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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Related Studies

Ontology: Genital Herpes (C0019342)

Definition (MEDLINEPLUS)

Genital herpes is a sexually transmitted disease (STD) caused by a herpes simplex virus (HSV). It can cause sores on your genital or rectal area, buttocks, and thighs. You can get it from having sex, even oral sex. The virus can spread even when sores are not present. Mothers can also infect their babies during childbirth.

Symptoms of herpes are called outbreaks. You usually get sores near the area where the virus has entered the body. They turn into blisters, become itchy and painful, and then heal. Sometimes people do not know they have herpes because they have no symptoms or very mild symptoms. The virus can be more serious in newborn babies or in people with weak immune systems.

Most people have outbreaks several times a year. Over time, you get them less often and the symptoms become milder. The virus stays in your body for life.

Medicines do not cure genital herpes, but they can help your body fight the virus. This can help lessen symptoms, decrease outbreaks, and lower the risk of passing the virus to others. Correct usage of latex condoms can reduce, but not eliminate, the risk of catching or spreading herpes.

NIH: National Institute of Allergy and Infectious Diseases
Definition (NCI) Herpes simplex infection on the genitals, most commonly caused by the herpes simplex-1 virus.
Definition (CSP) infection caused by herpes simplex virus type 2 (HSV-2) that is usually transmitted by sexual contact; marked by recurrent attacks of painful eruptions on the skin and mucous membranes of the genital area.
Definition (MSH) Infection of the genitals (GENITALIA) with HERPES SIMPLEX VIRUS in either the males or the females.
Concepts Disease or Syndrome (T047)
MSH D006558
ICD9 054.10, 054.1
SnomedCT 154333002, 271463009, 186536000, 186539007, 33839006
English HERPES GENITALIA, Genital Herpes Simplex, Herpes Genitalis, Herpes Simplex, Genital, HERPES GENITAL, Genital herpes simplex NOS, Genital herpes unspecified, Herpes Simplex Virus Genital Infection, Herpes genital, Genital herpes, unspecified, Genital herpes, HERPES SIMPLEX VIRUS GENITAL INFECT, herpes genitalis, venereal herpes, Genital herpes NOS, Herpes Genitalis [Disease/Finding], Genital Herpes, simplex genital herpes, genitals herpes, genital hsv, genital herpes, Herpes, Genital, Genital herpes (disorder), Genital herpes unspecified (disorder), Genital herpes simplex NOS (disorder), genital herpes simplex (diagnosis), genital herpes simplex, herpes simplex genitalis, Herpes genitalis, Genital herpes simplex, Genital herpes simplex (disorder), genital; herpes, herpes; genital, Genital herpes simplex, NOS
French HERPES GENITAL, Herpès génital, non précisé, Herpès génital, Herpès simplex génital
Portuguese HERPES GENITAL, Herpes genital NE, Herpes genital, Herpes simples genital, Herpes Genital, Herpes Simples Genital
Spanish HERPES GENITAL, Herpes genital, Herpes genital no especificado, herpes genital no especificado (trastorno), herpes genital no especificado, Herpes simplex genital, SAI, Herpes simplex genital, SAI (trastorno), Herpes simplex genital, herpes genital, herpes simple genital (trastorno), herpes simple genital, herpes simplex genital, Herpes Genital, Herpes Simple Genital
German HERPES GENITALIS, genitaler Herpes, unspezifisch, genitaler Herpes, Herpes, genital, Genitaler Herpes simplex, Herpes genitalis, Herpes simplex genitalis, Genitale Herpesinfektion
Swedish Genitalherpes
Dutch herpes genitalis, genitale herpes, niet-gespecificeerd, herpes genitaal, genitale herpes simplex, genitaal; herpes, herpes; genitaal, Herpes genitalis, Herpes simplex genitalis, Genitale herpes
Italian Herpes genitale, non specificato, Herpes simplex genitale, Infezione genitale da virus herpes simplex, Herpes genitale
Japanese 陰部ヘルペス、詳細不明, ｲﾝﾌﾞﾍﾙﾍﾟｽ, ｲﾝﾌﾞﾍﾙﾍﾟｽｼｮｳｻｲﾌﾒｲ, 陰部単純ヘルペス, 陰部ヘルペス, ｲﾝﾌﾞﾀﾝｼﾞｭﾝﾍﾙﾍﾟｽ, 生殖器ヘルペス, 疱疹-陰部, 陰部疱疹, ヘルペス-生殖器, ヘルペス-陰部, 単純ヘルペス-陰部, 性器ヘルペス
Czech herpes genitalis, Herpes genitalis, Genitální herpes, Genitální herpes, blíže neurčený, genitální herpes, Genitální herpes simplex
Finnish Sukupuolielinherpes
Russian GERPES PROSTOI GENITAL'NYI, GERPES GENITAL'NYI, ГЕРПЕС ГЕНИТАЛЬНЫЙ, ГЕРПЕС ПРОСТОЙ ГЕНИТАЛЬНЫЙ
Polish Opryszczka narządów płciowych
Hungarian Genitalis herpes, nem meghatározott, Genitalis herpes, herpes genitalis, genitalis herpes, Genitalis herpes simplex
Norwegian Herpes genitalis, Genital herpesvirusinfeksjon, Kjønnsherpes
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Human Herpesvirus 2 (C0019351)

