Genital Herpes can be defined as a sexually transmitted viral infection that can be caused by having sexual interaction with an infected person. Once encountered, the virus may manifest its infectious nature multiple times in the lifetime of a single host.

The disease may or may not be symptomatic. It causes redness, swelling, itch, and pain in the genital area.

Overview: 

Genital herpes is caused by a group of viruses called Herpes Simplex belonging to a family of double-stranded DNA viruses called Herpesvirales. These viruses are classified into two main types: 

1. Herpes Simplex type 1 (HSV-1): This type mainly causes oral herpes. However, it can also lead to genital herpes as well. For oral herpes to occur, the transmission is mainly vial oral-oral or oral-genital route. In both types of cases, the infection leads to swelling, pain, and redness in the area of the body involved. In some cases, oral sores from type 1 can lead to genital herpes in the other partner transferred via oral route.
2. Herpes Simplex type 2 (HSV-2): Genital infections are mainly caused by HSV-2. It spreads through physical contact and touch. HSV-2 can be both symptomatic and asymptomatic. It’s a highly contagious form of virus and can transfer even if the host does not show any symptoms of swelling, redness, and blisters. Other common symptoms include itching, rash, ulcers, and tenderness in the infected area.

Epidemiology

Herpes genitalis is still one of the most often spread sexually transmitted illnesses (STI). While HSV-2 is responsible for the vast majority of cases, uncommon but growing occurrences of herpes simplex virus type 1 have been discovered (HSV-1). Both HSV-1 and HSV-2 are mostly transmitted through direct contact with open sores.

From 2005 to 2010, 16% of patients aged 14 to 49 were found to be HSV-2 seropositive. Antibodies to HSV-2 are frequently present by puberty, and their existence commonly corresponds with the individual's level of sexual activity. An infection has been documented in more women than males, and as predicted, the frequency rises with the number of sexual partners.

Non-Hispanic African Americans had higher infection rates than non-Hispanic whites. Approximately 85 to 90 percent of illnesses go unnoticed and untreated.

HSV remains one of the best most prevalent causes of genital ulcers in the United States, and more than 23 million new cases are recorded each year worldwide.

Causes the spread of Genital Herpes

• Herpes genitalis is caused by the herpes simplex virus types 1 and 2 and can show as a primary or recurring illness.
• Genital Herpes is a viral disease and needs physical contact for it to transfer from one person to another. However, it can also be traveled via saliva, mucous and genital discharge. This occurs due to frequent virus shedding that occurs in both active and inactive cases.
• In case of an infected pregnant woman, the virus can be passed onto the child during the delivery procedure. This leads to a condition called Neonatal Herpes.
• For an asymptomatic person carrying the HSV virus, the chances of disease transfer are typically low, yet it is still possible.
• In cases of contact with the infected area that possess the symptoms, there is a high chance of disease transfer.
• Using condoms during sexual intercourse can help reduce the chance of acquiring the disease substantially. However, the disease will spread if the genital area uncovered by condom carries the virus.
• Herpes can also spread from one person to another without any sexual contact. If there is an outbreak of herpes in a certain area, the disease will spread merely by skin-to-skin contact. 
• There are minimal chances for disease transmission via using an infected person’s toiletries, bed linen, or swimming in the same pool water.

Pathophysiology

HSV-2 is mostly spread through sexual contact, which accounts for its prevalence beginning in adolescence. HSV can only remain infectious on damp surfaces for days due to its limited stability outside the body. As a result, transmission routes other than sexual intercourse are frequently minimal. In pregnant women, both primary and recurrent HSV infections can result in intrauterine transmission and congenital HSV infection.

The virus predominantly affects the skin and mucous membranes, infecting epithelial cells and eventually reproducing intracellularly at that place. The virus then lays latent in the periaxonal sheath of the sensory neurons of the trigeminal, cervical, lumbosacral, or autonomic ganglia after the initial exposure, and symptoms diminish in 10 to 14 days on average.

