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Genital Herpes: Transmission, Diagnosis, Treatment and Long Term Expectations

Men's Health, General, Women's Health | September 15, 2014 | Author: The Super Pharmacist

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Genital Herpes: Transmission, Diagnosis, Treatment and Long Term Expectations

Genital herpes is common throughout the world. Over 50 million people have genital herpes in the United States, and perhaps 10 times as many have genital herpes in the world. While cold sores are usually caused by herpes simplex virus type 1 (HSV-1) and genital herpes are caused by herpes simplex virus type 2 (HSV-2), both viruses can cause either illness.

Transmission of genital herpes

Genital herpes can be transmitted between sexual partners or from an infected mother to her fetus/infant. While the herpes simplex virus can cause painful genital lesions in adults, the virus can be devastating to newborns. Transmission from mother to infant usually occurs during labor and delivery when the child comes in contact with infected areas on the mother such as the cervix or the vagina.

Once infected, the person with genital herpes will always have the herpes simplex virus somewhere in his/her body, though it may not be visually apparent because the virus lives in a dormant phase in nerve cells. Transmission from an infected to a non-infected partner may occur as early as the first sexual encounter. While transmission of the herpes simplex virus is more likely to occur when the infected person has visible genital lesions, infected people who appear healthy and have no visible lesions can still transmit the virus through sexual contact. Consistent use of latex condoms can reduce the risk of transmitting the herpes simplex virus.

Symptoms of genital herpes

Genital herpes infection is divided into primary and recurrent infection.

Primary infection occurs soon after a person acquires genital herpes—from 2 to 12 days after infection with the average being four days. Primary infection may have no symptoms, mild symptoms or severe symptoms. 

Symptoms of genital herpesThe main signs of genital herpes are painful sores and swollen lymph nodes on or around the genitals.

The sores may be raised and contain pus, may be depressions, called ulcers, or both. These lesions last between two and three weeks.

Symptoms of genital herpes include fever, headache, malaise, pain with urination, and muscle aches.

Recurrent infections with genital herpes cause the same symptoms as a primary infection, but are usually less severe. In a recurrent infection, the sores usually last between two and five days.

Recurrent infection does not mean a new infection; recurrent infection indicates the herpes simplex virus has been reactivated causing skin sores and other symptoms. In a small percentage of patients, the herpes simplex virus can affect other areas of the body besides the genitals. For example, some patients may get viral meningitis from herpes simplex. Likewise, a person with genital herpes may develop skin lesion somewhere other than the genitals. In people who have receptive anal intercourse, the herpes simplex virus can cause an inflammation of the rectum and anus.

Diagnosis of genital herpes

The diagnosis of genital herpes usually begins with a history and targeted physical examination of the genital region. Cases of suspected genital herpes are confirmed with laboratory tests. 
Diagnosis of genital herpesIf a genital lesion is visible, the physician can break open any fluid-filled sore and send the fluid for viral culture. 
Viral culture is still the first diagnostic test used by most physicians. But, in as many as 50% of genital herpes cases, this test may come back as negative.

In other words, half of all people with genital herpes may be mistakenly told they do not have the infection.

Therefore, some physicians will also send the swab for PCR testing which will detect the presence of the herpes simplex virus DNA in the fluid directly. The swab can also be tested for the presence of antibodies that the immune system has developed against herpes simplex virus. Recently a number of blood tests have become available for genital herpes diagnoses. These tests detect the presence of antibodies in the blood. The advantage of genital herpes blood tests is that they can also be used for patients who do not have visible sores. 

Treatment of genital herpes

Primary infection

People who have primary infection with genital herpes may have painful lesions that last a long time. Therefore, the standard of care is to treat anyone with the primary genital herpes infection with an oral antiviral medication, such as aciclovir, famciclovir, or valaciclovir. These medications are most effective when they are started within three days of the first lesion’s appearance. The Centers for Disease Control and Prevention recommend one of the following for primary genital herpes infection:

  • Aciclovir - 400 mg three times daily or 200 mg five times daily
  • Famciclovir - 250 mg three times daily
  • Valaciclovir - 1000 mg twice daily

Painful lesions may require some sort of pain relieving therapy, such as oral analgesics or, for women, Sitz baths.

