Lana, 15, attends urgent care one bank holiday weekend. Three days ago her GP gave her nitrofurantoin for a presumed UTI. At triage she tells the nurse she has “the worst pain ever – even when I try to pee. It’s like razor blades only worse”. She has a fever of 38.1 and says her groins feel sore. When you examine her you find bilateral inguinal lymphadenopathy.
Dysuria is a common symptom in adolescents and adult women. It is commonly ascribed to UTIs, though, as a single symptom it has only, at best, a 30% positive predictive value. It is common to treat post-pubertal female patients with dysuria AND other suggestive symptoms (such as frequency, nocturia and/or cloudy urine) as uncomplicated lower UTIs. NICE/CKS remind us that dip-testing or culture is not necessary on the first presentation of UTI. Dysuria has many other causes, some of which are not relevant in children and adolescents but many of which are.
Lana has had 3 days of nitrofurantoin for a presumed UTI. It has got worse rather than better and so she needs more careful history taking and examination.
She has had stinging and burning for 3 days but no abdominal pain or frequency. If anything, she is going to the toilet less often as it hurts so much. She hasn’t had much to drink today as she is so scared of needing to pee. Now, her bladder feels uncomfortably full. It has been really sore when she wipes after the toilet and so she had a look and thinks her vulva looks “all manky and blistery”.
She feels all achy all over as if she has the ‘flu.
When you ask her about sexual activity she is adamant that she is a virgin. Further sensitive questioning reveals that whilst she has never had penetrative intercourse, she has recently had oral sex with her boyfriend. He suffers from cold sores.
Many of us were taught that HSV1 causes oral herpes simplex “cold sores” and HSV2 causes genital herpes. The vast majority of all herpes simplex infections are caused by HSV1. Around 30% of HSV infections are asymptomatic though many of us will be familiar with the presentation of primary herpetic gingivostomatitis in young children. Following a primary attack of HSV the virus remains dormant in the local sensory ganglia and can be reactivated symptomatically or result in asymptomatic shedding. If someone has already been infected with HSV1 and are then exposed to HSV2, the subsequent infection is usually less severe than a de-novo primary HSV infection. Autoinoculation from oral lesions to the genital region has been shown to be one of the commonest causes of genital lesions.
You reassure Lana that you think you know what is causing her symptoms and perform an external genital examination with a colleague as a chaperone. She has extensive vesicles bilaterally on her labia minora and tender inguinal lymphadenopathy. She has no abdominal tenderness. Her temperature remains slightly raised.
Recurrent attacks of HSV tend to localise to a single dermatome but primary herpes is frequently bilateral. This can cause diagnostic confusion for the less experienced clinician.
You ask Lana more about her relationship. Her boyfriend is in the same school year as she is. They’ve been together for 3 months and her parents are aware of the relationship. She has an appointment at the GP surgery next week to talk about contraception as they have been talking about having sex. Lana is sure she has not been pressurised into any sexual activity and you do not consider this to be a safeguarding concern.
The HEEADSSS template can be a really helpful structure to your history taking to enable coverage of important risk areas.
Lana is under the legal age of consent in many Western Countries. It is important to be clear about what your own country’s laws and your own departmental guidelines say about reporting sexual activity in a minor.
If there are any concerns around sexual abuse these must be escalated using your departmental safeguarding children policy.
Investigations
It is worth swabbing the vesicles using a viral swab, as there are prognostic implications depending on whether HSV1 or HSV2 is detected. HSV2 infection is more likely to cause recurrent attacks than HSV1, with a mean recurrence rate of 4 attacks per year in the first 2 years after primary HSV2 infection. It may therefore be appropriate for patients with HSV2 to be given “rescue medication” by their primary care physician to use when an attack recurs.
You take a viral swab of the vesicle fluid and explain why you are doing this. You explain that the results will take 48 hours or so to be back but that you will treat Lana’s current symptoms as primary HSV.
Treatment
Self-care advice for immediate symptom management is important for all patients with genital herpes. Urinary retention is not uncommon, as a result of severe periurethral pain and the scalding pain as urine touches the blistered vulva. Saline bathing can help and patients can be encouraged to pass urine in the bath or into a bidet full of water. If this isn’t possible, pouring a jug of water over the genital region whilst urinating can make this much more comfortable. Some women will require catheterisation for acute urinary retention in a severe attack. In a young person, consideration needs to be given for how traumatic this can be and whether a suprapubic approach may be a better option.
Analgesia in the form of paracetamol and or ibuprofen is helpful for the myalgia and tender inguinal nodes.
Topical local anaesthetic such as lidocaine gel can be really helpful to reduce pain and allow a teenager to try to urinate. It is an unlicensed but well recognised use of Instillagel or other catheterisation gels.
Oral antiviral drugs are indicated within 5 days of the start of the episode, while new lesions are still forming, or if systemic symptoms persist. Aciclovir, valaciclovir, and famciclovir all reduce the severity and duration of episodes. There is no evidence for the use of topical antiviral agents for genital herpes.
Recurrent attacks of genital herpes can be treated with the following drug regimens:
Short-course therapies:
- Aciclovir 800 mg three times daily for 2 days
- Famciclovir 1 g bd for 1 day
- Valaciclovir 500 mg bd for 3 days
Alternative 5-day treatment regimens:
- Aciclovir 200 mg five times daily
- Aciclovir 400 mg three times daily for 3–5 days
- Valaciclovir 500 mg twice daily
- Famciclovir 125 mg twice daily
Lana manages to pass urine in the toilet with the aid of some lidocaine gel and a jug of tepid water. She is discharged home with acyclovir 400mg three times daily for 5 days, safety netting advice to return if she cannot pass urine or develops a high fever or confusion. Her mum reassures you she will arrange follow up with their GP when you apologise that the UTC does not have a follow up or returns service commissioned for results reporting and follow up.
References
2014 UK national guideline for the management of anogenital herpes found here: https://www.bashhguidelines.org/media/1019/hsv_2014-ijstda.pdf Int J STD AIDS OnlineFirst, published on April 9, 2015 as doi:10.1177/0956462415580512
https://pubmed.ncbi.nlm.nih.gov/11149188/
https://www.bashhguidelines.org/current-guidelines/genital-ulceration/anogenital-herpes-2014/
