Genital Herpes


Genital herpes is a sexually transmitted condition that is widely known among the public due to the extensive prevalence of the disease in several countries – resulting in its name being known among sexually active individuals as a matter of concern. With such a widely misunderstood condition at large, the intricacies of its transmission, manifestation, diagnosis, and management must be relayed to provide affected individuals with the freedom to make an informed decision regarding their next steps, rather than to either let them use medications improperly or guilt them into seeking professional help with no explanation whatsoever regarding this necessity in the first place.

In demonstrating this further, the outline below highlights several key points regarding genital herpes and how one could address the manifestations or even recognize the condition from other diseases that closely resemble its manifestations. After all, the first step to a successful management plan is to correctly identify the disease present by either knowing its manifestations or realizing that specific laboratory tests are necessary to provide a conclusive diagnosis.

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Genital Herpes: The Important Facts

Understanding Herpes

Herpes is a relatively widespread sexually transmitted condition that is essentially already widely familiar among the public due to the several cases that have been recorded for this case already. It is a common condition within the United States, and it is mainly recognized by its manifestation of fluid-filled vesicles that slightly resemble blisters in cases where the disease is symptomatic. Herpes is initially transmitted by two variations of the same virus – the Herpes Simplex Virus. The two types are HSV-1 and HSV-2, further defined as HSV Type 1 and HSV Type 2, respectively. What makes herpes a commonly misunderstood condition is that many believe that HSV only colonizes the genitalia, when in fact, it may likewise affect other mucosal areas such as the mouth or the anal region – resulting in oral and anal herpes cases, respectively. In most cases, HSV-2 infections only result in genital herpes cases wherein contact must be between infected genitalia and healthy genitalia to facilitate transmission. HSV-1 infections, on the other hand, may cause both oral and genital herpes, wherein receiving oral sex from a person with an oral HSV-1 infection may lead to the development of a genital HSV-1 infection.

Knowing Genital Herpes

Genital herpes is a particular variation of the herpes infection that mainly affects the genitalia, specifically the mucosal tissues of the genital, due to the tendency of the pathogenic microorganism to primarily colonize these tissues during such infections. Genital herpes is a variation of the disease mainly caused by herpes simplex virus type-2 – mainly being transmitted through pure genital contact wherein an infected tissue can transmit the microorganism when it comes into contact with healthy tissue whether there are symptomatic manifestations or not. Do note, however, that despite being mainly caused by the type 2 variation of the virus, genital herpes may likewise be caused by HSV-1, albeit the cases are relatively scarce and are more often observed in the case of oral herpes infections. Oral sex with a person infected with oral herpes may develop genital herpes in the recipient if the conditions are sufficient to allow for the proliferation of the virus within the area.

Difference with Oral/Extra-Genital Herpes

Genital herpes, as previously mentioned, is slightly different from other types of herpes that may include oral and other extra-genital variations of the infection in terms of its causative microorganism, or rather, its type, as well as in its specific manifestations. Apart from HSV-2 causing genital herpes alone, the location of the blisters or the hallmark sign of an active herpes infection appears in different parts of the body depending on the variation of the disease that a particular patient is currently experiencing. However, the appearance of the blisters itself is not entirely different between each variation.

The Prevalence of the Condition

According to the Centers for Disease Control and Prevention, genital herpes is relatively prevalent within the United States, with an estimate of over 500,000 new genital herpes infections being recorded annually in the US – still not considering the variety of cases that often remain asymptomatic if the patient’s immune system is resilient enough to prevent the symptomatic manifestation of the infection. Based on the data obtained, cases of genital herpes are increasing further compared to the cases recorded for other types of herpes as more HSV-1-caused genital herpes infections are being recorded on top of the inherently genital-based HSV-2 infections that are already prevalent, to begin with. This has been associated with the common occurrence of oral HSV-1 infections during childhood, resulting in fewer oral HSV-1 infections in the recent decade among adults and a subsequent increased susceptibility for HSV-1-caused genital herpes infections instead.

The data that the CDC has collected also highlights a higher prevalence of the infection among women – recording a 15.9% and 8.2% prevalence within 14 to 49-year-old infected female and male patients, respectively. This has been associated with the observed increased virus transmission from men to women during penetrative sex than women to men.

Is Genital Herpes a Sexually Transmitted Disease?

Considering that the condition is transmitted through contact between the affected tissues and the healthy tissues of the patient’s partner, genital herpes is therefore considered a sexually transmitted disease by all conventions.

