Family doctor

Overview:

• Genital herpes is a sexually transmitted disease
• It can also be spread by other skin contact
• Genital herpes is mainly caused by the herpes simplex virus type II
• Many people have been infected without being aware and have no symptoms
• Diagnosis is generally made by taking a swab of the infected site
• A first attack of genital herpes occurs about one to 21 days after sexual contact
• Recurrent episodes occur twice a year on average and are usually less severe
• Antiviral tablets are used to treat genital herpes

What is genital herpes?

Genital herpes is caused by the Herpes simplex virus. It can be passed on during sex or by other skin contact.

There are two types of Herpes simplex; Type I and Type II. They may cause painful blisters and skin sores. Type I often affects the mouth and lips (called 'cold sores'), while Type II mostly affects the genitals. Through oral sex Type I can be found in the genitals (in about 25 percent of cases). Type II can be found around the mouth.

The infection can occur elsewhere, e.g. buttocks, fingers, which have contacted an infected sore.

The virus is very common in New Zealand. Most adults have antibodies to herpes but have no knowledge of ever having mouth or genital symptoms.

Most people are infected unknowingly and never have any noticeable symptoms.

How do I know if I have herpes?

Approximately 80% of people with genital herpes do not have symptoms they recognise. Until recently, only people who experienced symptoms (approximately 20% of those with genital herpes) who went to a doctor to have the symptoms assessed clinically and confirmed by a laboratory through culture swab taken from the lesion, could be positively diagnosed. This still remains the preferred method of diagnosis.

Recently however, blood tests that can distinguish between herpes simplex virus type I (HSV-I) and herpes simplex virus type II (HSV-II) antibodies are now becoming available. The time taken to develop these antibodies can be up to six months after infection. It is important to remember that false positive and false negative results are common with these tests. Because of the limitations of a blood test to diagnose genital herpes, it is recommended that you discuss the implications of the test with someone who has experience with these tests.

How have I caught it?

Having close skin contact with an infected person who is shedding virus from sores on the skin, lips or genitals. This can be by kissing, sexual intercourse, close body or skin touching. The virus can be shed by a person who has never experienced symptoms and therefore doesn't know they have the virus. This is quite common.

The first episode

A small number of people experience a painful first attack. This occurs at the site of infection with a small group of painful blisters on red skin which ulcerate into tender sores. They occur from 1-21 days after sexual contact (average 7-14 days). They are often on the penis or scrotum in men and on the vulva in women. Often the first attack is so mild it can be missed, or confused with thrush (candida), or a urinary tract infection.

There can be flu-like symptoms with joint aches, headache and tiredness, and the glands in the groin become enlarged and tender. If urine runs over the ulcers it can be painful.

Sometimes there are shooting pains or numbness in the buttocks or thighs and women may notice a vaginal discharge.

Very rarely there can be difficulty urinating or having a bowel motion. The ulcers gradually dry, crust and heal during the next three weeks. After the ulcers have healed the skin looks perfectly normal, but the virus retreats into the sensory nerves (carrying sensations to the spinal cord) and lies dormant. From there it may become active again at a later date.

Recurrent episodes:

Herpes Simplex may be reactivated at times when the body is stressed by fevers, illness, emotional stress, skin trauma, drugs, alcohol, cigarettes, poor diet, or menstruation. It cannot be predicted if or when you will ever get a recurrence. Some people will never experience another episode again. However, most people would recognise about two recurrences a year. Recurrent episodes are much less painful than the primary episode.

Often before an attack starts there are symptoms of burning, itching or pain in the buttocks or thighs called a 'prodrome' as the virus returns down the nerve endings to the same patch of skin. The attack continues with tingling, redness, blisters, ulceration, crusting and healing.

Recurrences usually get less frequent and milder as time goes by as the immune system recognises and controls later attacks better.

When is it infectious?

The first episode has a large amount of virus. You are infectious from blistering until skin healing, but the peak of infectivity is when the skin is moist and ulcerated. Recurrent episodes are milder and shed less virus.