Definition (NCI_CDISC) Any viral organism that can be assigned to the species Human Herpesvirus 2 within the genus Simplexvirus.
Definition (NCI) A species of enveloped and spherical viruses with a capsid with T=16 icosahedral symmetry and surrounded by amorphous tegument, in the Herpesviridae family and Simplexvirus genus. The genome is composed of monopartite, linear double-stranded DNA. Human herpesvirus 2 is found in humans and causes genital herpes in the form of watery blisters. Human herpesvirus 2 is transmitted mainly via direct sexual contact.
Definition (MSH) A species of SIMPLEXVIRUS associated with genital infections (HERPES GENITALIS). It is transmitted by sexual intercourse and close personal contact.
Definition (CSP) similiar to herpes simplex 1 except that it is usually transmitted sexually; causes genital lesions and may cause carcinoma of the cervix.
Concepts Virus (T005)
MSH D018258
SnomedCT 154332007, 266191005, 13687007
LNC LP14401-1, MTHU004637
English Herpes Simplex Virus 2, Herpesvirus 2 (alpha), Human, Herpesvirus 2, Human, HSV-2, HHV-2, HERPESVIRUS 2 ALPHA HUMAN, HHV 2, HSV 02, HERPESVIRUS HUMAN 02, HUMAN HERPESVIRUS 02, HERPES SIMPLEX VIRUS 02, human alphaherpesvirus 2, herpes simplex virus 2, HSV 2, Human Herpesvirus 2, Herpes simplex virus type 2, herpes simplex virus type 2, herpes simplex ii, hsv-2, HUMAN HERPESVIRUS 2, Herpes simplex virus (type 2), herpes simplex virus type 2 HSV-2, Herpes Simplex Virus Type 2, Herpes Simplex Virus type 2, Human herpesvirus 2, Herpes simplex virus 2, HSV 2 - Herpes simplex virus 2, Human (alpha) herpes virus 2, Human herpes simplex virus type 2, Human herpes simplex virus type 2 (organism)
Swedish Herpesvirus 2, humant
Czech herpesvirus 2 lidský, herpes simplex virus 2, herpesvirus 2 (alfa) lidský
Portuguese Herpesvirus Humano Tipo 2, Herpesvirus Humano 2, HSV-2, Vírus do Herpes Simplex 2
Spanish Herpesvirus Humano Tipo 2, Herpesvirus Humano 2, HSV - 2, virus del herpes simple humano tipo 2 (organismo), virus del herpes simple humano tipo 2, VHS - 2, HSV-2, Virus 2 del Herpes Simple
Finnish Ihmisen herpesvirus 2
Russian GERPESVIRUS 2 (AL'FA) CHELOVEKA, GERPES PROSTOGO VIRUSA 2, GERPESVIRUS 2 CHELOVEKA, ГЕРПЕСВИРУС 2 (АЛЬФА) ЧЕЛОВЕКА, ГЕРПЕСВИРУС 2 ЧЕЛОВЕКА, ГЕРПЕС ПРОСТОГО ВИРУСА 2
Italian HSV-2, Herpesvirus simplex 2, HHV-2, Herpesvirus 2 (alfa) umano, Herpesvirus simplex di tipo 2, Herpesvirus 2 umano
German HERPESVIRUS HOMINIS TYP 02, HSV 02, HERPES SIMPLEX VIRUS TYP 02, HUMANES HERPESVIRUS 02, HERPESVIRUS HUMANES 02, Herpes-simplex-Virus Typ 2, Herpesvirus 2, humanes, Herpesvirus hominis, Typ 2, HSV-2, Humanes Herpesvirus 2
Polish Wirus opryszczki pospolitej 2, Herpes simplex 2, HSV-2, Herpeswirus 2 ludzki
Japanese ヒトヘルペスウイルス2型, 単純ヘルペスウイルス-2, ヒトヘルペスウイルス2(アルファ), ヒトヘルペスウイルス2, 単純ヘルペスウイルス2, ヒトヘルペスウイルス-2, ヘルペスウイルス2-ヒト, ヘルペスウイルス2型-ヒト
French Herpèsvirus humain de type 2, Herpes simplex virus 2, HHV-2 (Human HerpesVirus 2), HSV-2 (Herpes Simplex Virus 2), Virus de l'herpès simplex de type 2, Human herpesvirus 2
Croatian HERPES SIMPLEKS VIRUS, TIP 2, HERPESVIRUS 2, HUMANI
Dutch HSV 2, HSV-2, Herpes simplex type 2, Herpesvirus 2, Herpesvirus 2, humaan, Herpesvirus hominis type 2, Humaan herpesvirus 2, Virus 2, humaan herpes-
Derived from the NIH UMLS (Unified Medical Language System)

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