Genital Herpes
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Introduction
Statistics
Signs and Symptoms
Transmission
Management
Prevention
This infection is caused by the Herpes simplex virus.
Genital infection may be caused by Type 1 (HSV-1) or Type 2 (HSV-2). The
symptoms are similar, and can result from either oral-to-genital or
genital-to-genital contact. The virus causes blisters on the genitals,
similar to the cold sores that occur on the mouth. Cold sores on the mouth
are also caused by the herpes virus.
These infections are caused by viruses and definitive
cures are not available. However, many patients are distressed by the
recurrent nature of the infections and perceived serious complications.
Because genital herpes is not a notifiable disease,
there are no accurate statistics on its prevalence in South Australia.
However, in recent years, approximately 2% of the clients with STDs
diagnosed at Clinic 275 have had
active episodes of the infection.
Various studies in the USA and Australia have
demonstrated the presence of HSV-2 antibodies in 20-60% of the populations
tested.
It has been estimated that approximately 1 in 6 people
in Australia has had a history of genital herpes outbreaks at some time.
Not all people infected with the herpes simplex viruses
will develop symptoms. As many as 60-70% of people with evidence of herpes
simplex virus type 2 infection (as diagnosed by a blood
test) have not had
symptoms diagnosed as genital herpes.
For those who develop symptoms, the typical clinical
course is as described below.
Primary Herpes
Lesions occur most often on the penile shaft, prepuce,
glans or anal region and on the labia, clitoris, introitus, vagina and/or
cervix. They can also occur around the mouth or on the throat following
oral sex.
Incubation takes 2 to 20 days from when the infection is transmitted.
After a 12-24 hour period of hypersensitivity or local discomfort (burning
or tingling), multiple vesicular lesions (small blisters) appear which may
subsequently produce a rosette formation.
Between 24 and 72 hours after their appearance vesicles
rupture to form superficial shallow painful ulcers which occasionally
become secondarily infected. Regional lymph nodes are enlarged and tender
in some 75 percent of cases and may remain enlarged for up to six weeks.
Genital herpes is usually more painful in women because of
their anatomy. Vaginal and labial blisters may be so painful that women
become unable to pass urine and require catheterisation. It is important
to seek early medical assistance in order to prevent this complication.
Herpetic cervicitis, because of its necrotising nature, frequently
produces a sanguineous vaginal discharge.
Symptoms persist for 1 to 3 weeks.
The duration of the initial episode is shorter and less
severe in those with a pre-existing HSV-1 antibody response (i.e. in
people with pre-existing cold sores).
Extragenital inoculation of fingers, buttocks, torso
and/or eyes can occur.
Recurrent Episodes
Herpes continues to live in the body between outbreaks,
and recurrent episodes of symptoms may occur. Relapses can be precipitated
by emotional or physical stress, fever, trauma, hormonal changes,
sunlight, alcohol and immunological deficiencies. These occur after a
variable latency period.
Relapses are characterised by:
Asymptomatic Infections
Asymptomatic viral shedding has been reported from the
cervix and vulva in women and from the urethra in males. Women are usually
not aware of severe lesions which are confined to the cervix. It is likely
that people who are asymptomatic carriers of the herpes viruses are still
able to transmit the infection.
Neonatal Infections
Neonatal transmission occurs during birth if the mother
is actively shedding the virus. Infection of the infant causes severe
illness and has a high mortality rate. Transmission of herpes during birth
is rare, and occurs usually in cases where the woman is experiencing
primary herpes at the time of the delivery, (i.e. no previous history of
genital herpes). The risk is further reduced by informing the obstetrician
and performing testing during pregnancy. Caesarean section may be
performed if lesions are present or if swabs detect active shedding near
term.
Genital herpes can be passed on through most forms of
sexual contact, genital-to-genital, oral-to-genital, and mutual
masturbation. Many people are unaware that oral cold sores may cause
genital infection during oral sex. It is also possible for a person to
transfer herpes from their own mouth to their genitals, and to their eyes.
New lesions that are filled with fluid are the most infectious.
Greatest risk of transmission occurs during sexual
contact with open lesions of the oral or anogenital area, but transmission
may occur at other times from asymptomatic shedding. Individuals should
avoid all sexual contact until lesions have fully healed. Condoms may
further reduce spread between attacks.
Symptomatic treatment
Treatments that can relieve discomfort include:
-
Keeping sores clean and dry with "Betadine"
and warm, dry air;
-
Wrapping an ice-block in a towel if herpes is
developing but blisters haven't yet appeared, and applying it
frequently to the tender areas for an hour may stop the blisters from
forming;
-
Bathing in salt water - 2 teaspoons of salt per litre
of water;
-
Drinking plenty of water;
-
If urination is painful, urinating in a hot bath or,
for women, using both hands to separate the lips of the vulva to
achieve a free stream of urine, preventing urine from touching the
ulcers;
-
Wearing loose, cotton underpants and avoiding tight
trousers;
-
Rest;
-
Analgesics (eg aspirin or paracetamol). Keep lesions
clean and dry (Betadine, warm dry air)
Anti-Herpes Drugs
Aciclovir, Valaciclovir, Famciclovir
Because herpes is a virus, it cannot be treated with
antibiotics. Although the herpes virus cannot be eradicated from the body,
the drugs aciclovir, valaciclovir and famciclovir hasten healing and
reduces the risk of recurrence while they is being administered.
Because anti-herpes medications are expensive and in
some cases must be taken several times each day, their use is usually
limited to patients suffering particularly painful episodes or those
experiencing multiple recurrences.
Primary attacks or painful recurrences- orally or
intravenously for 5 days - speeds healing, reduces symptoms, reduces
duration of viral shedding
Recurrent attacks (moderate to severe attacks, limiting
the patient's normal activities, several times per year). A 6 month trial
may be warranted-reduces number and duration of recurrences.
The anti-herpes drugs do not eliminate the virus and
have no effect on the long term natural history of the disease.
The use of condoms during vaginal and anal intercourse
reduces the risk of genital herpes, but protects only those areas in
contact with the condom.
Because herpes can be transmitted from mouth-to-genitals
and vice versa, condoms or dental dams may be used during oral sex. If
sores are present, it is important to avoid oral sex.
Because herpes can be spread by the hands between
people, and from site to site on one person's body, it is important to
wash hands if they have come into contact with lesions, particularly new
lesions.
During an attack, it is important to avoid sexual
contact involving the genitals until the sores have disappeared. This will
aid healing and help prevent transmission.
Transmission may occur during periods of asymptomatic
viral shedding. People with herpes should be aware that although the risk
of transmission is greatest during symptomatic episodes, there is a
potential for transmitting the infection at any time.
Acknowledgment
Clinical photographs contributed by Dr Ross Philpot, carlisle@chariot.net.au. |
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