A 32-year-old man presents at your SH clinic complaining of a ‘sore penis with cuts on it’. On further questioning he has had discomfort for 2–3 days. He denies urethral discharge but says he that he has slight pain when passing urine. He is otherwise well, apart from a recent viral illness. He has been in a monogamous relationship with a male partner for just over a year. His most recent sexual contact was with this partner about 10 days ago. He had receptive and insertive oral sex on this occasion. His RMP is asymptomatic. The man asks if herpes can be caught from oral sex, as his partner suffers from cold sores.
On examination, he has tender bilateral inguinal lymphadenitis. The glans penis is swollen and erythematous. There are three small shallow tender ulcers on the glans penis. There are no blisters or urethral discharge.
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1. What is the differential diagnosis?
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Correct answer: The differential diagnosis of genital ulcers is listed in Chapter GUD 1. The most likely diagnosis in this man is genital HSV infection, but syphilis infection can present atypically and should be excluded. The mild viral illness may be a systemic manifestation of primary HSV. In the UK the majority of primary genital herpes infections in adults are due to HSV-1.
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2. What investigations should you perform?
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Correct answer: A specimen should be taken from the ulcer bases for a NAAT test e.g. HSV-PCR. This may be a combined test which also detects syphilis. Typing of the virus (into HSV-1 and HSV-2) aids counselling on prognosis. A full STI screen should be offered including HIV and syphilis serology. If there is a high index of suspicion of syphilis, dark ground microscopy could be performed (on a specimen from the ulcer) if available.
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3. What treatment (if any) should you offer?
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Correct answer: A presumptive diagnosis of HSV can be based on the symptoms and clinical appearance whilst awaiting results of investigations. Antiviral treatment should be initiated if presentation is within 5 days of the start of the episode (or new lesions are still appearing) e.g. aciclovir 200 mg five times daily for 5 days. Supportive measures should be advised, e.g. saline bathing and analgesia, yellow soft paraffin on lesions.
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4. What other issues should be discussed?
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Correct answer: Advise abstinence from SI while lesions are present. Repeat STI testing out with the window period may be required depending on the sexual history, e.g. at 3 months for HIV and syphilis. Counselling and support may be required to reduce anxiety about the diagnosis. The role of the sexual health advisor is important in this situation. Partners should be encouraged to attend for assessment however it is not usually possible to confirm the HSV status of the partner unless they also have lesions. As this patient is an MSM, hepatitis B testing and vaccination should be offered if he has not been previously vaccinated.
