Episode 121: Genital Herpes.     
Wendy and Grace discuss the signs, symptoms, diagnosis, and management of genital herpes. 

Written by Jaspreet Johal, MS4, Ross University School of Medicine. Edits by Grace Yi, MS2, University of California Los Angeles; and Wendy Collins, MS3, Ross University School of Medicine. Comments by Hector Arreaza, MD.  December 1, 2022.

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Definition & Epidemiology

Genital herpes is a common sexually transmitted infection caused by a virus called herpes simplex virus (HSV for short). There are two types of HSV. HSV type 1 commonly causes orolabial herpes (known as cold sores), and HSV type 2 typically causes genital herpes, which can present as painful blisters or ulcers in the genital regions. 

In recent years, an increasing number of genital herpes cases have been associated with HSV-1, especially in women. 

HSV infections are widespread among the global population and spread person to person through oral-to-oral contact or vaginal, anal, and oral sexual contact. Transmission can occur during periods of subclinical viral shedding, as in even when individuals are asymptomatic. In 2020, the seroprevalence of HSV-2 in the United States was approximately 13 percent among patients aged 15 to 49, with more women affected than men. Fifty to 80 percent of American adults have oral herpes (HSV-1), which causes cold sores or fever blisters in or around the mouth. 

HSV is a lifelong infection characterized by periodic reactivations that can be triggered by fatigue, stress, or illness, among other factors. Antiviral therapy can shorten symptom duration in primary infection and can also treat and prevent recurrences. 

Types of Infection

Genital HSV infection can be classified into three types: primary, nonprimary, and recurrent. 

• Primary – Primary infection refers to an infection in a patient without preexisting antibodies to either HSV-1 or HSV-2.
• Nonprimary infection, a patient has a first occurrence of a genital HSV lesion but already has pre-existing HSV antibodies that are different from the HSV type related to the genital lesion.
• Recurrent – Recurrent infection refers to the reactivation of genital HSV (so the patient already has pre-existing antibodies in the serum)

Clinical Features 

The incubation period for developing genital herpes after exposure ranges anywhere from 2 to 12 days.

Most patients with primary HSV infection are asymptomatic or mildly symptomatic. However, in more severe cases, individuals can present with painful genital ulcers, dysuria, fever, tender local inguinal lymphadenopathy, and headache. HSV infection also presents with characteristic 2-4mm wide skin lesions that are vesicular or ulcerated. The vesicles are often clustered and can be fluid-filled with underlying erythema. Sometimes vesicles might have a depression in the center (called “umbilicated” vesicles.” 

It’s important to note, though, that the clinical presentation can vary based on the type of infection (primary, nonprimary, or recurrent). As a general rule of thumb, the initial presentation of a non-primary genital infection tends to be milder (as in, fewer systemic symptoms and lesions) than that of a primary infection. Recurrent infections also tend to be less severe than primary or nonprimary infections. Also, around 50% of patients with symptomatic recurrent infections might experience prodromal symptoms in recurrent infections, like burning, pain, or pruritus, before lesions become visible.

Symptoms in patients with primary infections typically resolve after an average of 19 days, whereas symptoms in nonprimary or recurrent infections resolve within 10 days. Also, there are no clear differences in a clinical presentation based on whether the virus is caused by HSV-1 or HSV-2. However, infections due to HSV-2 are associated with a higher recurrence rate than infections due to HSV-1. 

Extragenital complications 

Genital HSV infection can cause extragenital manifestations that typically occur during the primary episode of HSV infection but can reappear with subsequent episodes. Complications include aseptic meningitis, urinary bladder retention, proctitis, and lumbosacral radiculitis. Other areas that can be affected outside of the genital area are fingers, eyes, and other skin areas.

Diagnosis.

A clinical diagnosis of genital herpes is usually initiated by the finding of vesicular or ulcerated genital lesions. The diagnosis can be confirmed with lab testing like viral culture, polymerase chain reaction (PCR), direct fluorescence antibody, and type-specific serologic testing. The most appropriate test for a patient depends on their clinical presentation. 

We might opt for PCR-based testing and cell culture if a patient has active lesions. Viral culture has typically been the gold standard method to isolate HSV, but HSV PCR assays are becoming increasingly popular as they have the best overall sensitivity and specificity. Cell cultures are most accurate in the early stages of the disease and have greater diagnostic yield with primary as opposed to recurrent genital herpes. 

