SX21

Genital herpes

Content written by Hossein Sadeghi-Nejad

Genital herpes (GH) is caused by herpes simplex virus (HSV). There are two types: 1 and 2. HSV 2 is the type that is commoner and is passed from one person to another at sexual intercourse. However type 1 is becoming an increasingly common cause nowadays and is usually passed from a person with an oral cold sore to the genital area of their partner at oral sex.. A recent USA study estimated that 17% of those between the ages of 14 and 49 had acquired HSV type 2 .Up to 90% of those who acquire HSV type 2 do not know they have it . Symptoms can be severe in a first outbreak, particularly in women, where fever, headache, muscle aches are reported in up to 70% of cases . The GH outbreak progresses from local redness to small blisters which then break down to form red bordered painful ulcers or open sores. . About 30% of patients have a milder outbreak.

Patients are usually in too much pain to even consider intercourse during a primary infection. Untreated the symptoms can persist for weeks, but antivirals such as aciclovir can resolve the symptoms within days. Recurrences of genital herpes are less common where the initial infection was HSV type 1.

Many patients have frequent recurrences. These are usually confined to a small area of the genitals and rarely persist for longer than 7 days even if untreated. It is not so much the pain of the genital lesions that may prevent some patients from having intercourse but rather the concern of transmission even if they do not have any current outbreak. Other important patient issues are the stigma of having a sexually transmissible disease as well as the psychosocial and psychosexual issues that may accompany recurrences in some patients.

There is little doubt that recurrent GH is associated with psychological distress and psychosexual problems. However opinion differs as to whether these problems are the result of the stress of having genital herpes, caused by pre-existing stressors or a combination of the two. Many patients with recurrent GH complain of feeling low in mood, tense and having sleep disturbances for a day or two prior to a recurrence. This may be because of the release of the body’s chemical response to GH (called cytokines) prior to the clinical manifestations of the recurrence.

Disclosure to partners may be problematic. Patients with recurrent GH appear less likely to tell partners their diagnosis if they perceive them as “casual” and if they are depressed.. Decisions to inform partners are more based on perceived likelihood of discovery and honesty rather than control of transmission. Clinical experience strongly suggests that being upfront about having GH in a new relationship results in the best outcome for both partners.

Patients who have frequently recurrent GH should be well informed about this infection. Even if they abstain from intercourse at outbreaks, there is still about a 5% chance per year that the partner will acquire GH (via silent shedding of virus). This rate can be halved if the patient takes continuous antiviral prophylaxis and is significantly decreased with regular condom use. Patients should be told that even if the recurrence is not in the genital area e.g. buttock region, that silent genital shedding of virus is a common contemporaneous event.

Continuous antivirals for patients with regular and frequent recurrences, such as aciclovir, valaciclovir or famciclovir will significantly decrease the clinical outbreak rate , increase the quality of the patient’s life in general, decrease anxiety, illness concern and the chance of transmission at sex . It is the clinical impression of clinicians that psychosexual problems per se also decrease. Patients should also be told that in general that recurrence rates decrease over the years .

In the USA there are some units that advocate serological screening (blood test) as part of routine screening for STIs. In spite of concerns that this will cause psychological issues , this does not appear to be the case in general , although those who are vulnerable prior to testing e.g. depression, poor self image may suffer consequent psychological distress .

It is generally thought that lesions of GH can enhance rates of transmission of HIV.

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