International Journal of STO & AIDS 1992; 3: 58-59
CASE REPORT
Herpetic adhesions causing dyspareunia J Davidson Parker
MB BChir DipVen, and
J Bullough
MB FFARCS
Department of Genitourinary Medicine, St Ann's Hospital, London N15 Keywords: Herpes simplex, adhesions, dyspareunia
Occasional acute complications of genital herpes in otherwise healthy adults have been well documented. These include the appearance of extragenital lesions--' and neurological sequelae such as sacral radiculitis" and aseptic meningitis'. Persistent local complications are rarely recorded. This report describes a case of fusion of the labia minora following primary genital herpes and resulting in dyspareunia.
CASE REPORT A 21-year-old Afro-Caribbean woman was referred to the department of Genitourinary Medicine at St Ann's Hospital by her general practitioner in August 1990.Three months earlier she had attended the accident and emergency department of another hospital with painful vulval ulceration of 2 days' duration. Genital herpes was diagnosed on clinical grounds and she was treated with oral acyclovir and analgesics. HSV 2 infection was confirmed by viral culture. The lesions subsided within 10 days. There had been no recurrence of herpetic ulceration but the patient found that attempted coitus was persistently painful. She felt that 'her vagina had shrunk'. She had a regular partner but no full intercourse between first presentation and referral to St Ann's. On examination there was a band of adhesion joining the labia minora which reduced the size of the introitus by 50%. The adhesion was about 1 em wide and so well healed that the precise site of the junction could not be clearly ascertained. There was considerable loss of pigmentation of the surrounding skin in keeping with clinically severe genital herpes. This was bilateral and punctate and the texture of the labial skin remained normal. The adhesion was divided with a scalpel under local anaesthesia and the patient discharged. At follow-up 2 months later she was well and had no further coital problems. There had been no herpetic recurrences.
Correspondence to: Dr J Davidson Parker, Department of Genitourinary Medicine, St Ann's Hospital, St Ann's Road, London N15
She admitted to only one sexual partner during the 6 months preceding and since her acute herpetic infection. He was apparently symptom free and declined to attend for screening.
DISCUSSION While transient dyspareunia is a common symptom in patients with herpetic ulceration of the genital area or indeed any other painful vulval condition, persistent coital difficulty due to herpetic adhesions necessitating surgical intervention is very uncommon. Several decades ago Brain" noted that in severe genital herpes 'the labia were often stuck together by a viscid, serous discharge' but permanent adhesions were not described. There are two recent reports of similar cases to ours: De Marco et a1. 6 described a 35-year-old Caucasian woman who presented 21J2 years after her primary herpetic episode which was accompanied by fever and arthralgia. Shortly after this attack she was unable to have sexual intercourse or insert a tampon. It is not clear from the text why she had delayed in seeking medical advice. Possibly she was temporarily without a sexual partner. The labial adhesions were successfully dispersed with laser therapy. In the second case? labial adhesions were present for 3 112 months following primary infection but spontaneously resolved before surgical intervention, due perhaps to resumption of sexual intercourse although this is not suggested in the text. The appearance of the adhesions was attributed to delayed initiation of antiviral treatment. In the case now presented labial adhesions appeared to develop in spite of early acyclovir therapy and formed a barrier which was unlikely to have ruptured during the course of coital or manual stimulation. It is possible that saline washes in the acute st~ge of the infection might have prevented the formation of adhesions. The patient described was not instructed to do this. It is our current practice to recommend warm saline soaks twice daily to all patients with genital herpes receiving systemic antiviral therapy.
Davidson Parker and Bullough.
References 1 Sumers KD, Sugar J, Levine R. Endogenous dissemination of genital herpesvirus hominis type 2 of the eye. BT ] Ophtha/mo/1980i 64:770-4
2 Mindel A, Carney 0, Williams P. Cutaneous herpes simplex infections. Genitourin Med 1990;66:14-15 3 Caplan LR, Kleeman P], Berg S. Urinary retention probably secondary to herpes genitalis. N Eng/ ] Med 1977;297: 920-3
Herpetic adhesions causing dyspareunia
59
4 Bergstrom T, Vahlne A, Alestig K, [eansson 5, Forsgren M, Lycke E. Primary and recurrent HSV 2 induced meningitis. ] Infect Dis 1990;162:322-3
5 Brain RT. Clinical vagaries of herpes B. 1956;1:1061-6 6 De Marco BJ, Crandall RS, Hreshchyshyn MM. Labial agglutination secondary to a herpes simplex 2 infection. Am ] Obstet Gynecol 1987;157:296-7
7 Walzman M, Wade AA. Labial Adhesions after genital herpes infection. Genitourin Med 1989;65:187-8 (Accepted 20 May 1991)
CASE REPORT
Herpetic adhesions causing dyspareunia J Davidson Parker
MB BChir DipVen, and
J Bullough
MB FFARCS
Department of Genitourinary Medicine, St Ann's Hospital, London N15 Keywords: Herpes simplex, adhesions, dyspareunia
Occasional acute complications of genital herpes in otherwise healthy adults have been well documented. These include the appearance of extragenital lesions--' and neurological sequelae such as sacral radiculitis" and aseptic meningitis'. Persistent local complications are rarely recorded. This report describes a case of fusion of the labia minora following primary genital herpes and resulting in dyspareunia.
