Viral vulvo-vaginal infections and how to recognise and manage them

In the final part of our miniseries on vulval health care, GP and women’s health specialist Dr Louise Clarke discusses presentations of viral vulvo-vaginal infections and how nurses can ensure prompt diagnosis and appropriate care

Viral vulvo-vaginal infections are a common presentation in primary care and sexual health settings. They often cause significant anxiety, discomfort and stigma for affected women.

Genital herpes, genital warts and molluscum contagiosum all present with skin lesions, these have key differences which, when recognised, allow early identification and prompt management.

Sensitive communication, advice on contraception, symptom relief and vulval care are central to effective management. This article reviews the presentation and management of common viral vulvo-vaginal infections and outlines key counselling points to support women’s sexual health and long-term wellbeing.

Bacterial and fungal vulvo-vaginal infections are discussed in a previous article in this series.

Genital herpes

Presenting features – include painful blisters and sores

Genital herpes is a painful viral infection caused by the herpes simplex virus (HSV). In women it is associated with blistering, sores and ulcers on the vulval-vaginal area. The blisters appear first, approximately 4-7 days after infection, and then usually quickly burst, leaving the sores or ulcers.

These lesions are usually painful, with the first episode causing the most pain. They can also result in pain on urinating, and as a result, acute urinary retention can occur. The vulvo-vaginal pain can start up to 48 hours before the lesions appear and is often described as a ‘burning’ pain.¹

Related Article: Bacterial and fungal vulvo-vaginal infections – how to recognise and manage them   

As well as affecting the vulvo-vaginal area, lesions can occur on the thighs and buttocks, and the infection can cause tender, enlarged lymph nodes in the groin.

Prevalence – rising again

HSV is the most common sexually transmitted viral infection. In the UK in 2024, over 27,000 people had a first episode of genital herpes, representing 7.6% of all STI cases. HSV infections are also on the increase, with a 3.5% jump in cases between 2023 and 2024 in the UK.

The number of new infections still remains lower than before the Covid-19 pandemic, however, during which cases markedly dropped.² Genital herpes is much more common in women than in men, with 65% of cases affecting women worldwide.³ Even though genital herpes infection is sexually transmitted, first episodes can occur years into a monogamous relationship, through a partner without symptoms shedding the virus.¹

Infection course and transmission

Two strains of HSV cause genital herpes – HSV-1 is the most common, while HSV-2 is more likely to cause recurrent infection, which is due to reactivation of pre-existing HSV infection in local sensory nerve ganglia.  The recurrences tend not to be as severe as the first episode, causing small crops of blisters affecting a particular dermatome (the patch of skin supplied by one nerve).¹

HSV-2 used to be the predominant cause of genital herpes, with HSV-1 responsible for causing oral-labial herpes (affecting the mouth and lips, or ‘cold sores’).

However, HSV-1 can also cause genital lesions via transmission during oral sex and is now responsible for more first episodes of genital herpes in the UK and US than HSV-2.^1,3 As above, HSV-1 causes fewer recurrent episodes than HSV-2. People with genital herpes caused by HSV-1 will have, on average, one recurrence over the subsequent year, whereas those with HSV-2 will have five.

Treatment and self-care advice

Genital herpes is treated with an oral course of an anti-viral medication such as acyclovir or valaciclovir, the course length is dependent on whether this is a first episode or a recurrence, and the course can be extended if there are still new lesions appearing.¹ Continuous anti-viral medication may be appropriate in women who have multiple episodes in a year.

As the lesions can be really painful, it is important to advise on self-care measures, such as the use of over-the-counter pain killers, saline bathing, keeping well hydrated to dilute urine to aid passing and avoiding tight clothing. Applying gels containing anaesthetic agents and petroleum jelly to the area can be soothing.

It is important to tell women to avoid intercourse whilst lesions are present. Using barrier methods decreases the risk of transmission, but this can still occur even with condom use. Specialist advice should be sought if the woman affected is pregnant due to the risk of transmission to the newborn, which can cause serious illness and has a high mortality rate.³

Genital warts

Infection causes and presentation

Genital warts are caused by the human papillomavirus (HPV) and usually transmitted during sex, but, more rarely, can also occur due to transmission from hand warts and during birth.⁴

Genital warts tend to be painless, cauliflower-like, benign growths, which are under 1cm wide. More rarely, they grow larger or form plaques and can be pigmented.