In these areas, viral replication is frequently restricted by the patient's immune system and remains dormant until later in life, when it becomes reactive. When the virus reactivates, it travels via the sensory nerves until it reaches the mucocutaneous sites, where replication occurs, resulting in vesicular clusters at the dermatological site of that sensory neuron.

Genital herpes symptoms

Herpes may or may not present symptoms and can be inactive for a prolonged period of time without ever causing any clinical affliction. Its symptoms can vary depending upon 1st incidence of infection or subsequent and recurrent infection. 

The symptomatic and clinical disease state in the case of 1st-time infection is referred to as an outbreak. Once the virus enters the body, it usually takes about 2 to 3 days to up to two weeks for the first outbreak. The duration of an outbreak may last from 2 weeks to about a month

The characteristic signs include macular or papular skin and mucous membrane lesions that proceed to vesicles and pustules and can persist for up to three weeks. Genital lesions can be very severe, causing enlargement of the vulva, searing sensation, and dysuria in women. 

Where does the Herpes affect? 

Commonly Genital Herpes is specified to the genital area of the body. Commonly afflicted sites are the cervix, vagina, and vulva in women. In men, the painful symptoms are located on and around the anus, scrotum, and penis. Base of the penis shaft can also be severely affected as well as the tip.

The first outbreak is usually more severe and prolonged since the previous immunity has not been developed. In the case of subsequent infections, the severity of symptoms declines with time, and eventually, there is less severe infection and shorter duration and ultimately, rapid recovery.  In some patients, before the first outbreak, prodromal symptoms occur such as tingling and itching in the genital area which is a matter of few hours is accompanied by severe pain radiating around the pelvic area, hips, and legs. Next, the appearance of blisters and redness started.

Localized symptoms include:

• Redness: the area becomes distinctly red in appearance.
• Swelling: the genital gland will subsequently swell leading to other complications such as difficulty urinating and sitting down.
• Itching: there is severe itching around blisters and uneasiness while walking.
• Blisters and ulcers: these are more distinct symptoms of genital herpes. Formation of white blisters and scabs. These blisters may also contain fluid and occur mostly in the form of small clusters. It can start appearing a few days after the virus is transmitted. The blisters cause further complications such as severe itching and swelling in the area around the blister.
• Tenderness: due to swelling and blisters, the skin becomes extensively tender and painful to touch.
• Burning and stinging: Burning sensation during urination in the urethra occur in both men and woman.

Systemic symptoms are in accordance with any viral infection and can cause fever, chills, headaches, body aches, loss of appetite, pain and swelling of lymph nodes, etc.

Genital herpes women

Women are more likely than males to develop viral illness. Spread from males to women is reported to be more common than spread from women to men.

Genital herpes often produces blistering lesions on the vulva and surrounding the vaginal entrance in women, which proceed to ulcer development. In most cases, the infection extends to the cervix, resulting in cervicitis.

Genital herpes in babies

If the mother has genital herpes for the first time within the last 6 weeks of her pregnancy, the newborn infant is at risk of contracting herpes. If the mother had a vaginal birth, there's a chance she passed the virus on to her kid. If the mother has already had genital herpes, the risk is substantially reduced.

Genital herpes diagnosis

Genital herpes caused by HSV-2 can be detected by the following methods:

• Serological test: Serological serum test for antibody formed in response to herpes virus is used to detect the presence of virus in the body. This test is targeted at glycoprotein G presence in the serum. The accuracy is around 80-90% and thus can be used as a reliable testing method.
• Culture test: Culture is taken from the blisters and lesions and tested for the growth of the virus. This test can further differentiate between both HSV-1 and HSV-2 using a staining technique. However, a culture test is not entirely accurate in the case of an asymptomatic patient or a patient whose blisters have healed.
• PCR testing: Polymerase chain reaction along with the viral cultures are more accurate and reliable testing methods employed for Herpes diagnosis.