CASE REPORT A 21-year-old Afro-Caribbean woman was referred to the department of Genitourinary Medicine at St Ann's Hospital by her general practitioner in August 1990.Three months earlier she had attended the accident and emergency department of another hospital with painful vulval ulceration of 2 days' duration. Genital herpes was diagnosed on clinical grounds and she was treated with oral acyclovir and analgesics. HSV 2 infection was confirmed by viral culture. The lesions subsided within 10 days. There had been no recurrence of herpetic ulceration but the patient found that attempted coitus was persistently painful. She felt that 'her vagina had shrunk'. She had a regular partner but no full intercourse between first presentation and referral to St Ann's. On examination there was a band of adhesion joining the labia minora which reduced the size of the introitus by 50%. The adhesion was about 1 em wide and so well healed that the precise site of the junction could not be clearly ascertained. There was considerable loss of pigmentation of the surrounding skin in keeping with clinically severe genital herpes. This was bilateral and punctate and the texture of the labial skin remained normal. The adhesion was divided with a scalpel under local anaesthesia and the patient discharged. At follow-up 2 months later she was well and had no further coital problems. There had been no herpetic recurrences.
Correspondence to: Dr J Davidson Parker, Department of Genitourinary Medicine, St Ann's Hospital, St Ann's Road, London N15
She admitted to only one sexual partner during the 6 months preceding and since her acute herpetic infection. He was apparently symptom free and declined to attend for screening.
DISCUSSION While transient dyspareunia is a common symptom in patients with herpetic ulceration of the genital area or indeed any other painful vulval condition, persistent coital difficulty due to herpetic adhesions necessitating surgical intervention is very uncommon. Several decades ago Brain" noted that in severe genital herpes 'the labia were often stuck together by a viscid, serous discharge' but permanent adhesions were not described. There are two recent reports of similar cases to ours: De Marco et a1. 6 described a 35-year-old Caucasian woman who presented 21J2 years after her primary herpetic episode which was accompanied by fever and arthralgia. Shortly after this attack she was unable to have sexual intercourse or insert a tampon. It is not clear from the text why she had delayed in seeking medical advice. Possibly she was temporarily without a sexual partner. The labial adhesions were successfully dispersed with laser therapy. In the second case? labial adhesions were present for 3 112 months following primary infection but spontaneously resolved before surgical intervention, due perhaps to resumption of sexual intercourse although this is not suggested in the text. The appearance of the adhesions was attributed to delayed initiation of antiviral treatment. In the case now presented labial adhesions appeared to develop in spite of early acyclovir therapy and formed a barrier which was unlikely to have ruptured during the course of coital or manual stimulation. It is possible that saline washes in the acute st~ge of the infection might have prevented the formation of adhesions. The patient described was not instructed to do this. It is our current practice to recommend warm saline soaks twice daily to all patients with genital herpes receiving systemic antiviral therapy.
Davidson Parker and Bullough.
References 1 Sumers KD, Sugar J, Levine R. Endogenous dissemination of genital herpesvirus hominis type 2 of the eye. BT ] Ophtha/mo/1980i 64:770-4
2 Mindel A, Carney 0, Williams P. Cutaneous herpes simplex infections. Genitourin Med 1990;66:14-15 3 Caplan LR, Kleeman P], Berg S. Urinary retention probably secondary to herpes genitalis. N Eng/ ] Med 1977;297: 920-3
Herpetic adhesions causing dyspareunia
59
4 Bergstrom T, Vahlne A, Alestig K, [eansson 5, Forsgren M, Lycke E. Primary and recurrent HSV 2 induced meningitis. ] Infect Dis 1990;162:322-3
5 Brain RT. Clinical vagaries of herpes B. 1956;1:1061-6 6 De Marco BJ, Crandall RS, Hreshchyshyn MM. Labial agglutination secondary to a herpes simplex 2 infection. Am ] Obstet Gynecol 1987;157:296-7
7 Walzman M, Wade AA. Labial Adhesions after genital herpes infection. Genitourin Med 1989;65:187-8 (Accepted 20 May 1991)