Knowing the Persons at Risk for the Infection

Although the transmission of the virus itself seems relatively straightforward due to its sole requirement of direct contact between the infected and healthy tissues during sexual intercourse, there are still specific populations, habits, and characteristics that may cause increased susceptibility to the disease – causing a higher chance that one will be infected when they are exposed to the virus, no matter how minimal the contact was overall.

Women

Based on the data that has been obtained by the CDC on the prevalence of genital herpes within the population, it has been found that women are more susceptible to the infection, or rather are recording more cases than men due to their increased susceptibility to the disease during sexual interaction. According to the CDC, this increased susceptibility is linked to the presumed increased transmission of the virus from men to women than the other way around during conventional penetrative sexual intercourse. This is not necessarily saying that women are the only ones at risk for contracting the infection during an interaction where one patient is infected, but it does show that women could easily contract the disease than men would in the same situation – provided that the conditions are similar and that neither is compromised in a way that would further increase the risk of transmission.

Engaging with Multiple Sexual Partners

Although having multiple partners has become more and more prominent in modern society as the public becomes more comfortable with their sexuality, it is still important to note that safe sex practices would ultimately still matter, especially when it comes to the participants’ awareness of their own and their partners’ sexual status. While there is no direct causality between having multiple sexual partners and an increased risk for contracting the infection, it does provide additional avenues where one might acquire the disease in contrast to having a sole partner who you could be confident with to be safe and healthy before engaging in safe sex. Again, it is all a matter of employing safe sex practices ultimately.

Improper Use of Contraception

While contraceptives are, in fact, effective for most instances, they will only be effective in preventing or lowering the risk for infection if the contraceptive tool is used correctly. For example, condoms and oil-based lubricants are a discouraged combination as the oil-based product may break down the condom’s material while wearing the right-sized condom will ensure that the genitalia is properly encapsulated to protect both you and your partner during your interaction. There is no one way to relay the proper use of contraception, but it does bode well to point out that using these products according to the instructions provided in the packaging will go a long way in ensuring that you will be receiving the intended effect of the product.

Immunocompromised State

As previously mentioned, a person who is immunocompromised is inherently susceptible to genital herpes or any infection for that matter, as their immune system is not sufficiently equipped to fight off against the initial entrance of the disease – resulting in a more straightforward transmission process that would almost always guarantee an active infection when the patient is exposed to the pathogenic microorganism.

Preventive Measures Against Genital Herpes

When it comes to sexually transmitted conditions, there is no one way to prevent transmission as there are several instances wherein one method may work for some while it does not work effectively for others as well. Adding to this concept is the inherent possibility still of transmission in most of these preventive measures – making abstinence the only way to eradicate the source of infection in all instances completely.

However, even though it is still possible to contract the virus amidst these preventive measures, implementing these practices will go a long way in minimizing the risk of contracting the virus, even if it does not completely eradicate the possibility. Knowing how to protect yourself from the virus sufficiently to at least minimize the risk of infection will always be superior to exposing yourself willingly with no regard for the inherent risk of transmission – preventing potential complications that could arise from a single instance of infection.

Use of Contraception

Obvious as this might be, we would still like to reiterate that the most common way to minimize the risk of infection and keep most of the sexually-active population safe from potential infections is to use contraception – with condoms being one of the most convenient and readily-available tools to the public. Of course, other devices could likewise be utilized by females during sexual intercourse, but condoms remain the most popular option among the general population.

Condoms are not necessarily the perfect tool that could be used in preventing infection as some regions of the genitalia remain exposed nonetheless while bodily fluids such as the semen can still come into contact with their partner during climax. However, it does significantly cover the potentially infected areas to lower the risk of viral transmission, mainly when the patient is unaware that they are currently infected.

Monogamy

Similar to how a condom reduces the risk of viral transmission by covering the areas that could be a potential source of infection, implementing monogamy – or at least even a simple awareness of your partners’ sexual health status – will reduce the risk of disease by covering or reducing the potential sources of infection which are in this case, their partners. It is a well-known fact that awareness regarding your sexual health status is already implied for many, but some remain oblivious to the importance of knowing these details about your health. As such, limiting your sexual partner to just one, or even by simply ensuring that your partner is aware of their sexual health status, will go a long way in ensuring, at the very least, that you are not unknowingly exposing yourself to a person with a questionable health status – who, in all bases of merit, may be a potential source of infection during your interaction. Sure, it might be hard at first to broach the question to someone who you are not as familiar with (and yes, it does sometimes happen in real life), it is much better to take the risk of them being defensive regarding their status than to expose yourself to an infection that will lead to further health issues. Be kind, though – it is all a matter of execution.

