Genital Herpes (Herpes Simplex Virus)

Genital herpes is a contagious viral infection that affects an estimated 23 percent of adult Americans. Each year, as many as 500,000 new cases are believed to occur. The infection is caused by the herpes simplex virus (HSV).

There are two types of HSV, and both can cause the symptoms of genital herpes. HSV type 1 most commonly causes sores on the lips (known as fever blisters or cold sores), but it can cause genital infections as well. HSV type 2 most often causes genital sores, but it also can infect the mouth.

HSV 1 and 2 can both produce sores in and around the vaginal area, on the penis, around the anal opening, and on the buttocks or thighs. Occasionally, sores also appear on other parts of the body where broken skin has come into contact with HSV. The virus remains in certain nerve cells of the body for life, causing periodic symptoms in some people.

Genital herpes infection usually is acquired by sexual contact with someone who has an outbreak of herpes sores in the genital area. People with oral herpes can transmit the infection to the genital area of a partner during oral-genital sex. Herpes infections also can be transmitted by a person who is infected with HSV but has no noticeable symptoms. The virus is spread only rarely, if at all, by contact with objects such as a toilet seat or hot tub.

Symptoms

Most people who are infected with HSV never develop any symptoms. When symptoms do occur, they vary widely from person to person. Symptoms of a first episode of genital herpes usually appear within two to 10 days of exposure to the virus and last an average of two to three weeks. Early symptoms can include:

• Itching or burning sensation.
• Pain in the legs, buttocks, or genital area.
• Vaginal discharge.
• Feeling of pressure in the abdominal region.

Within a few days, sores (also called lesions) appear at the site of infection. Lesions also can occur on the cervix in women or in the urinary passage in men. These small red bumps may develop into blisters or painful open sores. Over a period of days, the sores become crusted and then heal without scarring. Other symptoms that may accompany a primary episode of genital herpes can include:

• Fever.
• Headache.
• Muscle aches.
• Painful or difficult urination.
• Vaginal discharge.
• Swollen glands in the groin area.

Recurrences

In genital herpes, after invading the skin or mucous membranes, the virus travels to the sensory nerves at the end of the spinal cord. Even after the skin lesions have disappeared, the virus remains inside the nerve cells in an inactive, latent state. In most people, the virus will reactivate from time to time. It travels along the nerves to the skin, where it multiplies on the surface at or near the site of the original herpes sores, causing new sores to erupt. It also can reactivate without causing any visible sores. At these times, small amounts of the virus may be shed at or near sites of the original infection, in genital secretions, or from barely noticeable lesions. This shedding is infrequent, however, and usually lasts only a day, but it is sufficient to infect a sex partner.

The symptoms of recurrent episodes usually are milder than those of the first episode and typically last about a week. A recurrent outbreak may be signaled by a tingling sensation or itching in the genital area, or pain in the buttocks or down the leg. These are called prodromal symptoms, and, for some people, they can be the most painful and annoying part of a recurrent episode. Sometimes only the prodrome is present and no visible sores develop. At other times, blisters appear that may be very small and barely noticeable, or they may break into open sores that crust over and then disappear.

The frequency and severity of the recurrent episodes vary greatly. While some people recognize only one or two recurrences in a lifetime, others may experience several outbreaks a year. The number and pattern of recurrences often change over time for an individual. Scientists do not know what causes the virus to reactivate. Although some people with herpes report that their recurrences are brought on by other illness, stress, or menstruation, recurrences often are not predictable. In some cases, exposure to sunlight is associated with recurrences.

Diagnosis

The sores of genital herpes in its active stage are usually visible to the naked eye. Several laboratory tests may be needed, however, to distinguish herpes sores from other infections. The most accurate method of diagnosis is by viral culture, in which a new sore is swabbed or scraped and the sample is added to a laboratory culture containing healthy cells. When examined under a microscope after one to two days, the cells show changes that indicate growth of the herpes virus.

A newer, more rapid, but somewhat less accurate way of diagnosing herpes involves detection of viral protein components in lesion swabs. These tests should be done when the sores first appear to ensure the most reliable results. Other laboratory tests also are available to physicians. It is important to note that because clinicians commonly fail to detect HSV in an active sore, a negative virus culture does not always mean that a person is not infected with the virus.

A blood test cannot determine whether a person has an active genital herpes infection. A blood test, however, can detect antibodies to the virus, which indicate that the person has been infected with HSV at some time and has produced antibodies to it. (Antibodies are proteins made by a person's immune system to fight infections.) Unlike antibodies to some other viruses, however, antibodies to HSV do not totally protect an individual against another infection with a different strain or a different type of herpes virus, nor do they prevent a reactivation of the latent virus. Antibody tests are the best way to determine if a person is an HSV carrier. The standard blood tests only reliably indicate whether a patient has had a herpes infection, not the type of HSV.

New blood tests have been developed that can distinguish whether a person has had prior type 1 or type 2 infection, or both. However, these tests are available mainly in research hospitals and are not used routinely in the doctor's office.

Treatment

During an active herpes episode, whether primary or recurrent, it is important to follow a few simple steps to speed healing and to avoid spreading the infection to other sites of the body or to other people:

• Keep the infected area clean and dry to prevent secondary infections from developing.
• Try to avoid touching the sores; wash hands after contact with the sores.
• Avoid sexual contact from the time symptoms are first recognized until the sores are completely healed, i.e., the scab has fallen off and new skin has formed over the site of the lesion.

Researchers have shown that the oral form of acyclovir (Zovirax®) is a superior and safe treatment that helps patients with first or recurrent episodes of genital herpes. The oral form of the drug is taken five times a day and markedly shortens the course of the first episode and limits the severity of recurrences, particularly if taken within 24 hours of onset of symptoms. People who have very frequent recurrent episodes of the disease can take oral acyclovir twice daily for up to one year at a time to suppress the virus' activity and prevent most recurrences. After a year, it is reasonable to stop the medication and only to restart it if frequent recurrences resume. Acyclovir is not a cure for herpes—the virus remains in the body; but while taken regularly, the medicine interferes with the virus' ability to reproduce itself.

The U. S. Food and Drug Administration recently approved two new drugs, famciclovir (Famvir®) and valacyclovir (Valtrex®), to treat recurrent episodes of genital herpes. Famciclovir also has been approved for use in suppressing viral activity and preventing recurrences. These two drugs can be taken less frequently than acyclovir, i.e., three times a day for recurrent episodes and twice daily to help stop further recurrences.

Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.