Monday, October 15, 2007

Genital herpes

WHAT IS GENITAL HERPES? — Genital herpes is a common sexually transmitted disease that is caused by the herpes simplex virus. It is estimated that at least one in five adults in the United States is infected with the virus, but many people have no symptoms and do not realize that they are infected.

Genital herpes is a lifelong condition that, at the present time, cannot be cured. However, the infection can be managed with medication and self-care measures. Infected individuals are encouraged to talk to their sexual partner and use condoms and take other preventive measures; genital herpes can be spread even when there are no visible ulcers or blisters.

Being diagnosed with genital herpes can be an emotional and distressing experience, and it is important for patients to speak with their healthcare provider about how to manage symptoms and avoid passing the virus to their sexual partner. Counseling and support groups can also be beneficial to individuals living with genital herpes infection.

Cause — Genital herpes is caused by infection with the herpes simplex virus (HSV, usually type 2 (HSV-2)). It can also be caused by herpes simplex virus type 1 (HSV-1), the most common cause of oral herpes (cold sores on the mouth and lips).

The virus can be passed from one person to another during oral, anal, or vaginal sex, even if the person with herpes has no visible ulcers or sores.

SIGNS AND SYMPTOMS — Many people infected with genital herpes never experience symptoms. The symptoms of genital herpes can vary widely depending on whether an individual is experiencing an initial or recurrent episode.

Initial episode — For most people, the first herpes outbreak is the most severe, and symptoms tend to be more severe in women than men. The first outbreak usually occurs within a few weeks of infection with the virus. Symptoms tend to resolve within two to three weeks.

The signs of an initial (or primary) episode of genital herpes include multiple blisters in the genital area. For women, the sites most frequently involved includes the vagina, vulva, buttocks, anus, and thighs; for men, the penis, scrotum, anus, buttocks and thighs may be affected. Signs and symptoms typically include blisters that become painful ulcers. Blisters on the penis and outer labia may crust over and heal. New lesions may develop for up to 5 to 7 days after the first group appears. Some individuals also get blisters in non-genital areas such as the mouth and lips. There may also be tender, swollen lymph nodes in the groin, painful urination, and flu-like symptoms such as joint pain, fever, and headache.

A small percentage of people develop additional non-genital symptoms, including meningitis (inflammation of the tissue covering the brain and spinal cord) and an inability to urinate (from the effects of the virus on the nervous system). The virus can also cause proctitis (inflammation of the rectum or anus), particularly in men who have sex with men.

Latent stage — After the initial outbreak, the virus travels to a bundle of nerves at the base of the spine, where it remains inactive for a period of time. This is called the latent stage. Patients have no symptoms during this stage.

Recurrent episodes — Many people experience recurrent episodes of genital herpes, which occur when the virus travels through nerves to the skin's surface, causing an outbreak of ulcers. These recurrent episodes tend to be milder than the initial outbreak, and some recurrences cause no noticeable symptoms at all. When blisters are present, they are usually present for a shorter duration, about 10 days on average.

Ulcers may develop in the same area as during the first outbreak, or may appear in other areas. Sexual contact in the area where herpes lesions develop is not necessary; for example, it is possible to have lesions around the anus without having had anal sex.

Likelihood of recurrence — Recurrence is more common in individuals infected with HSV-2 compared to those with HSV-1. In one study of individuals infected with HSV-2, 89 percent had one recurrence over the 13 months following the initial episode, 38 percent had up to six recurrences, and 20 percent had more than ten [1]. The likelihood of an individual experiencing recurrences appears to be related to the length and severity of the person's initial episode.

However, it is also possible to have a recurrence many years (20 to 40 years) after the initial HSV infection was acquired. This type of delayed herpes outbreak can be especially distressing for those who never had symptoms during the initial infection, and it may cause concern about the sexual activities of past or present sexual partner(s).

Prodrome — As many as 50 percent of people with recurrences experience mild symptoms before a recurrent outbreak; these may include itching, tingling, or pain in the buttocks, legs, and hips. Recurrences tend to become less frequent and less severe after the first year.

