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Genital Herpes
Aka: Genital Herpes, Herpes Simplex Virus 2, Herpes Genitalis, HSV II, HSV2, Human Herpes Virus 2
- See Also
- Primary Genital Herpes (Initial Genital Herpes)
- Secondary Genital Herpes (Recurrent Genital Herpes)
- Genital Herpes in Pregnancy
- Herpes Virus
- Oral Herpes
- Neonatal Herpes Simplex Virus
- Genital Ulcer
- Sexually Transmitted Disease
- Epidemiology
- Most common cause of Genital Ulcer in United States
- Responsible for 60-70% of Genital Ulcers in sexually active patients
- Affects 12% of sexually active patients aged 14 to 49 years in U.S.
- Prevalence is as high as 34% in non-hispanic black patients
- U.S. Prevalence: 30-45 Million
- U.S. Incidence: 300,000 new symptomatic cases yearly
- Not a reportable STI
- Pathophysiology
- DNA Virus
- Cause of Genital Herpes
- Previously HSV II accounted for 80-90% of cases (and HSV I the rest)
- HSV I now accounts for at least 50% of new cases in U.S.
- Once infected with Primary Genital Herpes, virus remains latent in spinal nerve roots until outbreaks
- Outbreaks may be triggered with various stressors
- Precautions
- Genital Herpes is asymptomatic in 65-90% of patients
- Asymptomatic viral shedding occurs on 10-20% of all days (regardless of outbreak)
- Most common in the first year of infection, but frequent shedding may persist for years
- Symptoms
- Primary infection (Primary Genital Herpes)
- May be associated with fever, malaise and adenopathy
- HSV DNA migrates up the infected axon to the affected spinal cord sensory Ganglion
- HSV persists in the sensory Ganglion life long, dormant until next outbreak
- On periodic reactivation, HSV DNA migrates down axon and erupts again
- See Secondary Genital Herpes (Recurrent Genital Herpes)
- Prodromal symptoms (duration hours to days)
- Focal, genital pain, Paresthesias, burning, itching
- Lesions occur at the perineum, buttock, upper thigh or perianal area
- Vesicular (duration 2 weeks for primary herpes, and 6-12 days for secondary herpes)
- Vesicles erupt at the areas of pain and ultimately ulcerate and then heal
- Course
- First outbreak (primary) is typically worse, and subsequent
- Secondary outbreaks are less severe, and decrease in frequency over time
- Genital Herpes due to HSV 1 is more mild and with fewer outbreaks (initially 1-2 per year)
- Genital Herpes due to HSV 2 is more severe with more outbreaks (initially 4-5 per year)
- Genital Herpes is more severe and atypical in those with HIV Infection
- Signs
- See Primary Genital Herpes
- See Secondary Genital Herpes
- Vesicle
- Multiple vesicular lesions on foreskin, labia, vagina, anus, perineum, buttock or upper thigh
- Ulcer
- Painful shallow ulcers result when Vesicles rupture
- Lymphadenopathy
- Accompanied by lymhadenopathy with primary (first) infection (Primary Genital Herpes)
- Differential Diagnosis
- See Genital Ulcer
- Diagnosis
- Clinical diagnosis
- See HSV Test
- Management
- See Genital Herpes in Pregnancy
- Precautions
- Antivirals due not cure the infection
- Antivirals suppress symptoms and reduce viral shedding
- Primary Infection (Initial episode)
- See Primary Genital Herpes (Initial Genital Herpes)
- Recurrent Infection
- See Secondary Genital Herpes (Recurrent Genital Herpes)
- Suppression/Prophylaxis
- See Secondary Genital Herpes (Recurrent Genital Herpes)
- Pregnancy
- See Genital Herpes in Pregnancy
- General measures
- Keep infected area clean and dry
- Avoid secondary Bacterial Infections
- Avoid spread to uninvolved skin (autoinoculation)
- Wear comfortable clothing
- Loose fit
- Cotton underwear
- Apply an ice pack or baking soda compress to area
- Topical (systemic agents are preferred)
- Penciclovir 1% cream ($20 for 2g tube)
- Efficacy
- Significant shortens duration of pain, healing
- (1997) Med Lett Drugs Ther 39(Issue 1003):57-8 [PubMed]
- Dosing
- Start at first prodromal symptom
- Continue every 2 hours while awake for 4 days
- Viscous Lidocaine
- Applied to genital lesions
- Can give significant relief
- Investigational
- L-lysine 1000 mg PO three times daily
- Aspirin 125 mg PO daily
- Local licorice root gels applied three times daily
- Lemon balm applied four times daily
- Zinc applied daily
- Aloe vera 0.5% applied three times daily
- Prevention
- Avoid sexual contact during prodrome or when lesions are present
- However, asymptomatic shedding is common (up to 10-20% of days), esp. in first year
- Discordant couple (one with herpes, one without)
- Consider antiviral suppressive therapy for the patient's first year of new HSV infection
- Viral shedding occurs in 10% of asymptomatic patients and 20% of symptomatic patients
- Women may consider peri-coital Tenofovir gel application to reduce transmission risk
- Consider HSV serology for the patient's partner to determine status
- Inform sexual partners of Genital Herpes
- Transmission can occur even when asymptomatic
- Condoms reduce transmission (especially for transmission from men to women)
- However partners still have a 10% conversion rate/year despite Condom use
- Also helps prevent HIV Transmission, for which Genital Herpes patients have 3 fold increased risk
- Much more effective in preventing transmission from men to women than vice versa
- Condom must cover active lesions
- Wald (2001) JAMA 285:3100-6 [PubMed]
- Course
- See Primary Genital Herpes
- See Secondary Genital Herpes
- Complications
- Primary or secondary HSV
- Transmission of other Sexually Transmitted Infection
- HIV Transmission risk is increased 3 fold in those with Genital Herpes
- Neonatal HSV (perinatal transmission)
- See Genital Herpes in Pregnancy
- Primary HSV
- HSV Meningitis (Mollaret Meningitis)
- Causes primary and secondary recurrent lymphocytic Meningitis
- Contrast with HSV1, which causes HSV Encephalitis
- Pneumonitis
- Pelvic Inflammatory Disease
- Aseptic Meningitis
- Occurs in 15% with Primary Genital Herpes
- Mollaret's Meningitis
- May present with inability to urinate, as well as paralysis and Paresthesias
- Sacral radiculopathy syndrome
- Sacral Anesthesia, Urinary Retention
- May last up to 8 weeks
- Extragenital lesions (Disseminated HSV)
- Autoinoculation of buttocks, hands, eyes
- Transverse Myelitis
- HSV Hepatitis (rare)
- Acute life-threatening hepatitis with high mortality rate
- Resources
- Herpes Resource Center: (919) 361-8488
- Herpes Web
- http://www.herpesweb.net
- CDC Herpes site
- http://www.cdc.gov/std/herpes/stdfact-herpes.htm
- References
- Beauman (2005) Am Fam Physician 72(8):1527-34 [PubMed]
- Groves (2016) Am Fam Physician 93(11): 928-34 [PubMed]
- Kimberlin (2004) N Engl J Med 350(19): 1970-7 [PubMed]
- Nadelman (2000) Postgrad Med 107(3):189-95 [PubMed]