Treatment for HSV-2 and Concurrent UTI
Treat both conditions simultaneously: initiate valacyclovir 1 gram orally twice daily for 7-10 days for the HSV-2 infection, and start empiric antibiotic therapy (such as nitrofurantoin or trimethoprim-sulfamethoxazole) for the presumed urinary tract infection based on the smelly urine symptom. 1
HSV-2 Treatment Approach
First Episode Management
If this is the patient's first recognized episode of genital herpes, the CDC recommends longer treatment courses 2, 1:
- Valacyclovir 1 g orally twice daily for 7-10 days (preferred due to convenient dosing) 1, 3
- Alternative: Acyclovir 400 mg orally three times daily for 7-10 days 1, 3
- Alternative: Famciclovir 250 mg orally three times daily for 7-10 days 1, 3
Treatment should be extended beyond 10 days if healing is incomplete 1, 3. The key is to initiate therapy as soon as possible—ideally within 72 hours of symptom onset for maximum effectiveness 3.
Recurrent Episode Management
If this represents a recurrent episode, shorter 5-day courses are appropriate 1:
- Valacyclovir 500 mg orally twice daily for 5 days 1
- Alternative: Acyclovir 400 mg orally three times daily for 5 days 1
- Alternative: Famciclovir 125 mg orally twice daily for 5 days 1
Episodic therapy is most effective when started during the prodromal period or within 1 day after onset of lesions—delayed treatment beyond 72 hours significantly reduces effectiveness 1.
UTI Management
The smelly urine strongly suggests a concurrent urinary tract infection, which requires separate treatment 1:
- Obtain urinalysis and urine culture before starting antibiotics
- Initiate empiric antibiotic therapy immediately (nitrofurantoin 100 mg twice daily for 5 days or trimethoprim-sulfamethoxazole DS twice daily for 3 days are standard first-line options)
- Adjust antibiotics based on culture results if needed
Important caveat: If the patient is pregnant, ciprofloxacin is contraindicated 1. Nitrofurantoin or cephalexin would be safer alternatives in pregnancy.
Long-Term HSV-2 Management Considerations
Suppressive Therapy Indication
If the patient develops ≥6 recurrences per year, strongly recommend daily suppressive therapy 1, 3:
- Valacyclovir 1 g orally once daily (or 500 mg once daily) 1
- Alternative: Acyclovir 400 mg orally twice daily 1
- Alternative: Famciclovir 250 mg orally twice daily 1
Suppressive therapy reduces recurrence frequency by ≥75% and reduces asymptomatic viral shedding, which decreases transmission risk to sexual partners 1. After 1 year of suppressive therapy, consider discontinuation to reassess recurrence frequency 1.
Critical Patient Counseling Points
- HSV-2 is a chronic, incurable infection—antiviral medications control symptoms but do not eradicate latent virus 3
- Asymptomatic viral shedding occurs, allowing transmission even without visible lesions 3, 4
- Consistent condom use reduces transmission risk by approximately 50% but does not eliminate it 1
- Abstain from sexual activity when lesions or prodromal symptoms are present 1
- Women of childbearing age must inform obstetric providers due to neonatal transmission risk 4
Treatment Failure Red Flags
If lesions do not begin to resolve within 7-10 days after initiating appropriately dosed antiviral therapy, suspect acyclovir resistance 1, 3:
- Obtain viral culture and susceptibility testing 3, 5
- For confirmed acyclovir-resistant HSV, switch to IV foscarnet 40 mg/kg every 8 hours 1, 3, 5
Other considerations for treatment failure include incorrect diagnosis, co-infection with another STD, HIV infection, or poor medication adherence 1.
Monitoring Requirements
No laboratory monitoring is needed for patients on episodic or suppressive therapy unless substantial renal impairment exists 1. Common side effects include nausea and headache 1.