Amanda B. Murchison and Megan Metcalf
History of present illness
A 19-year-old gravida 0 woman presents complaining of 3 days of worsening vulvar pain and vaginal discharge. The pain is bilateral and“burning.”She reports dysuria, which has become more severe, and she is now unable to void. She has no hematuria, frequency, or urgency. She was last able to void eight hours ago.
She is currently sexually active and reports that she entered a relationship with a new partner approximately two weeks ago. She is not using any birth control. She denies fever or chills but reports increasing lower abdominal pain over the past four hours. She has no significant past medical or surgical history. She takes no medications.
Physical examination
General appearance: Well-developed, well-nourished, young woman appearing uncomfortable and tearful Vital signs:
Temperature: 36.7°C Pulse: 93 beats/min
Blood pressure: 116/79 mmHg Respiratory rate: 18 breaths/min Oxygen saturation: 98% on room air BMI: 23.9 kg/m2
Weight: 135 lb
Cardiovascular: Regular rate and rhythm with no murmurs Lungs: Clear to auscultation
Abdomen: Some tenderness to palpation of suprapubic region External genitalia: Bilateral swollen labia, which were erythematous with numerous coalescing ulcerative lesions (Fig. 15.1). Labia are tender to touch
Urethra: Urethral meatus appears normal Vagina: Patient unable to tolerate speculum or bimanual exam
Voiding trial: Patient unable to void Laboratory studies:
Urine pregnancy test: Negative WBCs: 5500/μL
Hb: 13.3 g/dL Ht: 39.8%
Platelets: 245 000/μL
How would you manage this patient?
The patient appears to be having a first clinical episode of genital herpes simplex virus (HSV) infection. Given the sever- ity of the outbreak, the patient has significant discomfort and swelling which has led to urinary retention. Management of this patient included performing polymerase chain reaction (PCR) testing from the vulvar ulcerations to confirm the diagnosis. Given the clinical appearance, treatment should be initiated for presumed HSV while the results were pending.
Primary management was directed at relieving her urinary retention and controlling her pain. A Foley catheter was placed after the application of lidocaine jelly to the urethral area.
Given the severity of the pain, she was admitted for pain control with intravenous narcotics. The patient was started
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
Fig. 15.1Labia showing multiple herpetic lesions secondary to HSV-2.
(Photograph provided by Steven Cohen, MD.)
on acyclovir and recommended sexually transmitted disease testing, which she accepted. As the patient could not tolerate a speculum exam, urine nucleic acid amplification tests (NAATs) were sent for gonorrhea and chlamydia. The patient was discharged home on hospital day 2 once her pain was under better control. The Foley catheter was left in place at the time of discharge and was removed at a follow-up visit two days later. She completed a 10-day course of acyclovir. PCR testing of the vulvar lesion returned positive for HSV-2. The likelihood of recurrence was discussed with the patient, and she was started on suppressive therapy.
Genital herpes simplex virus
Genital herpes simplex virus (HSV) infection is the most prevalent cause of ulcerative genital disease. Both HSV-1 and HSV-2 can cause genital herpes. Serologic surveys show that 26% of women of reproductive age and older are seropositive for HSV-2. However, HSV-2 prevalence underestimates the overall prevalence of genital herpes as outbreaks associated with HSV-1 are becoming more frequent [1]. The mean incu- bation period is one week. The virus enters the body via direct contact of epidermal cells with secretions or mucosal surfaces from an infected individual. The classic clinical presentation includes clusters of painful vesicles and ulcerations [1,2]. Pain, itching, dysuria, vaginal or urethral discharge, and inguinal adenopathy are the most common presenting symptoms [2].
Thefirst clinical episode is defined as thefirst presentation of genital herpes and can be caused by HSV-1 or HSV-2. Primary first episodes refer to patients who were previously seronega- tive for HSV, while nonprimaryfirst episodes refers to a first clinical infection in a patient who has preexisting antibodies to the other HSV type [3]. Primary infections are typically more severe than recurrent or first episode nonprimary infections.
