From the Guidelines
Diagnosing herpes vulvovaginitis without visible lesions requires a combination of clinical assessment and laboratory testing, with a focus on PCR testing of genital swabs and type-specific serologic testing to detect HSV antibodies, as recommended by the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infections Treatment Guidelines 1. When lesions are absent, healthcare providers should rely on PCR testing of genital swabs, which can detect viral DNA even during asymptomatic shedding.
- Blood tests for HSV antibodies (IgG) can help determine if a patient has been previously infected, though they cannot pinpoint the timing or location of infection.
- Providers should collect a thorough sexual history and note any symptoms like genital pain, burning, itching, or dysuria that might suggest herpes even without visible lesions.
- Viral culture is less sensitive than PCR but may be used, as noted in the Clinical Infectious Diseases study 1.
- Type-specific serologic testing can distinguish between HSV-1 and HSV-2 infections, with the gold standard being Western blot/immunoblot assays, which target antibodies to several HSV antigens in addition to glycoprotein G 1.
- If clinical suspicion is high despite negative initial tests, repeat testing during symptomatic periods may be warranted. Early diagnosis is important as antiviral medications like acyclovir, valacyclovir, or famciclovir can help manage symptoms and reduce viral shedding, even in patients without visible lesions who experience recurrent symptoms, as discussed in the Annals of Internal Medicine study 1.
From the Research
Diagnosing Herpes Vulvovaginitis without Lesions
To diagnose herpes vulvovaginitis without lesions, several methods can be employed:
- Type-specific serology based on glycoprotein G can be used for detecting asymptomatic individuals 2
- HSV type-specific serologic assays can identify women with recurrent genital HSV-2 infection, as well as those with unrecognized or subclinical infection 3
- Polymerase chain reaction (PCR) has greater sensitivity and should be the test of choice for symptomatic cases, but can also be used for asymptomatic cases 4
- Antigen detection, such as immunofluorescence test or enzyme immunoassay, can be employed, but HSV type determination is of importance 2
Importance of Accurate Diagnosis
Accurate identification of persons with genital herpes is necessary for optimal patient management and prevention of transmission 4
- The current strategy for diagnosing genital HSV infection in women misses many cases, and newly developed type-specific serologic methods can identify women with recurrent genital HSV-2 infection, as well as those with unrecognized or subclinical infection 3
- Treatment is not curative, but rather serves to shorten the duration of symptoms and improve quality of life 5
Laboratory Methods
Laboratory methods include:
- Antigen detection
- Culture
- Polymerase chain reaction (PCR)
- Conventional and type-specific serology (TSS) 4
- HSV-2 TSS is indicated for patients with genital lesions in whom antigen detection, culture or PCR fail to detect HSV, and for patients who are asymptomatic but have a history suggestive of genital herpes 4