Genital Herpes

Aka: Genital Herpes, Herpes Simplex Virus 2, Herpes Genitalis, HSV II, HSV2, Human Herpes Virus 2

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II. Epidemiology

  1. Most common cause of Genital Ulcer in United States
    1. Responsible for 60-70% of Genital Ulcers in sexually active patients
  2. Affects 12% of sexually active patients aged 14 to 49 years in U.S.
    1. Prevalence is as high as 34% in non-hispanic black patients
  3. U.S. Prevalence: 30-45 Million
  4. U.S. Incidence: 572,000 new symptomatic cases yearly (in 2018)
  5. Not a reportable STI

III. Pathophysiology

  1. DNA Virus
  2. Cause of Genital Herpes
    1. Previously HSV II accounted for 80-90% of cases (and HSV I the rest)
    2. HSV I now accounts for at least 50% of new cases in U.S.
  3. Once infected with Primary Genital Herpes, virus remains latent in spinal nerve roots until outbreaks
    1. Outbreaks may be triggered with various stressors

IV. Risk Factors

  1. See STI Risk Factor
  2. Factors that increase the risk of genital tract shedding of HSV2
    1. Bacterial Vaginosis
    2. Group B Streptococcus vaginal colonization
    3. Hormonal Contraception

V. Precautions

  1. Genital Herpes is asymptomatic in 65-90% of patients
  2. Asymptomatic viral shedding occurs on 10-20% of all days (regardless of outbreak)
    1. Most common in the first year of infection, but frequent shedding may persist for years

VI. Symptoms

  1. Primary infection (Primary Genital Herpes)
    1. May be associated with fever, malaise and adenopathy
    2. HSV DNA migrates up the infected axon to the affected spinal cord sensory Ganglion
    3. HSV persists in the sensory Ganglion life long, dormant until next outbreak
    4. On periodic reactivation, HSV DNA migrates down axon and erupts again
      1. See Secondary Genital Herpes (Recurrent Genital Herpes)
  2. Prodromal symptoms (duration hours to days)
    1. Focal, genital pain, Paresthesias, burning, itching
    2. Lesions occur at the perineum, buttock, upper thigh or perianal area
    3. May also be associated with urinary symptoms (e.g. Dysuria, Urinary Retention)
  3. Vesicular (duration 2 weeks for primary herpes, and 6-12 days for secondary herpes)
    1. Vesicles erupt at the areas of pain and ultimately ulcerate and then heal
  4. Course
    1. First outbreak (primary) is typically worse, and subsequent
    2. Secondary outbreaks are less severe, and decrease in frequency over time
    3. Genital Herpes due to HSV 1 is more mild and with fewer outbreaks (initially 1-2 per year)
    4. Genital Herpes due to HSV 2 is more severe with more outbreaks (initially 4-5 per year)
    5. Genital Herpes is more severe and atypical in those with HIV Infection

VII. Signs

  1. See Primary Genital Herpes
  2. See Secondary Genital Herpes
  3. Vesicle
    1. Multiple vesicular lesions on foreskin, labia, vagina, anus, perineum, buttock or upper thigh
  4. Ulcer
    1. Painful shallow ulcers result when Vesicles rupture
  5. Lymphadenopathy
    1. Accompanied by lymhadenopathy with primary (first) infection (Primary Genital Herpes)

VIII. Differential Diagnosis

  1. See Genital Ulcer

IX. Labs

  1. See HSV Test
  2. Screen for other STI (HIV, Gonorrhea, Chlamydia, Syphilis) in patients suspected of having Genital Herpes
    1. See STI Screening
    2. HSV2 Infection increases HIV Infection risk by 2-3 fold

X. Diagnosis

  1. Symptomatic patients
    1. See HSV Test
    2. Genital Herpes is a clinical diagnosis during an active outbreak
  2. Asymptomatic patients
    1. Screening is not recommended (high False Positive Rate)