Triggers for recurrence — Illness, stress, sunlight, birth control pills, and fatigue can trigger recurrent herpes outbreaks. Menstruation in women may also trigger an outbreak.

Shedding stage — Viral shedding means that the virus is present in the urinary and genital tract. During this period, often called asymptomatic shedding or asymptomatic reactivation (because no ulcers are present), the infection can be transmitted between sexual partners. Shedding of HSV-2 occurs approximately 20 percent of the time (an average of 72 days per year), mostly before, during, or after ulcers are present. The virus is shed on 3 percent of days when there are no signs or symptoms of the virus. Some people with HSV shed virus more frequently than others.

DIAGNOSIS — The diagnosis of genital herpes is based on an individual's history of possible exposure to the virus, the presence of characteristic signs and symptoms, and the results of diagnostic tests. A careful diagnosis is especially important for distinguishing genital herpes from other sexually transmitted diseases, particularly those that also produce genital ulcers, such syphilis and chancroid.

Along with a patient's history and physical symptoms, several diagnostic tests may be used to diagnose genital herpes. These tests can usually confirm infection and identify which virus (HSV-1 or HSV-2) is responsible. They can also detect asymptomatic shedding in individuals with known infection, although routine testing for this purpose is not usually performed.

Culture test — A culture test determines if herpes simplex virus is present on the skin and in secretions from the urinary and genital tracts. This is the test most commonly used to diagnose genital herpes; however, this test detects the virus in only about 50 percent of individuals with genital ulcers. The culture test is more likely to detect the virus when ulcers are new and open, as compared to when they are older and healing. Therefore, it is important to see a healthcare provider within 48 hours of the first symptoms. The test is also more sensitive in individuals experiencing an initial episode of genital herpes than in individuals experiencing a recurrent episode.

Blood test — Blood tests are often used when a person believes he or she may have been exposed to the herpes virus in the past, but has no visible ulcers. A blood test can detect antibodies (proteins that are produced by the body in response to a foreign substance) to HSV-1 and HSV-2. Having a positive test for these antibodies indicates that an individual has been infected with the virus at some time in the past, although it is usually not possible to know when or from whom the virus was transmitted.

Because the antibody response takes time, the results of this test may be negative during the first episode of genital herpes. Within three to four months after an initial episode, HSV antibodies can usually be detected. The antibody test remains positive for life.

Blood tests may be helpful for couples in which one person has a history of genital herpes and the other does not. It is possible for a person to have HSV antibodies (indicating past infection), even if they have no memory or history of genital herpes.

Determining the type of herpes (1 or 2) can also help to predict the likelihood of future recurrences, given that type 2 recurs more frequently than type 1 (see "Likelihood of recurrence" above).

Polymerase chain reaction (PCR) test — The polymerase chain reaction (PCR) test is a very sensitive test for identifying the herpes virus in cells and secretions from the urinary and genital tracts. The PCR test is more sensitive than the culture test, but is not routinely used due to it's higher cost.

TRANSMISSION AND RISK FACTORS

Transmission between sexual partners — The herpes virus is most often transmitted between partners during oral, anal, or vaginal sex. It is possible for a person to develop genital herpes after exposure to a cold sore on an infected person's lip during oral sex; in this case, genital herpes may be due to infection with HSV-1. Transmission from person to person can occur even if there are no visible ulcers, as a result of asymptomatic viral shedding. However, the risk of transmission is much greater when a person has signs or symptoms of active infection. Individuals do not need to be concerned about the possibility of viral transmission from environmental surfaces (door knobs, toilet seats, utensils, bed sheets).

The risk of transmission from an infected male to an uninfected female partner is slightly higher than the risk of transmission from an infected female to an uninfected male partner. The risk of infection is also higher in men or women who receive anal sex.

If both sexual partners have the same type of herpes virus (eg, HSV-1 or HSV-2), there is no risk of repeated transmission. It is possible for a person with one type of herpes virus to become infected with the other type; for this reason, testing to determine virus type is important.

One study examined rates of genital herpes transmission in heterosexual couples in whom only one partner was initially infected [2]. Over one year, the virus was transmitted to the other partner in 10 percent of couples. In 70 percent of cases, infection occurred at a time when there were no symptoms.

