Genital Herpes is caused by herpes simplex virus (HSV) type l or type ll. Either type can infect the mouth (producing cold sores) or the genital area (genital herpes).
When a person is first infected with the herpes virus, the infection may pass unnoticed. This is called subclinical infection. The majority of people infected with herpes in the genital region remain unaware that they have the infection.
However, some people do experience symptoms, and there is no way to predict which people will develop symptoms after exposure to the virus.
The first symptoms of herpes may occur at any time from days to years after the virus first enters the body. Because it is a viral illness, flu-like symptoms may occur¡ªfeeling unwell, headaches, fever, swollen glands, pain in the back and legs. These symptoms may occur when a person is first exposed to the herpes virus but not usually with future outbreaks.
The first outbreak may produce small painful blisters which break open to form shallow painful sores. These scab over and heal completely without scarring after 1-2 weeks. Sometimes, the first outbreak may cause considerable pain and distress. Fortunately this is not common and any future attacks are likely to be less serious.
Even though the sores go away, the virus probably remains in the body for life and may produce sores again at a later date. These outbreaks are called recurrent outbreaks and do not mean a new infection.
Recurrent outbreaks usually occur on the same part of the body but are usually shorter and not as painful as the first attack. They may be triggered by general illness, stress, menstruation or sexual activity. However a recurrence may occur without any trigger being identified. In most cases, recurrences become less frequent with time and may eventually stop altogether.
The virus is initially transmitted through direct contact, with cold sores on the mouth being a potential source of genital infection following mouth-genital contact (oral sex).
Because recurrent herpes may cause few problems or pass unnoticed, it is possible to pass on the virus even when there are no blisters or sores visible. This needs to be understood, so discuss it fully with a doctor or health adviser.
Recurrent attacks are usually caused by reactivation of the virus already present in your body rather than by reinfection.
Herpes is most reliably diagnosed when a sample is taken from an infected area during an outbreak. The herpes virus will probably grow from a direct swab from a ruptured blister. There is no routine blood test available to reliably diagnose genital herpes.
Betadine paint will dry out the blisters and help prevent secondary infection. Salt baths may also help. Passing urine I a warm bath may help if urination is painful. Aspirin or paracetamol will help relieve pain.
Aciclovir, valaciclovir and famciclovir are anti-viral medications prescribed by a doctor. They will reduce the severity of an outbreak, particularly if taken early in the course of the outbreak (preferably within the first three days of symptoms appearing). Valaciclovir and famciclovir can also be taken continuously as preventive medication, if outbreaks are very frequent. The medications do not get rid of the virus from the body.
You are most likely to transmit the infection to another person if you have oral, genital or anal sex while you have an actual outbreak of sores or blisters on your genitals or mouth. You may decide not to have sex at that time or to use condoms.
It is possible to transmit the infection even if your genital skin is not obviously infected. If you do not have any blisters or sores present, it is an individual decision to use condoms or not when having sex.
Herpes in pregnant women may be transmitted to the baby at delivery, causing serious illness. This is uncommon, but the obstetrician should be aware of past herpes infections so that this complication can be prevented.
Much unnecessary anxiety and fear has been caused by exaggerating the dangers of genital herpes. Genital herpes blisters are cold sores in the genital area. The condition should not be regarded as a particularly serious illness, a source of shame or guilt, or a serious barrier to sexual and other loving relationships.
This infection is caused by the Herpes simplex virus. Genital infection may be caused by Type 1 (HSV-1) or Type 2 (HSV-2). The symptoms are similar, and can result from either oral-to-genital or genital-to-genital contact. The virus causes blisters on the genitals, similar to the cold sores that occur on the mouth. Cold sores on the mouth are also caused by the herpes virus.
These infections are caused by viruses and definitive cures are not available. However, many patients are distressed by the recurrent nature of the infections and perceived serious complications.
Because genital herpes is not a notifiable disease, there are no accurate statistics on its prevalence in South Australia. However, in recent years, approximately 2% of the clients with STDs diagnosed at Clinic 275 have had active episodes of the infection.
Various studies in the USA and Australia have demonstrated the presence of HSV-2 antibodies in 20-60% of the populations tested.
It has been estimated that approximately 1 in 6 people in Australia has had a history of genital herpes outbreaks at some time.
Not all people infected with the herpes simplex viruses will develop symptoms. As many as 60-70% of people with evidence of herpes simplex virus type 2 infection (as diagnosed by a blood test) have not had symptoms diagnosed as genital herpes.