If they become irritated, they become painful and bleed due to trauma. In women, they are most commonly found around the entrance to the vagina.⁴

Related Article: Interview: closing the nine-year gap in endometriosis diagnosis

Genital HPV infection risks

The number of new cases of genital warts is decreasing as a result of the HPV vaccination programme; there were still over 25,000 new cases of genital warts in the UK in 2024.²

Still the risk of a person having genital warts at some point during life is approximately 10%, and lesions are difficult to treat with a high relapse and failure rate.⁴

There are over 150 subtypes of HPV, some of which are associated with cancer in the anogenital region.⁵ The subtypes that tend to cause genital warts are 6 and 11, which don’t increase the risk of cancer, but women with one type of HPV are also more likely to have a higher risk type.⁴

Management – includes topical treatments and cryotherapy

Genital warts spontaneously resolve in 30% of people within 6 months. The lesions can be persistent and difficult to treat, with recurrence common.

Treatments include podophyllin toxin and imiquimod applied topically to the lesions. It is important to warn women that imiquimod can weaken condoms.⁴

Cryotherapy and excision are often offered in a sexual health clinic. Complications of treatments include scarring and permanent changes to skin pigmentation. Condom use should be advised, as well as smoking cessation, which improves response to treatment.⁴

In pregnancy, genital warts often get bigger and increase in number. As they rarely cause problems in newborns, treatment is often delayed until after delivery.⁴

Molluscum contagiosum

Infection causes and presentation

Molluscum contagiosum are skin lesions that can occur anywhere on the body caused by a virus of the same name. Molluscum are very common in children, but genital infections are more common in young adults, usually having been transmitted by sexual contact.⁶ The incidence of genital molluscum is increasing worldwide.⁶

Related Article: Mythbuster: ‘This patient’s tested positive for Candida – can you arrange a prescription?’

Molluscum is diagnosed by its characteristic appearance on examination, which is the presence of 2-5mm smooth-surfaced, dome-shaped lesions with a central dimple.⁷ They normally cause no symptoms but can be itchy and red, with larger lesions sometimes being present.⁷

Management and self-care – advise against shaving, sharing towels

The infection and lesions self-resolve within 12-18 months, usually without complication. As a result, it is often appropriate to recommend no treatment, although women often seek treatment for cosmetic reasons, due to fears regarding transmission and concerns around stigma.⁶ As with genital warts, molluscum can be treated with podophyllotoxin and cryotherapy, but treatment failure is common with scarring as a result of treatment.⁶

Lesions can spread to other areas around the body, to other people or spread in the genital area. Advise against shaving, electrolysis or waxing in women with genital molluscum as this increases the risk of spread. Women should be advised to use barrier methods to reduce the risk of transmission to others, as well as to avoid sharing towels, bed linen and clothes.⁶

Key practice points

• Viral vulvovaginal infections, including genital herpes, genital warts and molluscum contagiosum, are relatively common and may cause significant psychological distress alongside physical symptoms.
• First episodes of genital herpes are often the most painful; recurrence patterns differ between HSV-1 and HSV-2.
• Asymptomatic viral shedding means HSV infection can occur within established monogamous relationships.
• Suppressive antiviral therapy may be appropriate for women with frequent herpes recurrences.
• Most genital warts are caused by low-risk HPV types (6 and 11), but co-infection with high-risk types is possible.
• Many genital warts and Molluscum contagiosum can resolve spontaneously; treatment decisions should balance symptom burden, cosmetic concerns and potential complications.
• Pregnancy requires careful consideration in herpes infection due to the risk of neonatal transmission.
• Smoking cessation improves treatment response in genital warts.

References

1. NICE CKS. Herpes Simplex – genital. Last revised 2024
2. UK Health Security Agency. Sexually transmitted infections and screening for chlamydia in England: 2024 report. Last updated December 2025
3. Johnston C, Wald A. Genital Herpes. JAMA 2024 Sep 10;332(10):835-836
4. NICE CKS. Warts – anogenital. Last revised 2024
5. Dermnet NZ. Anogenital Wart. Last revised 2021
6. Fernando I et al. British Association for Sexual Health and HIV national guideline for the management of Genital Molluscum in adults (2021). Int J STD AIDS 2022;33(5):422-32
7. NICE CKS. Molluscum Contagiosum. Last revised March 2022