and pain usually are the initial symptoms, followed in 24-48 hours by more troublesome signs and symptoms.

Lesions evolve from vesicles to pustules to wet ulcers and heal by crusting. New lesions develop over 7-8 days, and are primarily distributed over the labia majora, labia minora, mons pubis, vaginal mucosa, cervix, and on the shaft of the penis. Painful inguinal lymphadenopathy, dysuria, and vaginal discharge are frequent complaints. Complications in both sexes can include paresthesias of the legs and perineum. Urinary retention, more common in women than in men, may be reported. Approximately 85% of women report vaginal discharge, with 25% of men reporting urethral discharge [18] . Mean duration of viral shedding is 12 days.

Preexisting antibodies to HSV-1 have an ameliorating effect on the severity of disease caused by HSV-2. Previous orofacial infection with HSV-1 generally protects a person against genital infection with HSV-1 but not HSV-2.

Most primary genital herpes simplex virus infections are asymptomatic, and 70-80% of seropositive individuals have no history of symptomatic genital herpes. Periodic subclinical recurrences with viral shedding make these individuals sources of infection, however. [49]

Nonprimary first episode infections have lower frequencies of systemic symptoms, fewer lesions and more rapid healing of those lesions than in patients with primary infections, presumably due to preexisting heterologous antibodies.

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