For those who develop symptoms, the typical clinical course is as described below.
Lesions occur most often on the penile shaft, prepuce, glans or anal region and on the labia, clitoris, introitus, vagina and/or cervix. They can also occur around the mouth or on the throat following oral sex.
Incubation takes 2 to 20 days from when the
infection is transmitted. After a 12-24 hour
period of hypersensitivity or local discomfort
(burning or tingling), multiple vesicular
lesions (small blisters) appear which may
subsequently produce a rosette formation.
Between 24 and 72 hours after their appearance
vesicles rupture to form superficial shallow
painful ulcers which occasionally become
secondarily infected. Regional lymph nodes
are enlarged and tender in some 75 percent
of cases and may remain enlarged for up to
six weeks.
Genital herpes is usually more painful in
women because of their anatomy. Vaginal and
labial blisters may be so painful that women
become unable to pass urine and require catheterisation.
It is important to seek early medical assistance
in order to prevent this complication. Herpetic
cervicitis, because of its necrotising nature,
frequently produces a sanguineous vaginal
discharge.
Symptoms persist for 1 to 3 weeks.
The duration of the initial episode is shorter and less severe in those with a pre-existing HSV-1 antibody response (i.e. in people with pre-existing cold sores).
Extragenital inoculation of fingers, buttocks, torso and/or eyes can occur.
Herpes continues to live in the body between outbreaks, and recurrent episodes of symptoms may occur. Relapses can be precipitated by emotional or physical stress, fever, trauma, hormonal changes, sunlight, alcohol and immunological deficiencies. These occur after a variable latency period.
Relapses are characterised by:
Asymptomatic viral shedding has been reported from the cervix and vulva in women and from the urethra in males. Women are usually not aware of severe lesions which are confined to the cervix. It is likely that people who are asymptomatic carriers of the herpes viruses are still able to transmit the infection.
Neonatal transmission occurs during birth if the mother is actively shedding the virus. Infection of the infant causes severe illness and has a high mortality rate. Transmission of herpes during birth is rare, and occurs usually in cases where the woman is experiencing primary herpes at the time of the delivery, (i.e. no previous history of genital herpes). The risk is further reduced by informing the obstetrician and performing testing during pregnancy. Caesarean section may be performed if lesions are present or if swabs detect active shedding near term.
Genital herpes can be passed on through most forms of sexual contact, genital-to-genital, oral-to-genital, and mutual masturbation. Many people are unaware that oral cold sores may cause genital infection during oral sex. It is also possible for a person to transfer herpes from their own mouth to their genitals, and to their eyes. New lesions that are filled with fluid are the most infectious.
Greatest risk of transmission occurs during sexual contact with open lesions of the oral or anogenital area, but transmission may occur at other times from asymptomatic shedding. Individuals should avoid all sexual contact until lesions have fully healed. Condoms may further reduce spread between attacks.
Treatments that can relieve discomfort include:
Because herpes is a virus, it cannot be treated with antibiotics. Although the herpes virus cannot be eradicated from the body, the drugs aciclovir, valaciclovir and famciclovir hasten healing and reduces the risk of recurrence while they is being administered.
Because anti-herpes medications are expensive and in some cases must be taken several times each day, their use is usually limited to patients suffering particularly painful episodes or those experiencing multiple recurrences.
Primary attacks or painful recurrences- orally or intravenously for 5 days - speeds healing, reduces symptoms, reduces duration of viral shedding
Recurrent attacks (moderate to severe attacks, limiting the patient's normal activities, several times per year). A 6 month trial may be warranted-reduces number and duration of recurrences.
The anti-herpes drugs do not eliminate the virus and have no effect on the long term natural history of the disease.
The use of condoms during vaginal and anal intercourse reduces the risk of genital herpes, but protects only those areas in contact with the condom.
Because herpes can be transmitted from mouth-to-genitals and vice versa, condoms or dental dams may be used during oral sex. If sores are present, it is important to avoid oral sex.
Because herpes can be spread by the hands between people, and from site to site on one person's body, it is important to wash hands if they have come into contact with lesions, particularly new lesions.
During an attack, it is important to avoid sexual contact involving the genitals until the sores have disappeared. This will aid healing and help prevent transmission.
Transmission may occur during periods of asymptomatic viral shedding. People with herpes should be aware that although the risk of transmission is greatest during symptomatic episodes, there is a potential for transmitting the infection at any time.
