16.4 Genital Herpes, Syphilis & Anogenital Warts

Genital Herpes Simplex Virus (HSV-1 & HSV-2)

Genital herpes is a lifelong viral infection characterized by neurotropic latency within the dorsal root sacral sensory ganglia (S2–S4).

• Primary (Initial) Episode: Severe, bilateral clusters of painful vesicles on an erythematous base that rapidly rupture into exquisitely tender, shallow, non-indurated ulcerative lesions. Accompanied by systemic symptoms: high fevers, headaches, malaise, severe bilateral inguinal lymphadenopathy, and dysuria (frequently precipitating acute urinary retention). Lesions persist for 2 to 3 weeks.
• Recurrent Episodes: Viral reactivation traveling retrogradely down sensory axons. Unilateral, milder, localized clusters with fewer lesions that heal within 5 to 7 days. Typically preceded by a characteristic sensory prodrome (tingling, burning, paresthesias, or neuralgic pain in the buttocks or vulva 12 to 24 hours prior to vesicle eruption).
• Diagnostic Modalities: Type-specific HSV Polymerase Chain Reaction (PCR) performed on active lesion swabs is the gold standard (vastly superior to viral culture). Type-specific glycoprotein G IgG serology distinguishes HSV-1 from HSV-2.
• Pharmacologic Management:
  • Primary Episode: Acyclovir 400 mg PO TID for 7 to 10 days, OR Valacyclovir 1 g PO BID for 7 to 10 days.
  • Episodic Recurrent Outbreaks: Initiated during the prodrome or within 24 hours of lesion eruption: Valacyclovir 500 mg PO BID for 3 days, or Valacyclovir 1 g PO daily for 5 days.
  • Daily Suppressive Therapy: For individuals with frequent recurrences (≥6 per year), severe emotional distress, or to reduce transmission to discordant partners: Valacyclovir 500 mg or 1 g PO once daily.
• Obstetric Management & Transmission Prevention:
  • Primary HSV acquisition in late pregnancy carries a catastrophic 30% to 50% risk of vertical neonatal transmission (disseminated disease, encephalitis).
  • Recurrent HSV at labor carries a much lower transmission risk (1% to 3%) due to protective transplacental maternal IgG.
  • Universal Suppression Protocol: All pregnant individuals with a documented personal history of genital HSV (regardless of recurrence frequency) must initiate daily antiviral suppression at 36 weeks gestation (Acyclovir 400 mg PO TID or Valacyclovir 500 mg PO BID) and continue through delivery to prevent clinical recurrences at term.
  • Delivery Route: At labor onset, perform a meticulous vulvar and perineal speculum inspection. If active genital lesions or prodromal symptoms are present, cesarean delivery is mandatory to prevent direct neonatal viral contact during descent.

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Syphilis: Staging, Serology & Gestational Management

Syphilis is a systemic chronic infection caused by the spirochete Treponema pallidum.

Clinical Staging & Manifestations

• Primary Syphilis: Hallmark is the chancre—a solitary, painless, indurated, clean-based ulcer with raised, rolled borders appearing at the inoculation site 10 to 90 days (average 21 days) post-exposure. Accompanied by painless, non-suppurative regional lymphadenopathy. Resolves spontaneously within 3 to 6 weeks without treatment, giving a false impression of cure while spirochetes disseminate hematogenously.
• Secondary Syphilis: Develops 4 to 10 weeks after the primary chancre, reflecting systemic bacteremic dissemination. Hallmarks include:
  • Highly characteristic diffuse, symmetrical, non-pruritic maculopapular rash involving the palms of the hands and soles of the feet.
  • Condylomata lata: Large, moist, flat-topped, highly infectious, cauliflower-like gray-white plaques in warm, intertriginous areas (vulva, perineum, perianal region).
  • Mucous patches in oral cavity, generalized painless lymphadenopathy, patchy "moth-eaten" alopecia, low-grade fever, and malaise.
• Latent Syphilis: Seropositive without clinical signs. Subdivided into:
  • Early Latent: Acquired within the preceding 12 months.
  • Late Latent / Unknown Duration: Infection duration ≥1 year, or unknown timing.
• Tertiary Syphilis: Occurs decades later in untreated individuals: destructive gummatous lesions of bone and soft tissue, cardiovascular syphilis (ascending aortic aneurysms, aortic insufficiency), and neurosyphilis.

