First-episode primary genital herpes is characterized by fever, headache, malaise, and myalgias. Pain, itching, dysuria, vaginal and urethral discharge, and tender inguinal adenopathy are the predominant local symptoms.
Characteristically widely spaced bilateral distributed lesions of the external genitalia are seen. Lesions may be present in varying stages including vesicles, pustules, or painful erythematous ulcers. Involvement of the cervix and urethra are seen in over 80 percent of women with first-episode infections. First episodes of genital herpes in patients who have had prior HSV-1 infection are associated with less frequent systemic symptoms and faster healing than primary genital herpes. The clinical courses of acute first-episode genital herpes among patients with HSV-1 and HSV-2 infections are similar. However, the recurrence rates of genital disease differ. Over 80 percent of patients with first-episode HSV-2 infection will have a recurrence within 12 months (median number of recurrences, four) compared to 55 percent of those with primary HSV-1 infections (median number of recurrences, less than one). Recurrence rates of genital HSV-2 infections vary greatly between individuals and over time within the same individual. HSV has been isolated from the urethra and urine from men and women without concomitant external genital lesions. A clear mucoid discharge and dysuria are characteristic of symptomatic HSV urethritis. HSV has been isolated from the urethra of 5 percent of women with the dysuria-frequency syndrome. Occasionally, genital tract disease manifested by HSV endometritis and salpingitis in women and HSV prostatitis in men may occur.