Another method, type-specific serologic testing, tells us if a patient has type-specific antibodies to HSV, which develop in the first few weeks after infection and persist indefinitely. We might opt for this method if a patient has a history of genital lesions without a diagnostic workup or if the patient has an atypical presentation, in which case we may get type-specific serologic testing in addition to PCR. 

Management. 

All individuals experiencing a first episode of genital HSV should be treated with antiviral therapy, ideally as soon as a lesion appears. Most cases of genital HSV can be treated with oral drug therapy for 7 to 10 days, and as of 2021, the CDC recommends 3 different options for treatment: acyclovir, famciclovir, and valacyclovir. These drugs have been shown to decrease the duration of lesion healing time, duration of pain, and duration of viral shedding. For example, if the disease is disseminated or ocular, we may use IV acyclovir in complicated infections. 

It is important to note that treating the initial episode does not eliminate the latent virus. Patients are still at risk for recurrence and may require additional antiviral therapy. 

For recurrent infections, treatment options include episodic therapy and chronic suppressive therapy. 

Episodic therapy – involves patients starting therapy at the very first sign of prodromal symptoms (tingling, paresthesia, pruritus). Patients with infrequent recurrences or mild symptoms might opt for episodic therapy. 

• Wendy: Chronic suppressive therapy – involves daily antiviral therapy to decrease the risk of reactivation and recurrences. Suppressive therapy is helpful in patients with frequent recurrences or severe symptoms or at high risk for severe infections, such as those with HIV.

Screening

According to the US Preventive Services Task Force (USPSTF), routine screening for HSV-1 or HSV-2 is not recommended in asymptomatic adolescents and adults. The lack of specific treatment interventions for asymptomatic individuals, and the significant limitations of serologic testing, including low specificity and high false-positive rate, outweigh the potential benefits of screening. 

Prevention. 

Measures to prevent genital HSV infections include the use of barrier protection, patient education, and chronic suppressive therapy. 

• Barrier protection – The use of condoms is one of the best ways to prevent the spread of genital HSV infection and other sexually transmitted diseases. It reduces the risk of transmission while patients are asymptomatic but are in the viral shedding stage. Patients with active lesions or prodromal symptoms should abstain from sexual activity completely while having an active episode. 
• Patient Education – Counseling patients along with their sex partner(s) about safe sexual practices can decrease the incidence of HSV in our community and prevent the further spread of the disease. 
• Chronic suppressive therapy – can reduce recurrences and viral transmission.

Conclusion: Genital herpes is a sexually transmitted, worldwide infection that can be asymptomatic but often presents with painful vesicles that progress to ulcers in the genital area. Even though the course can be shortened, and the symptoms can be improved with medications, it is frequently recurrent. So, prevention is key to avoiding complications.

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Now we conclude episode number 121, “Genital herpes.” You listened to Grace and Wendy discuss the basics of genital herpes. They explained that episodic treatment of genital herpes with antivirals helps reduce the severity and duration of symptoms, while suppressive therapy prevents recurrences and transmission. Dr. Arreaza reminded us that screening asymptomatic adults and adolescents is not recommended by the USPSTF. HSV serology has a low sensitivity and specificity. PCR and viral culture are better diagnostic tools in most cases. And, as with all other STIs, promoting safe sex practices is key to the prevention of genital herpes.

We thank Hector Arreaza, Grace Yi, Wendy Collins, and Jaspreet Johal this week. Audio edition by Adrianne Silva.

Even without trying, you go to bed a little wiser every night. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you. Send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! 

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Links:

1. Albrecht, Mary A. Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection, Up to Date, last updated: Dec 22, 2020. https://www.uptodate.com/contents/epidemiology-clinical-manifestations-and-diagnosis-of-genital-herpes-simplex-virus-infection.
2. Albrecht, Mary A. Treatment of genital herpes simplex infection, Up to Date, last updated: Jun 28, 2021. https://www.uptodate.com/contents/treatment-of-genital-herpes-simplex-virus-infection
3. James C, Harfouche M, Welton NJ, Turner KM, Abu-Raddad LJ, Gottlieb SL, Looker KJ. Herpes simplex virus: global infection prevalence and incidence estimates, 2016. Bull World Health Organ. 2020 May 1;98(5):315-329. doi: 10.2471/BLT.19.237149. Epub 2020 Mar 25. PMID: 32514197; PMCID: PMC7265941. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7265941/
4. Royalty-free music used for this episode: “Keeping Watch,” New Age Landscapes. Downloaded on October 13, 2022, from https://www.videvo.net/royalty-free-music-albums/new-age-landscapes/.