Abstinence

As previously mentioned, the only preventive measure that could prevent the transmission of the virus ultimately is to remove the source of an infection from the equation entirely – thus, abstinence. Abstinence is the act of abstaining from any sexual contact, whether it may be penetrative or not. By removing yourself from the context entirely, you are, by all means, completely protected from a virus that could only be transmitted through sexual contact. It might be a challenging task for some, that is sure, but preventive measures are always there to minimize the risk of infection, and maybe that is a worthy sacrifice to making sure that your health status remains clean.

Suppressive Antiviral Therapy

In the case of herpes – a condition that does not have a “cure” or a surefire way to eliminate the virus from the patient’s system – the best way to prevent the transmission of the virus from people who were previously treated for herpes infection is to employ suppressive antiviral therapy. This essentially entails that people who have an active herpes infection will need to take consistent antiviral medications aimed at suppressing the virus – preventing its transmission even though the patient still has the virus within their system. This measure is relatively fragile as it would depend on the patient’s response to the medication and how effectively they could suppress the virus’ proliferation, but it does provide previously infected individuals with an option when they still want to partake in sexual intercourse despite their condition.

Link Between Herpes Infections and HIV

While herpes infections are not necessarily a direct cause for an HIV infection, it does, however, increase the risk of contracting HIV from another infected individual by around 2 to 4 times – resulting in a higher susceptibility to the virus despite the implementation of various protective measures by both partners. This has been attributed to the formation of ulcerations during the symptomatic phases of active herpes infection – producing openings in the patient’s skin barrier that increase the number of areas or openings that the virus may use to cause a systemic infection. Furthermore, suppose a patient has both active herpes and HIV infection. When there is a local replication of HIV within the ulcerations formed by the herpes infection, the risk for transmitting the virus through oral or penetrative sex likewise becomes higher.

Genital Herpes: Pathophysiology and Transmission

Genital herpes is a condition caused by the herpes simplex virus or HSV. In the past few decades, the most common cause of genital herpes is the type 2 variation of the virus or HSV-2. Still, recent data obtained by the CDC show that genital HSV-1 infections are likewise on the rise due to the increased occurrences of oral HSV-1 infections in childhood, subsequently causing a decrease in oral cases among adults, and an overall increase of genital infections being noted for both HSV-1 and HSV-2 subtypes.

Genital herpes, as evident in its name, is a type of herpes that mainly manifests within the genitalia region with particularly prominent blisters that later on develop painful ulcerations. Considering that the condition is sexually transmitted, the only way the virus can be transmitted to another individual is through sexual contact, whether oral, anal or conventional penetrative sexual practices. The transmission of the virus occurs when there is direct contact between the tissue of an infected patient, more so when there are evident ulcerations within the genitalia and the tissue of a healthy patient. Depending on the affected mucosal tissue – whether it is within the genitalia or is extra-genital – the manifestations will present only on the tissue that has come into contact with the infected patient.

If you are sexually active, the virus can still be transmitted even from asymptomatic individuals due to the infection's intermittent viral shedding process, resulting in transmission even when it comes to patients with no apparent blisters or ulcerations within the genitalia. Following infection, the virus remains dormant within pelvic nerve cells – causing outbreaks once the body’s immune system is compromised and its natural defenses could no longer maintain the asymptomatic phase.

Although there is no outright cure for the virus, it is still possible for patients to engage in sexual intercourse for as long as they are currently undergoing suppressive antiviral therapy aimed at suppressing the viral load to manageable levels that would not result in transmission or recurrence upon contact with another healthy individual.

Genital Herpes: Presentations and Manifestations

Genital herpes often produces the same manifestations as other extra-genital variations as the causative microorganism is essentially the same in all types of infection. The most common distinguishing feature among these types is the location of the manifestation itself – with genital herpes primarily presenting within the genitalia as blisters and ulcerations that are often painful and recurrent through the duration of the infection.