They may be associated with systemic symptoms like general- ized flu-like complaints and can also be complicated by neu- rologic involvement.
Diagnosis has traditionally been made using a viral culture.
This test is specific but lacks sensitivity and has been shown to have a false negative rate as high as 25% for primary infection and 50% for recurrences. PCR testing is becoming more widely available and has increased sensitivity [1]. The specimen should be obtained from the lesion base or vesicular fluid.
According to the Centers for Disease Control and Prevention (CDC), serologic studies for type-specific antibodies for HSV- 1 and 2 should be considered in the setting of a clinical suspicion for HSV with a negative virologic test [4]. This patient has a first clinical episode, which was confirmed by PCR testing. It could be either a primary or nonprimary outbreak, as she had extremely severe local symptoms, but no systemic symptoms. As the management is determined by symptoms, it is not necessary to determine whether the out- come is primary or nonprimary.
This patient’s main issues are her pain from her lesions, and consequent urinary retention. The urinary retention is
likely a result of pain and induration surrounding the urethra.
It may be secondary to the dysuria caused by urine irritating the ulcerated skin and the patient’s need to avoid this pain. In this situation, topical lidocaine jelly applied to the vulva prior to voiding may be of some benefit. Other things that might be of value in cases of urinary retention include having the patient try to void while taking a warm bath or shower, which allows the urine to minimize contact with the herpetic lesions. Use of a peribottle to spray warm water on the perineum while voiding can also be attempted. Relaxation techniques such as having the patient blow into a glass of water with a straw while sitting on the commode may help relax the pelvic muscles.
There is no published evidence for any of these things, but they are all low risk and inexpensive.
If the patient is still unable to void, placement of a Foley catheter is necessary until the pain and swelling resolves enough for the patient to be able to void. Catheter placement can be difficult given patient pain and swollen anatomy.
Lidocaine jelly should be applied to the urethra for a few minutes prior to insertion of the catheter. Use of a pediatric catheter with a smaller diameter or a catheter that is more rigid such as a latex-free or coude catheter may make placement easier. Pain medication should be given, including intravenous sedation if necessary. Patients usually get substantial relief once the bladder begins draining.
The catheter should be left in place until the lesions have begun to crust and pain decreases. If the bladder has become overdistended (usually defined at600 mL of urine for at least 24 hours) then the patient may benefit from keeping the catheter in place for 2–3 days prior to attempting a voiding trial to allow restoration of bladder tone in addition to healing of the lesions. Our patient did require Foley catheter place- ment, which was kept in place for three days. The patient was successfully able to void once it was discontinued. At the time of catheter removal, the patient still had crusting HSV lesions that required approximately two more weeks to completely resolve. Primary lesions can last 2–6 weeks with new lesions continuing to form over thefirst 10 days [2]. Placement of a urethral catheter by itself does not necessitate hospitalization.
Patients can receive leg bag training and manage the catheter at home while the lesions heal.
The patient’s other main problem was pain from the lesions. Extensive ulceration of the vulva and vagina puts the patient at risk for bacterial superinfection. If superinfection develops, the patient may also need to be treated with an antibiotic. Frequent sitz bathing can provide pain relief and decrease the likelihood of superinfection. Pain medication with nonsteroidal anti-inflammatory drugs or oral narcotics can be helpful. For extremely severe infections, parenteral narcotics may be briefly necessary, as they were in this patient.
Antiviral medications are helpful in the management of both first clinical episode and recurrent genital herpes out- breaks.Table 15.1lists recommended treatment regimens for both. Although resolution of outbreaks is hastened by antiviral treatment, it does not eradicate latent virus or affect the long-
Case 15: Urinary retention in a 19-year-old woman
term disease process [3]. This patient was administered a 10-day course of acyclovir, which likely shortened the duration and severity of her symptoms. The earlier the antiviral is started in the course of an outbreak, the greater the improvement.
