Clinical Characteristics and Diagnostic Markers of Genital Varicella-zoster in Women: A 12-year Retrospective Cohort

BACKGROUND: Genital involvement in varicella-zoster virus (VZV) reactivation is uncommon and frequently misdiagnosed. Data on the clinical features of genital zoster are limited, particularly among female patients. METHODS: We conducted a retrospective case series of female patients with genital involvement by VZV at a tertiary referral center between 2013 and 2025. Inclusion required polymerase chain reaction (PCR)-confirmed VZV from genital swabs. Demographic characteristics, immune status, pregnancy status, clinical presentation, diagnostic pathways, and treatment patterns were extracted from electronic medical records and summarized descriptively. RESULTS: A total of 21 patients were included (median age, 32.5 y). Most patients were immunocompetent (71.4%), and six (28.6%) were pregnant. VZV was correctly identified at initial presentation in 61.9% of cases; the remainder were misdiagnosed as HSV (23.8%) or as bacterial or fungal conditions (14.3%). Documentation of sexual history and partner HSV status occurred in 28.6% of patients. Unilateral distribution was documented in 90.5% of cases, extragenital extension in 85.7%, and pain in 76.1%, representing the most consistent clinical features in the cohort. Notably, these findings were also present in cases that were initially misdiagnosed. Intravenous acyclovir was required in 23.8% of patients, predominantly among immunocompromised individuals. More than half of the cohort received systemic antibiotics before definitive diagnosis. CONCLUSIONS: Genital zoster is an under-recognized clinical entity with a relatively high rate of initial misdiagnosis. Recognition of three key clinical features-unilateral sacral distribution, pain, and extragenital extension-may substantially improve diagnostic accuracy, reduce misclassification as HSV, and mitigate sexual-health-related psychosocial burden.