When you have an active genital herpes infection, the most common manifestations would often appear within 2 to 12 days following exposure to a patient infected by the virus, whether they had an active herpes infection or not. During this symptomatic period, a patient may experience the following common presentations on top of the specific symptoms that are observed in each gender and phase:

  • Painful ulcerations
  • Itchy blisters or ulcerations
  • Small red bumps along with white-colored blisters
  • Scab formation following presentation of ulcerations

Males

In the case of infected male patients, they would often observe the formation of sores, blisters, and ulcerations within the buttocks, thighs, within the anal region, the mouth, and even experience the symptoms within the urethra. It does, however, still require that these areas come into contact with an infected tissue first, as these could essentially host the virus during the transmission process if they have been exposed during sexual intercourse.

Do note that these regions may likewise be affected in the case of females, except for the urethra.

Females

Meanwhile, infected female patients would often have presentations, on top of the commonly infected areas in males, in their general vaginal region, within the external parts of the genital itself, or within the cervix – a region that is relatively deeper than the aforementioned areas, but can still be affected due to its mucosal nature that is favored by the causative microorganism of the infection.

The manifestation of herpes can be divided into two stages: the first outbreak and the recurrent outbreak.

Outbreaks or episodes are defined as the tendency to develop painful blisters that then break to form ulcerations and scabbing throughout the infection within the patient’s system. The outbreaks experienced by affected patients may differ depending on whether it is the first outbreak they have experienced or if it is a subsequent outbreak caused by the lasting viral infection contracted by the patient.

First Outbreak

The first outbreak or episode is commonly associated with the development of longer-staying herpes lesions that likewise have an increased viral shedding process – resulting in an even higher transmission rate when an infected patient comes into contact with another healthy individual. The first outbreak may appear in as early as 48 hours or as late as a month after transmission, depending on the body’s response to the presence of the virus in the system.

During this first outbreak, the patient may likewise experience systemic symptoms, which may include:

  • Fever
  • Body pain
  • Swollen lymph nodes
  • Headache

These symptoms are often experienced by patients with an active infection on top of the development of the hallmark symptoms of herpes, such as blisters and ulcerations. A tingling or itching sensation may likewise be felt before the blisters appear – acting as prodromal symptoms for a potential outbreak. These ulcerations are self-limiting and may heal in around 2 to 4 weeks following the first appearance of the blisters.

Recurrent Outbreak

Recurrent herpes outbreaks, on the one hand, commonly entail nearly the same production of self-limiting blisters that then produce painful ulcerations as they heal. However, these would naturally come with prodromal symptoms or signs that would often signal the recurrence of an outbreak right before the growth of new blisters occurs. These prodromal symptoms may include:

  • Localized genital pain
  • Tingling or shooting painful sensation within the legs, hips, or buttocks

These could occur hours or days before an actual outbreak occurs, and these are possible throughout the lifetime of an infected individual as the infection could not be completely cleared with medications. It can, however, be managed to asymptomatic levels where the disease could no longer be transmitted, and symptoms are not present ultimately while under the therapy.

Genital Herpes: Testing, Diagnosis, and Laboratory Procedures

In diagnosing genital herpes, there are still several things that need to be considered, mainly because there are certain asymptomatic cases and the existence of two types of HSVs that may need to be addressed differently depending on how they will manifest in the patient’s system.

To obtain a more conclusive diagnosis regarding the condition you currently have, the following laboratory tests are often used by physicians to either identify the condition you have or distinguish between HSV-1 and HSV-2 infections in adequately addressing the manifestations that you are showing.

  • HSV Nucleic Acid Amplification Test – NAATs remain the gold standard in the diagnosis of most infections, but it does have a more significant error rate in the case of herpes due to the intermittent viral shedding process of the disease.
  • Type-Specific Virologic Test – this is the type of test that is often used when there is no confirmatory NAAT or culture result available to obtain a more specific outlook into the causative microorganism of the infection.
  • Viral Culture Test – this is a particular test that is only used when the resources are scarce to perform a more high-end diagnostic test such as NAAT. This test, however, takes time to allow the microorganism to grow within the selected medium.
  • Biokit or Western Blot – used as confirmatory tests for type-specific virologic testing due to the limitations of the test.
  • Serologic Testing – used to distinguish between HSV-1 and HSV-2 types.

Genital Herpes: Treatment and Management of the Disease

Before anything else, it is essential to note that herpes infections are considered lifetime infections as there is currently no available medication that can be used to eradicate the microorganism from the patient’s system entirely. However, physicians still perform steps to ensure that the patient’s quality of life is not affected and that they can no longer transmit the virus to their partners or other individuals that they come into contact with.

