Genital Herpes: From First Episode to Latency and Recurrence

A 24-year-old woman attends a sexual health service because passing urine has become extremely painful. Two days earlier she noticed tingling and soreness around the vulva, followed by several small blisters that have now broken down into shallow ulcers. She feels generally unwell and is frightened because she has never experienced anything like this before. She started a new relationship several months ago and asks whether the symptoms mean her partner has recently given her an infection.

What might her symptoms suggest?

The combination of painful genital vesicles or ulcers, dysuria and a preceding sensation of tingling or burning makes genital herpes an important possibility. Herpes simplex virus (HSV) type 1 and type 2 can both cause genital infection. HSV-1 is now an important cause of first-episode genital herpes, while genital HSV-2 is generally more likely to produce recurrent disease.

Appearance alone is not enough to make every diagnosis. Syphilis, traumatic ulceration, aphthous ulcers and inflammatory or dermatological conditions can also produce genital lesions. The patient's symptoms, examination, sexual history and appropriate testing need to be considered together.

What is happening and why?

HSV enters through skin or mucosa and begins replicating within epithelial cells. Infection damages these cells and produces the clusters of vesicles associated with herpes. The fragile vesicles can rupture, leaving the painful shallow ulcers our patient has noticed. Inflammation around the lesions contributes to tenderness and burning, while urine passing across ulcerated vulval tissue can make dysuria particularly severe.

A first recognised episode can also produce systemic symptoms such as fever, malaise, headache, myalgia and tender lymph nodes. Some people, however, acquire HSV with few or no recognisable symptoms. This means the first outbreak a patient notices is not necessarily the moment the infection was acquired.

Why doesn't herpes leave the body after the ulcers heal?

This is where HSV biology becomes particularly useful clinically. After replicating in skin or mucosa, the virus enters nearby sensory nerve endings and travels backwards along the axon by retrograde axonal transport. With genital infection, it commonly reaches sensory neurons within the sacral dorsal root ganglia. Viral DNA then remains within the neuronal nucleus in a latent state.

Latency means the virus is present but is not continuously producing the local tissue injury seen during an outbreak. Antiviral treatment can suppress active viral replication, but it does not remove latent HSV DNA from these sensory neurons. This is why treatment controls herpes rather than curing it.

What causes a recurrence?

Latent HSV can reactivate. Viral activity resumes within the neuron and virus travels back along the sensory nerve towards the skin or mucosa. Some patients notice a prodrome of tingling, burning, itching or pain before visible lesions appear. Others develop lesions without a clear warning.

Recurrent episodes are generally shorter and less severe than the first recognised episode. Genital HSV-2 tends to recur and shed asymptomatically more frequently than genital HSV-1, so identifying the viral type can help clinicians give patients more realistic information about what they may experience in future.

Reactivation does not always produce a visible outbreak. HSV can reach genital skin or mucosa and be released without causing lesions. This is asymptomatic viral shedding, and it explains how transmission can occur when a person feels well and their skin appears normal. BASHH notes that shedding is particularly frequent with genital HSV-2 during the first year after infection and in people with frequent symptomatic recurrences, although for many people it decreases with time.

What else would you want to know?

Start with the current episode. When did the tingling, pain or lesions begin? Is this genuinely the first episode she has noticed? Ask about dysuria, urinary retention, vaginal or urethral discharge, rectal pain, constipation, fever, headache, photophobia or neck stiffness. Severe pain, inability to pass urine, meningism or marked systemic illness changes the urgency of assessment and may require hospital care.

An appropriate sexual history should explore recent and previous partners, vaginal, oral and anal contact, condom use, previous sexually transmitted infections (STIs) and testing. Oral sex is relevant because oral HSV-1 can be transmitted to the genital area. Ask about pregnancy possibility, immune suppression and medicines as these can alter assessment or management.

The emotional history matters too. A patient may already have decided that the outbreak proves recent transmission or infidelity. Do not reinforce that assumption. HSV may have been acquired without recognised symptoms weeks, months or longer before the first obvious episode, and testing cannot usually tell the patient exactly when or from whom infection was acquired.

What investigations are recommended?

When vesicles or ulcers are present, the preferred diagnostic approach is to take material from an active lesion for HSV nucleic acid amplification testing, usually polymerase chain reaction (PCR). The result can confirm HSV and distinguish HSV-1 from HSV-2, which is useful for future counselling because recurrence patterns differ between the two types.

Sampling is most useful while a lesion is active. Older, healing lesions may contain less detectable virus, so a negative result from a late lesion needs to be interpreted alongside the clinical picture. If there is no lesion, there may be nothing suitable to swab.

HSV antibody testing is not a simple substitute for lesion PCR. A positive antibody result does not establish the anatomical site of infection or tell the patient when it was acquired. BASHH recommends that type-specific HSV serology is used selectively rather than as routine screening.

The consultation should also consider testing for other STIs according to the patient's history and risk. HIV testing is routinely relevant, and syphilis is particularly important in the differential diagnosis of genital ulceration.

How could genital herpes be managed?