Isolation of herpes simplex virus (HSV) in cell culture from the cervix, urethra or a genital or perianal lesion. Ideally, the specimen should be taken within 72 hours of the appearance of a suspicious lesion.
Currently available HSV serology is of no value in the diagnosis of genital herpes, other than to exclude the condition in individuals with negative HSV IgG.
Specimen from genital lesion demonstrates typical HSV morphology by electron microscopy
or
Evidence of HSV on Pap smear
Please note: ELISA test is not recommended because of defects in both sensitivity and specificity
Dark field negative, typical herpetic genital lesions (pre-emergent paraesthesiae; blisters; multiple, painful shallow ulcers)
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| Vesicular herpes of the penile shaft. Multiple small blisters of the genitals, particularly when preceded by characteristic paraesthesia, are virtually diagnostic of herpes. | Typical ulceration of the vestibule seen in a primary herpes attack. Multiple, shallow, uniform ulceration of the vestibule seen in a primary attack. Multiple, shallow, uniform ulceration of the genitals is highly suggestive of herpes infection. |
No treatment is available to eradicate the virus.
Antiviral agents reduce viral shedding from lesions, hastens healing and reduces the risk of recurrence while it is being administered. In the STD clinic aciclovir is used with the aim of avoiding hospitalisation and/or reducing severe patient distress in acute primary infection.
The recommended regimen is:
valaciclovir 500mg twice a day for 5 days. (The patient should be reviewed after 5 days to check for resolution of symptoms. A further 5 days of valaciclovir may be indicated.).
In cases of HSV proctitis, the recommended regimen is:
aciclovir 400 mg 5 times a day for 7 to 10 days.
Most immunocompetent patients with recurrent disease do not benefit from intermittent antiviral therapy. If indicated, treatment should be instituted during the prodrome or within 2 days of onset of lesions. The recommended regimen using valaciclovir is as for first episode genital HSV illness. Famciclovir 125mg twice daily for 5 days is an alternative treatment regime.
In patients with frequent (6 or more per year) severe recurrences daily suppressive therapy reduces the frequency of recurrences, although it does not totally eliminate symptomatic or asymptomatic viral shedding. The recommended regimen is:
valaciclovir 500mg daily for a minimum of 6 to 12 months. (This dose may be increased to 500mg bd if the patient has more than 10 recurrences in one year).
or
famciclovir 250mg twice a day for a minimum of 6 to 12 months
After 6 to 12 months, medication should be discontinued to allow evaluation of the rate and severity of recurrences.
The primary aim is supportive treatment by keeping lesions as clean and dry as possible while spontaneous healing occurs. This may be achieved by saline bathing (or other cleansing) of the ulcerated area, drying with tissues, application of "Betadine" paint and/or exposing the ulcers to air or the warmth of a reading light (a fan or hair dryer may be useful) for 10 to 15 minutes several times a day, particularly after urination (for women). Topical lignocaine and zinc creams should not be used.
Analgesics by mouth are often useful, particularly at night time.
Hospitalisation should be considered for patients who are in obvious distress from the physical effects of their lesions, particularly when pain is aggravated by walking or leads to urinary retention. This pattern occurs mainly in first attacks involving widespread ulceration of the vulval or perineal area.
Stress that the disease is common, is unlikely to interfere significantly with the patient's life after the first attack and is not likely to have serious complications. Women should be advised to continue with routine two yearly Pap smears and to inform the doctor managing any future pregnancies of the diagnosis.
The patient should not have sex whilst the lesions are present, but should also be made aware of the potential for asymptomatic viral shedding.
Provide the patient with or recommend literature on genital herpes.
Genital herpes affects an estimated 60 million Americans. Approximately 500,000 new cases of this incurable viral infection develop annually. Herpes infections are caused by herpes simplex virus (HSV). The major symptoms of herpes infection are painful blisters or open sores in the genital area. These may be preceded by a tingling or burning sensation in the legs, buttocks, or genital region. The herpes sores usually disappear within two to three weeks, but the virus remains in the body for life and the lesions may recur from time to time. Severe or frequently recurrent genital herpes is treated with one of several antiviral drugs that are available by prescription. These drugs help control the symptoms but do not eliminate the herpes virus from the body. Suppressive antiviral therapy can be used to prevent occurrences and perhaps transmission. Women who acquire genital herpes during pregnancy can transmit the virus to their babies. Untreated HSV infection in newborns can result in mental retardation and death.