Recurrent infection

After the initial sore has been successfully treated, people with HSV infection have several treatment options.

  • No treatment
  • Suppression
  • Treatment for outbreaks

For people who are not sexually active, have minimal symptoms, or rarely get outbreaks, it is perfectly acceptable to go without specific therapy for genital herpes.

People who choose to go without treatment and who are sexually active should consistently use latex condoms to protect uninfected partners.

For people who have frequent outbreaks of genital herpes or who have sexual partners who do not have the infection, it may be best to have suppressive antiviral therapy.

Suppressive antiviral therapy treatment requires the patient to take a relatively low dose of an antiviral medication every day to reduce the risk of developing a sore and/or passing the infection on to others.

Some people with genital herpes prefer to only take medication when they have an outbreak. When these individuals notice a genital herpes sore, they take a course of antiviral medication. Individuals in this group should also consistently use latex condoms because they risk infecting uninfected partners when they are not on antiviral medications.

Complicated infections

People who have severe genital herpes outbreaks may require intravenous antiviral medication. For example, people with herpes simplex virus infections of the brain (e.g., meningitis, encephalitis) will need intravenous medication, at least temporarily. Likewise, oral medication is not sufficient for people (adults and children) with disseminated or widespread herpes simplex virus infections.

Neonatal infection

Newborns who have herpes simplex virus infection should receive intravenous antiviral medication. If the disease affects the eyes, eye drops should be used to prevent complications and the child should be seen by an ophthalmologist. There is no universally accepted treatment for newborns with HSV infection. The risks of daily antiviral medication must be weighed against the direct effects of the infection. In most cases, children are treated daily with a low dose of aciclovir for the first year of life and then reevaluated to determine if treatment can be stopped or should be continued.

Long-term expectations

Neonatal herpes

Even with treatment, HSV infection lasts a lifetime.

Children who have infection in the eyes may develop blindness. About half of all children who have neonatal HSV will have some sort of skin lesion in the future. Three out of ten children with disseminated or widespread HSV infection at birth will die by their first birthday. Disseminated infection can cause prematurity, seizures, coma, and severe learning and developmental abnormalities.

Fortunately, death is rare in newborns who have infection only on the skin, eyes, and mouth and not the brain. Those who promptly receive aciclovir after birth greatly reduce the risk of having neurodevelopmental delays from HSV infection.

Genital herpes in the adult

Once a person has HSV infection, there is a risk that they may have recurrences of the disease periodically throughout their life. In most instances, these outbreaks can be managed with antiviral medications. People may have more difficult or more frequent outbreaks if their immune system becomes suppressed. This may occur in people who contract HIV/AIDS, develop cancer or are on immunosuppressant drugs (e.g. after organ transplantation). Women who have genital herpes and desire to become pregnant must discuss the risks with their OB/GYN to minimise transmitting the infection to their newborn babies.

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References

Xu F, Sternberg MR, Kottiri BJ, et al. Trends in herpes simplex virus type 1 and type 2 seroprevalence in the United States. JAMA. Aug 23 2006;296(8):964-973. doi:10.1001/jama.296.8.964

Kimberlin DW, Rouse DJ. Clinical practice. Genital herpes. N Engl J Med. May 6 2004;350(19):1970-1977. doi:10.1056/NEJMcp023065

Corey L, Adams HG, Brown ZA, Holmes KK. Genital herpes simplex virus infections: clinical manifestations, course, and complications. Ann Intern Med. Jun 1983;98(6):958-972.

Kimberlin DW, Lin CY, Jacobs RF, et al. Safety and efficacy of high-dose intravenous acyclovir in the management of neonatal herpes simplex virus infections. Pediatrics. Aug 2001;108(2):230-238.

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