XI. Management

  1. See Genital Herpes in Pregnancy
  2. Precautions
    1. Genital Herpes is a lifelong infection without cure
    2. Antivirals do not cure the infection
      1. Antivirals suppress symptoms and reduce viral shedding
  3. Primary Infection (Initial episode)
    1. See Primary Genital Herpes (Initial Genital Herpes)
  4. Recurrent Infection
    1. See Secondary Genital Herpes (Recurrent Genital Herpes)
  5. Suppression/Prophylaxis
    1. See Secondary Genital Herpes (Recurrent Genital Herpes)
  6. Pregnancy
    1. See Genital Herpes in Pregnancy
  7. General measures
    1. Keep infected area clean and dry
      1. Avoid secondary Bacterial Infections
      2. Avoid spread to uninvolved skin (autoinoculation)
    2. Wear comfortable clothing
      1. Loose fit
      2. Cotton underwear
    3. Apply an ice pack or Baking Soda compress to area
  8. Topical (systemic agents are preferred)
    1. Penciclovir 1% cream ($20 for 2g tube)
      1. Efficacy
        1. Significant shortens duration of pain, healing
        2. (1997) Med Lett Drugs Ther 39(Issue 1003):57-8 [PubMed]
      2. Dosing
        1. Start at first prodromal symptom
        2. Continue every 2 hours while awake for 4 days
    2. Viscous Lidocaine
      1. Applied to genital lesions
      2. Can give significant relief
  9. Investigational
    1. L-Lysine 1000 mg PO three times daily
    2. Aspirin 125 mg PO daily
    3. Local licorice root gels applied three times daily
    4. Lemon balm applied four times daily
    5. Zinc applied daily
    6. Aloe vera 0.5% applied three times daily

XII. Prevention

  1. Avoid sexual contact during prodrome or when lesions are present
    1. However, asymptomatic shedding is common (up to 10-20% of days), esp. in first year
  2. Inform sexual partners of Genital Herpes
    1. Transmission can occur even when asymptomatic
  3. Condoms reduce transmission (especially for transmission from men to women)
    1. However partners still have a 10% conversion rate/year despite Condom use
    2. Also helps prevent HIV Transmission, for which Genital Herpes patients have 3 fold increased risk
    3. Much more effective in preventing transmission from men to women than vice versa
      1. Condom must cover active lesions
      2. Wald (2001) JAMA 285:3100-6 [PubMed]
  4. Discordant couple (one with herpes, one without)
    1. Viral shedding occurs in 10% of asymptomatic patients and 20% of symptomatic patients
    2. Consider Antiviral suppressive therapy (e.g. Valacyclovir) for the patient's first year of new HSV infection
      1. Valacyclovir NNT 57 to prevent one HSV infection in 8 months
        1. Corey (2004) N Engl J Med 350(1):11-20 +PMID: 14702423 [PubMed]
      2. Suppressive therapy is not effective in patients coinfected with HIV
        1. Mujugira (2013) J Infect Dis 208(9):1366-74 +PMID: 23901094 [PubMed]
    3. Women may consider peri-coital Tenofovir vaginal gel application to reduce transmission risk
      1. However, compounded gel was only made available for the study
    4. Consider HSV Serology for the patient's partner to determine status
  5. Perinatal transmission prevention (prevention of Neonatal HSV)
    1. See Genital Herpes in Pregnancy

XIII. Course

  1. See Primary Genital Herpes
  2. See Secondary Genital Herpes

XIV. Complications

  1. Primary or secondary HSV
    1. Transmission of other Sexually Transmitted Infection
      1. HIV Transmission risk is increased 3 fold in those with Genital Herpes
    2. Neonatal HSV (perinatal transmission)
      1. See Genital Herpes in Pregnancy
  2. Primary HSV
    1. HSV Meningitis (Mollaret Meningitis)
      1. May present with inability to urinate, as well as paralysis and Paresthesias
      2. Causes primary and secondary recurrent lymphocytic Meningitis
      3. Contrast with HSV1, which causes HSV Encephalitis
    2. Pneumonitis
    3. Pelvic Inflammatory Disease
    4. Aseptic Meningitis
      1. Occurs in 15% with Primary Genital Herpes
    5. Sacral radiculopathy syndrome
      1. Sacral Anesthesia, Urinary Retention
      2. May last up to 8 weeks
    6. Extragenital lesions (Disseminated HSV)
      1. Autoinoculation of buttocks, hands, eyes
    7. Transverse Myelitis
    8. HSV Hepatitis (rare)
      1. Acute life-threatening hepatitis with high mortality rate

XV. Resources

  1. Herpes Resource Center: (919) 361-8488
  2. Herpes Web
    1. http://www.herpesweb.net
  3. CDC Herpes site
    1. http://www.cdc.gov/std/herpes/stdfact-herpes.htm

XVI. References

  1. Beauman (2005) Am Fam Physician 72(8):1527-34 [PubMed]
  2. Groves (2016) Am Fam Physician 93(11): 928-34 [PubMed]
  3. Kimberlin (2004) N Engl J Med 350(19): 1970-7 [PubMed]
  4. Nadelman (2000) Postgrad Med 107(3):189-95 [PubMed]
  5. Plunkett (2024) Am Fam Physician 110(5): 487-92 [PubMed]

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