Serologic Diagnostic Testing Algorithms

• Traditional Algorithm: Initial screening with a non-treponemal antibody test (RPR or VDRL), which measures anticardiolipin antibodies. Titers (e.g., 1:32) correlate with disease activity and treatment response (a four-fold change in titer, such as from 1:32 to 1:8, confirms therapeutic cure). All reactive non-treponemal tests must be confirmed with a specific treponemal test (FTA-ABS or TP-PA), which detects antibodies directed specifically against T. pallidum proteins and typically remains positive for life.
• Reverse Sequence Algorithm: Initial screening with an automated treponemal antibody enzyme immunoassay (EIA) or chemiluminescence immunoassay (CIA). If positive, reflex quantitative RPR is performed. If RPR is non-reactive, a second distinct treponemal test (TP-PA) is performed to resolve discordance.

CDC Recommended Treatment Protocols

• Primary, Secondary, & Early Latent Syphilis:
  • Benzathine Penicillin G 2.4 million units IM in a single dose.
• Late Latent, Latent of Unknown Duration, or Tertiary Syphilis (with normal CSF):
  • Benzathine Penicillin G 2.4 million units IM once weekly for 3 consecutive weeks (total cumulative dose: 7.2 million units).
  • The Invalidation Rule: In non-pregnant individuals, if the interval between weekly doses exceeds 14 days, the entire 3-week course must be restarted. In pregnant patients, the interval must not exceed 7 to 9 days; if a dose is delayed beyond 9 days, the entire 3-week series must be restarted from Day 1!

The Jarisch-Herxheimer Reaction

An acute, self-limiting systemic inflammatory response occurring within 2 to 24 hours of initiating penicillin therapy, triggered by the massive, simultaneous lysis of spirochetes releasing pyrogenic endotoxins. Manifests with acute fevers, chills, rigors, tachycardia, myalgias, and transient exacerbation of cutaneous lesions. In pregnant individuals, it can induce intense uterine contractions, preterm labor, and transient fetal heart rate decelerations. Treatment is supportive (antipyretics, hydration); patients must be reassured that this is an expected physiological reaction, not an allergic drug reaction.

[!CRITICAL] Mandatory Gestational Penicillin Rule: Penicillin G is the ONLY proven antimicrobial agent that effectively treats maternal syphilis, crosses the placenta in therapeutic concentrations, and cures congenital syphilis in the fetus. If a pregnant patient has a documented anaphylactic or severe penicillin allergy, non-penicillin alternatives (e.g., doxycycline, erythromycin, azithromycin) are strictly contraindicated or therapeutically ineffective. The certified nurse-midwife must coordinate immediate admission to an inpatient monitored unit for oral or IV penicillin desensitization, followed immediately by the standard gestational Benzathine penicillin G regimen!

Anogenital Warts (Condylomata Acuminata)

HPV types 6 and 11 cause about 90% of anogenital warts. These are low-risk types: warts are a cosmetic and psychological burden, not a precancerous lesion, and a wart is not an indication for colposcopy.

Diagnosis is clinical. Biopsy when the lesion is pigmented, indurated, fixed, ulcerated, bleeding, atypical, or fails to respond to treatment, and in any immunocompromised patient. Do not apply acetic acid to "screen" normal skin for subclinical HPV — it generates false positives and anxiety without benefit.

Treatment Options

No treatment eradicates HPV; all of them remove visible lesions, and recurrence in the first 3 months is common. Untreated warts may also resolve spontaneously, so observation is a legitimate choice.

[!CAUTION] In pregnancy: podofilox, podophyllin, sinecatechins, and imiquimod are not recommended. Acceptable options are cryotherapy, trichloroacetic or bichloroacetic acid, and surgical removal. Warts often enlarge in pregnancy and frequently regress postpartum. Cesarean birth is not indicated to prevent transmission — it is reserved for warts that obstruct the outlet or would cause excessive bleeding. Juvenile-onset recurrent respiratory papillomatosis is rare and is not prevented by cesarean.

Prevention: the 9-valent HPV vaccine covers types 6 and 11 along with the oncogenic types 16, 18, 31, 33, 45, 52, and 58 — so the same vaccine that prevents cervical cancer prevents most genital warts.