Initial Treatment

The initial treatment process essentially aims to resolve the patient’s symptoms during the first outbreak or episode - primarily targeting the relatively aggressive viral shedding process of the virus and managing the symptoms being experienced by the patient. This antiviral course would often last for around 7 to 10 days, but your physician may prescribe longer treatments if the symptoms do not resolve within this period. The common medications prescribed by physicians during this period are the following:

  • Acyclovir
  • Famciclovir
  • Valacyclovir

Note that this does not encourage self-medication as proper dosing is still essential in ensuring that the patient’s treatment is appropriate for their condition and circumstances.

Intermittent Treatment

The intermittent treatment process essentially provides the patient with the prescription for specific antivirals that they could take if they develop inevitable flare-ups or outbreaks while still on suppressive medication. Of course, the sores that will develop during this recurrent outbreak could resolve independently, but aiding the healing with medicine will generally hasten the process overall.

Suppressive Treatment

In the case of patients who experience frequent recurrent outbreaks throughout the infection, your physician may prescribe a long-term antiviral therapy that aims to prevent the development of these symptoms and prevent the transmission of the virus during sexual intercourse.

Frequently Asked Questions (FAQs)

Is it possible to transmit the virus even when there are no apparent sores in the genitalia?

Yes. Viral shedding occurs even among asymptomatic individuals.

What could happen to a pregnant woman with herpes?

The patient may transmit the infection to their baby during delivery, causing neonatal herpes. Neonatal herpes is associated with several complications such as cerebral damage, blindness, and even death.

What are the complications of herpes infection?

The most common complication is the development of extra-genital manifestations, but some people may also develop rare, life-threatening complications such as aseptic meningitis.

How long should I take my medications for herpes?

The treatment plan would depend on your physician’s judgment, but one could expect that it would generally be lengthy overall.

How many outbreaks should a patient with an active herpes infection expect?

A patient should expect an outbreak throughout their lifetime (average is roughly 4 per year), especially if not on suppressive antiviral medications.

Additional References

Centers for Disease Control and Prevention

World Health Organization

American Academy of Dermatology Association

References

  • Beth Israel Lahey Health. (n.d.). Risk Factors for Genital Herpes. https://www.winchesterhospital.org/health-library/article?id=103113
  • Centers for Disease Control and Prevention. (n.d.). Genital Herpes – CDC Fact Sheet (Detailed). https://www.cdc.gov/std/herpes/stdfact-herpes-detailed.htm
  • Centers for Disease Control and Prevention. (n.d.). Genital Herpes – CDC Fact Sheet). https://www.cdc.gov/std/herpes/stdfact-herpes.htm
  • Mayo Clinic. (n.d.). Genital Herpes. https://www.mayoclinic.org/diseases-conditions/genital-herpes/diagnosis-treatment/drc-20356167
  • Mospan, C., & Cluck, D. (2016). Prevention and Management of Genital Herpes. US Pharmacist, 41(4), 30-33. https://www.uspharmacist.com/article/prevention-and-management-of-genital-herpes
  • Planned Parenthood. (n.d.). How is herpes prevented? https://www.plannedparenthood.org/learn/stds-hiv-safer-sex/herpes/how-is-herpes-prevented
  • WebMD. (2020). Potential Herpes Triggers. https://www.webmd.com/genital-herpes/guide/potential-herpes-triggers
  • WebMD. (n.d.). 10 Ways to Reduce the Risk for Genital Herpes. https://www.webmd.com/genital-herpes/reduce-risk
  • WebMD. (n.d.). Treatment Options for Genital Herpes. https://www.webmd.com/genital-herpes/genital-herpes-treatment-options#1

Written by Mark Riegel, MD

Quick Snapshot

Can it be cured?

No. Viruses don't have cures, but symptoms can be controlled with proper treatment.

Type of Infection

Viral. Caused by the herpes simplex virus.

How is it treated?

Antiviral Medicine. Symptoms are treated with antiviral medications (Zovirax, Famvir, or Valtrex), however there is no cure.

Recovery Time

1 month or longer. The symptoms from the initial outbreak can take over 20 days to disappear.

Can I have sex?

Yes. During your initial outbreak, you should refrain from sex until all symptoms are gone.

Can I get re-infected?

Yes. Once you get infected, you will have the virus for life.

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