Objective: The rates of new HSV-1 and HSV-2 infections were 1.6 and 5.1 cases per 100 person-years, respectively. Of the 155 new HSV-2 infections, 57 (37 percent) were symptomatic, 47 of which (82 percent) were correctly diagnosed at presentation. Among the 74 patients given a clinical diagnosis of genital HSV-2 during the study, 60 were given a correct diagnosis and 14 were given an incorrect diagnosis of genital herpes, for a ratio of true positive results to false positive results of 4:1. Among the 98 persons with HSV-2 seroconversion, 15 percent had genital lesions at some time during follow-up. Women were more likely than men to acquire HSV-2 (P<0.01) and to have symptomatic infection. Previous HSV-1 infection did not reduce the rate of HSV-2 infection, but it did increase the likelihood of asymptomatic seroconversion, as compared with symptomatic seroconversion, by a factor of 2.6 (P<0.001). Of the 19 new HSV-1 infections, 12 were symptomatic. The rates of symptomatic genital HSV-1 infection and oropharyngeal HSV-1 infection were the same (0.5 case per 100 person-years).
Conclusions: Nearly 40 percent of newly acquired HSV-2 infections and nearly two thirds of new HSV-1 infections are symptomatic. Among sexually active adults, new genital HSV-1 infections are as common as new oropharyngeal HSV-1 infections.
(N Engl J Med. 1999;341:1432-1438)
(1999;341:1432-1438) Langenberg AG, et al, Chiron, Emeryville, CA.
New England Journal of Medicine
Vol. 159, pp. 2430-2436, November 4, 1999
A Prospective Study of New Infections With Herpes Simplex Virus Type 1 and Type 2: Chiron HSV Vaccine Study Group.
Langenberg AG, et al
Commentary by:
Keith Henry, MD
HIV/STD Clinic
St Paul Ramsey Health Department
St Paul, Minn
(Posted February 28, 2000)
Langenberg and colleagues presents a clinically important contribution to understanding of the natural history of herpes simplex infections among sexually active adults. The study population consisted of 2393 sexually active adults (1646 men) who were seronegative for herpes simplex type 2 (HSV-2) when enrolled in 1 of 2 similarly designed clinical trials to evaluate the efficacy of a candidate vaccine to prevent HSV-2 infection. Sixty-three percent of the study subjects were herpes simplex type 1 (HSV-1) seropositive.
The candidate vaccine demonstrated no efficacy, (1) so assignment to either vaccine arm of the studies would have had little influence on the rate of new cases of herpes infection. There were 19 new HSV-1 infections and 155 new HSV-2 infections (rates of infection, 1.6 and 5.1 per 100 person-years, respectively). The rates of new genital and oropharyngeal HSV-1 infections were equivalent.
Noteworthy findings in the study included that only 37% of the new HSV-2 infections were symptomatic, with 82% of those cases correctly diagnosed at presentation. Ninety-eight persons had asymptomatic HSV-2 infection; 85 of these individuals were prospectively followed and 13 (15%) had genital lesions at some point during follow-up. The rate of HSV-2 infection was higher in women, as was symptomatic infection. Prior HSV-1 infection did not influence the rate of new HSV-2 infection, but was related to a lower rate of symptomatic HSV-2 infection. This observation supports the view that exposure to natural or vaccine-related HSV antigens may have little effect on new HSV-2 infections, but could influence the subsequent clinical course.
Several other clinically relevant outcomes deserve mention. Staff at the study sites were experienced clinicians, yet genital HSV infections were often misdiagnosed. Thirteen percent of new, symptomatic HSV-2 infections were atypical prompting initial diagnoses of cystitis, urethritis, cervicitis, or meningitis. The positive predictive value of a clinical diagnosis of genital herpes was 81%, while the sensitivity for diagnosing HSV-2 infections was only 39%. Another important observation was that shedding from the genital tract is common among asymptomatic HSV-2 infected persons. (2) Overall, the results of this study document the high rate of new, asymptomatic HSV-2 infections and the potential merit of type-specific herpes virus testing.
References
1. Corey L, Langenberg AGM, Ashley R, et al. Recombinant glycoprotein vaccine for the prevention of genital HSV-2 infection: two randomized controlled trials. JAMA. 1999;282:3331-340. Abstract available at:JAMA Web site.
2. Wald A, Zeh J, Selke S, Ashley RL, Corey L. Virologic characteristics of subclinical and symptomatic genital herpes infection. N Engl J Med. 1995;333:770-775.
© 2000 American Medical Association
Genital herpes(Chinese Version)
