Infections

GENITAL HERPES

There are two types of virus both from the herpes virus family that cause genital herpes infection: Herpes Simplex 1 (HSV1) and Herpes Simplex 2 (HSV2).

Whilst HSV1 is usually associated with cold sores around the mouth and HSV 2 with genital ulcers, in practice each virus can cause both types of symptom. If a patient is already infected with HSV1 then it is likely that this will modify the severity of a subsequent infection with HSV2 thereby making the symptoms less severe.

There is often tremendous anxiety surrounding a diagnosis of Herpes. This is due not only to the painful nature of the lesions but also the fact that once acquired the virus remains in the body permanently. There is also a large amount of myth and stigma surrounding this infection.

An episode of ulceration can be thought of as primary (the first ever) or recurrent. Primary episodes are often the most painful and the severity of episodes often decreases greatly with recurrences.

In between episodes the virus lives in the body's nerve cells and periodically will cause either episodes of ulceration or asymptomatic viral shedding. This latter phenomenon is the release of the virus rendering it infective to a sexual partner without any symptoms at the time. It is impossible to predict when viral shedding or ulceration will occur and recognising clear precipitants is not often feasible. Some people associate periods of stress with development of Herpes ulcers however, this is largely anecdotal.

The symptoms of genital Herpes include painful blistering and ulceration or broken skin anywhere on the genitals: penis, scrotal skin, urethra, vulva, vagina and cervix. It is also possible to have ulcers on the skin of the thighs, pubic area and buttocks and also in the anus and rectum. Anal ulcers do not imply that a person has necessarily had anal sex. It is possible to pass Herpes infection on through oral sex if an infected partner has cold sores around the mouth. There are also general symptoms of fever, muscle aches and generalised pains in the groin and pelvis that can accompany attacks. The worst constitutional symptoms are often felt with a primary attack.

If the virus is to be isolated by taking a swab, it must be remembered that the test will only come out positive if there is fresh blister fluid (pus) on the swab and as such, a negative swab does not imply an absence of infection. This scenario often occurs when a swab is taken during the recovery phase of an attack and the skin has started to heal.

There is a also blood test available to show the presence of Herpes antibodies. In practice, this test is limited in that all it can do is tell you that if positive, you have been infected with the Herpes virus at some time in the past. It does not tell you when, by whom or whether you will experience any symptoms in future.

Treating Herpes attacks is relatively simple. The fundamental points are to keep the area clean and dry and avoid sex until the skin is fully healed. By doing this, the risk of transmission to a partner is minimized but not eradicated. If you think logically, the majority of sexual transmission will occur when someone is feeling well and has no ulcers.

Pain relief is vital and this can be achieved by using simple analgesics like Paracetamol and Ibuprofen, bathing in salt water and if necessary using local anaesthetic creams on the genitals. The body's immune system will gradually help the ulcers to heal given time and the main purpose of treatment is symptomatic relief.

In some cases drugs are prescribed for Herpes attacks. In general these are only effective if started in the first 24 hours and are reserved for very painful attacks. For example for those where there are severe constitutional symptoms and complications such as urinary retention. This is where severe pain caused by ulcers in the urethra prevents a patient from urinating and so causes a dangerous and painful build up of pressure in the bladder.

Occasionally an attack is so severe that a patient requires hospitalisation and needs drugs to be given by injection and a catheter inserted to help them pass urine. Fortunately, this is rare.

The drugs used to treat Herpes include Aciclovir and the related compounds: Famciclovir and Valaciclovir. In general these drugs are not effective if given as creams and most clinicians will only precribe them as tablets.

People who get regular recurrences of Herpes ulcers can take these medications as prophylaxis (prevention) against attacks. When taken daily, they can suppress the virus and can be very effective at minimizing or preventing further attacks and reducing the risk of passing on the infection. The drugs are taken in a different dosage to treatment and treatment is usually continued for 6 months to a year.

An important area to consider is the management of Herpes infection in pregnancy. Opinion is still divided as to what is best. However, most experts agree that a first episode in the third trimester of pregnancy is more serious than a recurrence. The main concern is the passage of HSV to the infant during delivery with subsequent development of a potentially serious eye infection in the child. As such, Obstetricians will consider giving Aciclovir to a woman with a primary Herpes attack in the third trimester of pregnancy and also performing a planned caesarean section.

On a practical level, it is worth remembering three important facts about genital Herpes. Firstly, infections are sometimes acquired a long time prior to the first recognised appearance of symptoms. As such, the development of Herpes ulcers may imply but not necessarily prove infection from a recent/current sexual partner. Secondly, treatment is simple and essentially aimed at keeping the patient free of pain whilst the immune system heals the skin. Finally, for particularly severe or frequently recurring attacks effective drug treatments are available.