Transmission of HSV may occur within a short time in new sexual relationships. In one study of 199 patients with newly acquired HSV genital infection, the average time from the first sexual encounter to the time a person was infected with HSV was 3.5 months (range 1.5 to 10 months) [3].

Pregnancy and herpes — Women who have a first outbreak of genital herpes near the time of delivery are at risk of transmitting herpes to their newborn.

Women who acquire genital herpes before becoming pregnant are not likely to pass the virus to the baby. However, it is possible for this to happen, particularly if the mother has symptoms of pain or burning, or has active lesions at the time of delivery. In patients with one or more recurrences during pregnancy, preventive antiviral therapy with acyclovir should be considered. A caesarean delivery is usually recommended in women who experience an outbreak of symptoms at the time of labor.

Since genital herpes in infants is a very serious condition, women should inform their healthcare provider if they have a history of the infection. Women with no history of genital herpes whose partner has a history of cold sores (generally HSV-1) or genital herpes (generally HSV-2) should avoid oral, vaginal, and anal sex during the last trimester of pregnancy. In this situation, condoms are recommended during the entire pregnancy. Careful planning during the pregnancy and precautions during pregnancy and at the time of delivery can reduce the likelihood of transmission and allow for a normal birth.

GENITAL HERPES AND HIV — Individuals with genital herpes are at an increased risk of acquiring HIV. During an outbreak, blisters and ulcers make it easier for a partner's genital fluids to enter the body. Therefore, if a person with herpes is exposed to HIV through sexual contact while herpetic lesions are present, HIV can more easily travel through the skin.

TREATMENT — Although there is no cure for genital herpes, the infection can be managed with antiviral drug therapy and self-care measures. A summary of the antiviral medications is available in table 1 (show table 1).

Antiviral drug therapy — Several antiviral drugs are available for treating genital herpes. There are two regimens of drug therapy for genital herpes: episodic therapy and suppressive therapy.

Episodic therapy — Episodic therapy is treatment with antiviral drugs as soon as the symptoms of genital herpes begin. The medication is stopped after 7 to 10 days. Antiviral medications can alleviate pain, reduce the healing time of ulcers, and shorten the duration of viral shedding (the time during which the virus can be transmitted to a partner).

Episodic therapy is usually recommended for individuals who have fewer than six recurrences each year. Unfortunately, episodic treatment does not reduce the frequency of recurrences. Antiviral treatment of recurrent episodes is most likely to be effective if started within 24 hours of the first symptoms.

Suppressive therapy — Suppressive therapy refers to the continuous use of antiviral drugs, even when there are no symptoms. Suppressive therapy increases the time between recurrences, decreases the number of recurrences, shortens the duration of symptoms during a recurrence, and can reduce the risk of transmission of HSV to an uninfected partner.

Suppressive therapy is usually recommended for HSV-positive individuals who have six or more recurrences each year and those with a weakened immune system due to the human immunodeficiency virus (HIV), use of immune-suppressing drugs, or other factors.

Suppressive therapy may also be considered for people who are in a sexual relationship with a partner who does not have a history of genital herpes or antibodies to HSV-1 or 2 (as determined by blood testing). This approach has been demonstrated to reduce transmission to the susceptible person by approximately one-half.

Antiviral medications — Three antiviral medications are used to treat genital herpes: acyclovir, famciclovir, and valacyclovir. They are usually taken by mouth (in pill form). Acyclovir (Zovirax®) — Acyclovir (Zovirax®) is the oldest and least expensive antiviral medication. It usually requires more frequent dosing than famciclovir and valacyclovir. It is available in pill, liquid, and injectable forms. Famciclovir (Famvir®) — Famciclovir (Famvir®) is another drug available for the treatment of genital herpes. It is usually taken two or three times per day. Valacyclovir (Valtrex®) — Valacyclovir (Valtrex®) may be more convenient than acyclovir and famciclovir because it is taken one to two times per day.