Recurrence of genital herpes occurs in many patients with a symptomatic first episode. Episodes are more frequent in HSV-2 infected individuals than in those with HSV-1. Recur- rent genital herpes can be managed with either episodic (at the time of a recurrent outbreak) or suppressive (daily prophylac- tic) therapy [1,4]. Recurrent outbreaks are typically milder thanfirst episodes, with fewer lesions and less viral shedding [2]. Episodic treatment (Table 15.1) has been shown to decrease the duration of recurrence symptoms including pain, lesion persistence, and viral shedding. Given that this was the patient’s first episode and was with HSV-2, episodic therapy would be a reasonable approach.
Suppressive therapy prevents 70–80% of recurrent episodes.
It is a good option for patients with: (1) frequent outbreaks;
(2) HSV-susceptible partners; or (3) psychosocial difficulty in coping with outbreaks. Breakthrough recurrences while on sup- pressive therapy are infrequent and typically short in duration.
Suppressive therapy also markedly decreases viral DNA shed- ding, translating into a 48% reduction in sexual transmission to a susceptible partner. Studies show many patients prefer suppressive therapy [1,4]. Our patient was having difficulty coping with the new diagnosis of genital herpes. This difficulty, combined with the severity of her outbreak, led to her decision for suppression.
When a patient is diagnosed with a sexually transmitted infection she should be counseled both about the infection and how it might affect her current or future partners. Patients with a diagnosis of genital herpes should be encouraged to discuss this diagnosis with their partner(s). Patients should be informed that transmission of genital herpes to a partner can be decreased by taking the following measures: (1) refraining from sexual activity during prodromal symptoms or when lesions are present; (2) consistent use of male, latex condoms;
and (3) daily use of antiviral therapy by the infected partner [4]. Many patients will experience feelings of anxiety, loneli- ness, and decreased self-worth as our patient did. Through educating patients, physicians can help empower patients to take an active role in managing this disease [2].
Key teaching points
Urinary retention can occur during an episode of genital herpes due to pain or induration surrounding the urethra.
Placement of a urinary catheter may be necessary.
Placement of a urinary catheter may require application of lidocaine jelly and supplemental pain medication.
Antiviral medications should also be given for outbreaks severe enough to cause urinary retention.
Primary genital herpes infections are typically more severe than recurrent infections. They may be associated with generalizedflu-like symptoms and can also be complicated by neurologic involvement.
References
1. American College of Obstetricians and Gynecologists. Gynecologic herpes simplex virus infections. Practice Bulletin No. 57.Obstet Gynecol 2004;104:1111–17.
2. Beauman JG. Genital herpes: a review.
Am Fam Physician2005;72(8):
1527–34.
3. Sen P, Barton SE. Genital herpes and its management.BMJ2007;334(7602):
1048–52.
4. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010.MMWR2010;59(RR-12):
1–116.
Table 15.1 Recommended treatment regimens for genital herpes based on the 2010 CDC guidelines *
Recommended regimens First clinical
episode of genital HSV
Acyclovir 400 mg PO TID for 7–10 days Acyclovir 200 mg PO 5 times a day for 7–10 days Valacyclovir 1 g PO BID for 7–10 days
Famciclovir 250 mg PO TID for 7–10 days Recurrent
episodes Acyclovir 400 mg PO TID for 5 days Acyclovir 800 mg PO BID for 5 days Acyclovir 800 mg PO TID for 2 days Valacyclovir 500 mg PO BID for 3 days Valacyclovir 1 g PO daily for 5 days Famciclovir 125 mg PO BID for 5 days Famciclovir 1000 mg PO BID for 1 day Suppressive
therapy Acyclovir 400 mg PO BID Valacyclovir 500 mg PO QD Valacyclovir 1 g PO QD Famciclovir 250 mg PO BID
Adapted from Centers for Disease Control and Prevention [4].
BID, twice a day; CDC, Centers for Disease Control and Prevention; HSV, herpes simplex virus; PO,per os(orally); QD, every day; TID, three times a day.