It is best to avoid intercourse from the time the early signs of an attack appear (skin tingling), until the area is healed.

Sometimes virus can be shed from the cervix or genital skin without there being any symptoms. It is hard to predict when this occurs. Approximately 80% of people who acquire genital herpes don't experience symptoms, so don't know they have had it, but can occasionally shed and transmit the virus without any symptoms.

Treatment:

Simple treatments for the relief of discomfort. The following treatments can alleviate pain and discomfort particularly in the first episode:

• Salt baths
• Drink plenty of fluids to keep your urine diluted and prevent urinary retention.
• Pain relief and simple analgesics such as paracetamol.
• Lignocain Jelly which you can apply 5 minutes before going to the toilet (will numb the area).
• Rest and eat well.
• Passing urine into a salt bath or while showering will diminish discomfort.
• Loose underclothes - preferably cotton, help minimise discomfort and allow healing.

Specific oral antiviral therapy (Zovirax)

Acyclovir (Zovirax) is a medication that acts to control the herpes simplex virus. It works by preventing the herpes virus from multiplying inside infected cells. As it only acts on cells that contain the virus it has a very high level of safety.

It is used effectively in two ways:

* First episodes - for people who experience an initial or primary episode. Zovirax 200mg tablets given 5 x day for 5 days markedly reduces the duration of the episode and gives effective relief of symptoms.

* Recurrent outbreaks - for people who experience frequent, prolonged or severe recurrences, Zovirax 400 mg twice daily can be prescribed for continuous use.

If you are experiencing problematic recurrences you should discuss this management with your doctor.

Complications:

There are usually no long term complications. The herpes simplex virus is a skin infection and does not spread up the genital tract like bacterial infections. It does not cause infertility and women can get pregnant without any problem. There is usually no danger to the baby while inside the uterus. It is important that you let your doctor/midwife know if you have a history of genital herpes.

In people with immune system depression, e.g. after transplant surgery or cancer drugs, or in people with HIV/AIDS, the attacks can be frequent and severe.

What about sexual partners?

Partners may not catch herpes as they have different immune systems. It is wise to protect your partner by using a condom during an attack or abstain from sex from the beginning of the outbreak until after healing. Tell regular partners so as a couple you can deal with it together. It may be helpful to talk to the doctor or a counsellor about how to discuss this with your partner or see a counsellor together. Herpes need not affect your relationship.

Condoms are recommended in casual relationships to protect against all STDs. Because of the risk of shedding virus without symptoms, condoms do not give complete protection against herpes infection.

How to stop recurrences:

Be kind to yourself. Have plenty of sleep, a good balanced diet and some regular exercise. Try to reduce stresses in your life to boost your immune system.

If you are getting regular recurrences keep a diary of when and how often they occur, and if there are any factors that trigger them.

Acyclovir tablets can be given by doctors as a preventative regime for many months if you are having a bad patch of frequent recurrences.

Try not to panic - getting distressed over herpes does no good and can often induce more attacks.

Where to go for help and support information:

The psychosocial effects of a diagnosis of herpes is usually far worse than the physical. Understanding and talking about the condition with a trained counsellor or another person with herpes is often a major step in recovery.

Sexual health and STD clinics offer free confidential specialist treatment.

The NZ Herpes Foundation has a toll free Herpes Helpline 0508 11 12 13 with pre-recorded information and the option of talking to a trained counsellor or a person with herpes.

There are also Herpes Support Groups in some areas. Your local Sexual Health Clinic and the NZ Herpes Foundation can give you information about those groups.

Whangarei Sexual Health Clinic 09 438 2070 X7652

Auckland Sexual Health Clinic 09 307 2885

Wellington Sexual Health Clinic 04 383 5996

Christchurch Sexual Health Clinic 03 364 0485

Dunedin Sexual Health Clinic 03 474 7919

Claire Hurst, NZ Herpes Foundation 09 360 1966

* Information supplied by the New Zealand Herpes Foundation