Our patient's painful first recognised episode is different from an occasional mild recurrence. BASHH recommends oral antiviral treatment for a first episode. Preferred five-day regimens include aciclovir 400 mg three times daily or valaciclovir 500 mg twice daily. Treatment may need to continue if new lesions are still appearing, symptoms remain substantial or healing is incomplete. (BASHH, 2024)

These medicines inhibit active viral replication. They can shorten the episode and reduce symptom severity, but they do not reach into the sensory ganglion and remove latent HSV. The patient therefore needs to understand why completing treatment does not mean the virus has been eradicated.

Symptom relief is an important part of care. BASHH recommends measures including saline bathing, analgesia, petroleum jelly and 5% lidocaine ointment where appropriate. For severe dysuria, passing urine while water flows over the genital area can reduce stinging. A patient who cannot pass urine, is severely unwell or has neurological symptoms needs further assessment rather than simply more home-care advice.

What if the herpes comes back?

Many recurrent episodes are mild and self-limiting. Management can therefore be individualised. Some people need only supportive care, while others use a short course of antiviral treatment started at the prodrome or very beginning of an outbreak. Early treatment is most effective because viral replication has already begun before fully developed lesions appear.

Suppressive antiviral therapy is another option. It can substantially reduce recurrent episodes and viral shedding and may be considered when recurrences are frequent, less frequent but particularly painful, associated with complications, causing significant psychological distress or when reducing transmission risk is an important goal. BASHH includes aciclovir 400 mg twice daily and valaciclovir 500 mg once daily among recommended suppressive regimens for immunocompetent adults. The decision should be made with the patient rather than using recurrence count alone as a rigid threshold. (BASHH, 2024)

What should we explain to the patient?

Begin with what the diagnosis does and does not tell her. Genital herpes is common and manageable. It does not tell us when she acquired HSV, and a first recognised outbreak does not prove that transmission occurred recently. That conversation can prevent a laboratory result from being turned into an unsupported conclusion about a relationship.

Transmission risk is highest when lesions or prodromal symptoms are present, so BASHH recommends avoiding sexual contact during these periods. Transmission can still occur through asymptomatic shedding between outbreaks. Consistent condom use reduces risk but cannot eliminate it because HSV can be present on genital skin not covered by a condom.

Suppressive antiviral treatment reduces symptomatic and asymptomatic shedding. In a clinical trial of heterosexual HIV-negative couples in which one partner had HSV-2, daily valaciclovir reduced HSV-2 acquisition, although this evidence should not be assumed to apply identically to every partnership or clinical situation. (BASHH, 2024)

Patients may also worry about touching objects, sharing bathrooms or everyday contact. HSV is transmitted through direct contact with infected skin or mucosa; BASHH specifically notes that genital HSV is not transmitted through fomites such as sheets, towels or toilets.

Future relationships are often a bigger concern than the physical symptoms. Counselling should include disclosure to current and new sexual partners, ways of reducing transmission, the fact that recurrence frequency often falls with time and the availability of episodic or suppressive treatment. The diagnosis should never be used to shame the patient or make assumptions about their sexual behaviour.

What changes if the patient is pregnant?

Pregnancy needs its own assessment because the concern is neonatal herpes, a rare but potentially severe infection. Risk depends strongly on when maternal infection was acquired. Someone with longstanding recurrent genital herpes has existing HSV antibodies that can cross the placenta and provide some passive protection to the baby. A first infection acquired late in pregnancy carries greater neonatal risk because there may be insufficient time for that antibody response to develop before birth.

Current UK pregnancy management is covered by the separate joint BASHH and Royal College of Obstetricians and Gynaecologists guideline. It includes antiviral treatment and, depending on the timing of infection and clinical circumstances, planning around suppressive therapy and mode of birth. The 2024 guideline changed routine suppressive antiviral prophylaxis for people with a history of genital herpes to begin from 32 weeks, with earlier treatment considered when there is significant risk of preterm birth. (BASHH/RCOG, 2024)

For a student nurse, the practical point is straightforward: a pregnant patient who develops a possible first episode of genital herpes needs prompt maternity and specialist assessment. Do not treat it as an ordinary recurrent outbreak without considering gestation and neonatal risk.

What could happen if genital herpes is not appropriately managed?

For most immunocompetent adults, genital herpes does not progress into a steadily worsening disease. The common difficulties are painful episodes, recurrent lesions, transmission and the psychological effect of the diagnosis. Severe first episodes can occasionally cause urinary retention, significant constitutional illness or neurological complications such as meningism, which may require hospital assessment.

HSV can be more severe, persistent or atypical in people who are significantly immunocompromised. Pregnancy creates a different concern because transmission around birth can cause neonatal herpes. Recognising these situations prevents a usually manageable infection from being treated too casually when the clinical context makes the consequences more serious.

The nursing contribution extends beyond identifying lesions. It includes recognising severe pain or urinary retention, taking concerns seriously, supporting testing and treatment, explaining latency and recurrence accurately, challenging stigma without minimising transmission, and giving patients information they can actually use in their relationships and future care.

References

British Association for Sexual Health and HIV (BASHH) (2024) UK national guideline for the management of anogenital herpes. Available at: BASHH anogenital herpes guideline.

British Association for Sexual Health and HIV and Royal College of Obstetricians and Gynaecologists (2024) Management of herpes simplex virus in pregnancy and the neonate. Available at: BASHH/RCOG herpes in pregnancy guideline.

NHS (2026) Genital herpes. Available at: NHS genital herpes.