Self-care measures — In addition to antiviral medications, local treatments may be used to relieve the pain of a herpes outbreak. Sitting in a few inches of cool water (called a sitz bath) can temporarily decrease pain. This can be done in a bathtub or a specially designed sitz bath, available at most pharmacies without a prescription. Women who are having trouble urinating may find it helpful to urinate in the sitz bath or at the end of a warm bath. Soaps and bubble baths should be avoided. It is important to keep the genital area clean and dry, and to avoid tight or irritating underwear and clothing.

Acetaminophen (Tylenol®) or ibuprofen (Advil®) may also help relieve the pain of genital ulcers. Over-the-counter creams and ointments are generally not recommended.

COUNSELING AND SUPPORT — The diagnosis of genital herpes can cause feelings of shame, fear, and distress. While these reactions are normal, it is important to remember that genital herpes is a manageable condition. Education is important for infected individuals and their partner to know what to expect and how to protect themselves.

Many patients find that counseling, either with their family healthcare provider or a mental health professional, is helpful in dealing with the issues that come with a diagnosis of genital herpes. Counseling may be especially important for people who have tested positive for the virus but have not developed symptoms, as these individuals may have difficulty understanding the impact of the disease in the absence of any physical signs.

There are many genital herpes support groups in the United States and worldwide; these provide a safe environment for people to share their experiences and feelings, and also to access accurate information about the disease. Infected individuals are encouraged to speak with their healthcare provider or visit the websites listed below (see "Where to get more information" below).

PREVENTION — Because all sexually active persons are at some risk of acquiring genital herpes, it is important to communicate with a sexual partner before the first sexual encounter. Discussing herpes can be uncomfortable and embarrassing, but it ensures that both partners understand the possibility of transmitting the infection through sexual activity. Regular testing for sexually transmitted diseases is also recommended, especially if one or both partners has other sexual partners.

After being diagnosed with genital herpes, it is still possible to have a safe and healthy sex life; however, it is important to take precautions. Use of a latex condom with every sexual encounter can reduce the risk that an infected male will pass the herpes virus to an uninfected male or female partner. Condoms are less effective in preventing an infected woman from transmitting the virus to an uninfected man, although there is probably some benefit. Even when a person is symptom-free, use of a condom is recommended. Sex should be avoided any time genital ulcers are present. Oral sex should be avoided if there are ulcers or blisters around the mouth, as a person with the oral form of herpes can give a partner genital herpes by performing oral sex.

SUMMARY Genital herpes is an infection that is spread during sex. Symptoms of genital herpes include blisters in the genital area (eg, penis, buttocks, anus, vulva). The blisters become painful ulcers. Some people have no symptoms at all. Many people have an outbreak of genital herpes more than once in their life. Later outbreaks can also cause blisters and painful ulcers. Outbreaks may occur frequently (eg, once per month) or rarely (eg, once per ten years). Sometimes, outbreaks are triggered by illness, stress, sunlight, birth control pills, or being tired. Several tests are available to diagnose genital herpes. Some tests use blood while others require a swab of the blister. It is possible to spread herpes even if there are no visible ulcers. It is not possible to catch herpes by touching a surface (door knobs, toilet seat, bed sheets). It is possible to spread herpes from the mouth (from a cold sore) to the genitals. Several medications are available to treat genital herpes (acyclovir, valacyclovir, and famciclovir). These drugs help to speed healing of ulcers and lower the risk of spreading the virus. Some people take the medicine every day to prevent future outbreaks or prevent spread to their sex partner. There are ways to lower the risk of being infected with genital herpes. Men should use a latex condom every time they have sex. Sex (oral, vaginal, and anal) is not recommended if a person has blisters or ulcers.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)
Centers for Disease Control and Prevention (CDC)

Phone: (404) 639-3534
Toll-free: (800) 311-3435
(www.cdc.gov)
National Institute of Allergy and Infectious Diseases

(www.niaid.nih.gov/)
Herpes Resource Center

American Social Health Association
Phone: (800) 230-6039
(www.ashastd.org)


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10. Fife, KH, Barbarash, RA, Rudolph, T, et al. Valaciclovir versus acyclovir in the treatment of first-episode genital herpes infection: Results of an international, multicenter, double-blind, randomized clinical trial. Sex Transm Dis 1997; 24:481.
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