Genital herpes

What is it?

Genital herpes is a sexually transmitted infection that can cause blisters and skin ulcers in the genital and anal area. It can be caused by either of two types of herpes simplex virus, HSV-1 or HSV-2. HSV-2 is the more common cause. HSV-1 more commonly causes sores on the face and mouth.

HSV spreads from person to person through kissing and skin-to-skin contact, as well as through vaginal, oral, or anal intercourse. An infected person often transmits the virus when skin blisters or ulcers are visible, but the virus also can be spread when there are no symptoms or skin sores at all. Herpes virus can be transmitted by people who don't know they are infected.

In a pregnant woman with HSV infection (usually HSV-2), the virus can pass to the baby during delivery, causing infections of the newborn's skin, mouth, lungs, or eyes. If the herpes virus spreads through the baby's bloodstream, it can cause serious infections of the brain and other vital organs.

Symptoms

Many people with genital herpes infection have no symptoms. When symptoms appear, they can include

• itching, burning, soreness, and small blisters in the genital or anal area
• small ulcers (skin sores) when the blisters break
• local pain if urine touches the genital ulcers
• enlarged or painful lymph nodes (swollen glands) in the groin
• headache, fever, muscle aches, and a generally sick feeling (more likely with the initial episode).

Less common problems related to genital herpes include

• urinary retention — difficulty urinating when the virus affects the nerves to the bladder
• encephalitis — herpes infection that has spread to the brain causing headache, fever, confusion, and sometimes seizures
• meningitis — inflammation of the lining around the brain. It can be recurrent, a condition known as Mollaret's meningitis.
• proctitis — inflammation of the rectum or anus that can involve pain, bleeding, fever, and chills, usually related to unprotected anal sex.

The first episode of herpes symptoms usually has the worst symptoms. When symptoms develop, they can occur from a few days to a few weeks after contact with an infected person, but sometimes an infected person might not have any symptoms for years. Almost everyone with symptomatic genital herpes will have at least one recurrence. In people who have repeated herpes episodes, symptoms can be triggered by physical or emotional stress.

Newborns infected with herpes around the time of delivery usually develop symptoms five to nine days after birth. Symptoms can include blisters on the skin, eyes, and mouth. If the virus spreads through the baby's bloodstream to the brain, there can be sleepiness or irritability, and seizures. The virus can also spread to the baby's liver, lungs, and other organs, causing disseminated (widespread) disease. Herpes in a newborn can be from either HSV-1 or HSV-2, but HSV-2 tends to cause more severe disease.

Diagnosis

Your doctor may suspect that you have genital herpes based on your sexual history, your symptoms, and the results of your physical examination. Your doctor may want to confirm the diagnosis by scraping the affected skin area for laboratory testing. He or she may also want to do a blood test to confirm the diagnosis.

People who have one type of sexually transmitted infection are at risk of others. Your doctor may wish to test you for other infections, such as syphilis, gonorrhea, chlamydia, trichomonas, and human immunodeficiency virus (HIV).

The diagnosis of herpes infection in the newborn can be difficult because other things can cause similar symptoms in babies, including other types of infections. Special cultures and blood tests similar to those used in adults help confirm the diagnosis in newborns.

Expected duration

There is no cure for genital herpes. Herpes infection remains persistent, but it can be dormant (asleep) for very long periods of time. The symptoms tend to return periodically. The pattern of recurrence (how frequently it happens, how long an episode lasts, and what the symptoms are) is different for every person.

Prevention

To avoid getting herpes, you should always follow safer sexual practices. Limit your number of sexual partners. Always use condoms unless you are in a monogamous relationship with an uninfected person.

People with genital herpes should abstain from sexual activity when they have symptoms. They also should tell all sex partners about their herpes infection and use condoms during sexual activity. Even without symptoms, a person can shed the herpes virus and infect others.

There is some evidence that people who are infected with genital herpes can reduce the frequency and severity of recurrences and reduce the risk of transmitting the infection to sexual partners by taking antiviral medication every day (see Treatment, below).

People with active genital herpes sores are more likely to become infected with HIV if they are exposed through sexual intercourse. If you have HIV and you are infected with HSV-2, you may be more likely to spread HIV to others.

Pregnant women who have visible ulcers from genital herpes at the time of delivery usually are encouraged to have a Caesarean section to prevent HSV from spreading to the newborn. Because the decision to have a Caesarean section is based on many factors, a pregnant woman with HSV infection should discuss the subject with her physician as early as possible in her pregnancy. Women with their first outbreak at the time of delivery have the highest risk of transmitting the virus to the baby. Women known to have herpes before delivery may be counseled to take antivirals for the last few weeks of their pregnancy, but this decision should be made on a case-by-case basis.

Treatment

Episodes of genital herpes can be treated with oral antiviral medications, including valacyclovir (Valtrex), famciclovir (Famvir) and acyclovir (Zovirax). Acyclovir also comes in a cream for application to the skin. The cream is not very effective, and generally is not recommended.

For severe herpes virus infections, people are treated with intravenous (IV) acyclovir.

Although these antiviral medications cannot cure the herpes infection, they can reduce the severity and shorten the duration of symptoms. The initial genital herpes outbreak should be treated as soon as possible. Ideally an antiviral should begin within three days of when symptoms start.

For recurrences, an antiviral medication can be started at soon as symptoms are noticed to make the outbreak less severe. People with severe or frequent recurrences should consider taking an antiviral medication daily. Daily use of antiviral medications can reduce the severity and frequency of recurrences. Daily antivirals might also help prevent transmission of herpes virus to sexual partners.

The decision about whether to treat a pregnant woman known to have herpes with antivirals during the weeks before delivery should be made on a case-by-case basis together with an obstetrician. If a newborn baby is infected with herpes, the infection is treated with an antiviral medication given intravenously.

When to call a professional

Call your doctor if you have any blisters or sores in your genital area, especially if you are pregnant, have frequent bouts of symptoms, or want to know how to best protect your sexual partner from getting infected.

Prognosis

Although there is no cure for genital herpes, the frequency and severity of recurrences often decreases with time. Daily oral antiviral medication also can decrease the number and severity of recurrences.

For babies with disseminated herpes infection (the most severe type), early treatment with antivirals improves the chance of survival and helps decrease the risk of long-lasting complications.

Additional info

Centers for Disease Control and Prevention
https://www.cdc.gov/std/

American Sexual Health Association
https://www.ashasexualhealth.org/