Given symptoms can mimic acute urinary tract infection, consider urinalysis and culture.

When to get tested for Genital Herpes?

 Herpes is a disease with multiple apparent signs and symptoms. The appearance of redness, blisters, and swelling are common signs of genital herpes. However, other STDs such as syphilis have the same clinical appearance and pathology. It is, therefore, a better choice to get a physical exam by a doctor before concomitant testing as prescribed.

Genital herpes treatment

The treatment of genital herpes focuses on avoiding transmission and decreasing viral shedding by antiviral medication and sexual transmission risk counseling.

Genital herpes requires both medical interventions as well as changes in lifestyle and hygienic habits.

Medicines to be taken in HSV-2 infection 

Although there is no cure for this condition, however, since Genital Herpes is a viral disease, the doctor will likely prescribe antiviral drugs. Medication does not entirely cure the symptoms such as blisters and sores etc. However, starting an antiviral therapy early on in the outbreak can substantially diminish the severity of the symptoms thus making it more manageable. 

These drugs are preferentially absorbed by virus-infected cells and prevent viral multiplication. All patients should be treated to avoid a lengthy duration of their symptoms, ideally promptly after the first lesion appears. Among these antivirals are:

• Acyclovir (200mg, 400mg)

Acyclovir is available in topical, oral, and intravenous forms. The oral formulation has a limited bioavailability, which has been enhanced with the addition of valacyclovir (see below). Acyclovir's advantages include its minimal side effect profile, which allows it to be tolerated for lengthy periods of time. Suppressive therapy with acyclovir can prevent or postpone up to 80% of recurrences, lowering shedding by more than 90%.

When administered at high doses, reported negative effects to include renal damage and neutropenia. Resistance has been documented in immunocompromised individuals and those who are immunocompetent who are receiving acyclovir as suppressive treatment for genital herpes.

• Famciclovir (250mg)
• Valacyclovir (500mg, 1g)

The treatment course is further classified into three types and a doctor will decide what course suits best to what patient. These include:

1. Initial course: When the first appearance of symptoms occurs, a doctor will prescribe antivirals for a course of 7-10 days. If the outbreak is severe, the course can be prolonged to up to 10-15 days. After the drug course is completed, the doctor will examine again and eventually halt the drug therapy if the condition subsides.
2. Recurrent outbreak prevention course: This is an intermittent course to prevent recurrent outbreaks. Subsequent outbreaks are very common with herpes virus infection. Usually, the doctor prescribes a set of antivirals for a course of 7-10 days. The patient is advised to start the therapy when they feel any redness, swelling, or formation of blisters, etc.
3. Recurrent outbreak suppression course: Some people have a tendency to develop a new outbreak more often than others. This strongly damages the lifestyle of a person. In such cases, if the number of outbreaks exceeds 5 to 7, then the doctor prescribes a set of antiviral therapy prophylactically. The purpose of this course is to prevent any further outbreaks. This therapy is especially suitable for immuno-compromised patients such HIV positives, cancer patients, transplant patients who are on immunodeficiency medication, etc.

Over the counter medication for genital herpes

There is only one FDA-approved over-the-counter antiviral (Docosanol). It can be obtained from a pharmacy after talking to a pharmacist about the condition and disease.

• Docosanol (Abreva): It is an antiviral topical cream to be applied to the infected area every four hours. It should be strictly applied to the infected area of the skin only.
• Topical ointments and creams: there are a number of options available in topical preparations to relieve pain, itching, and swelling. Consultation with the on-call pharmacist is always advised for the selection of the best options.
• OTC pain killers: Pain management during a severe outbreak is essential. Fever, body aches, and pain in the blistered area go hand in hand with a flared-up herpes infection. Oral NSAIDs such as acetaminophen (Tylenol), Ibuprofen, Paracetamol, etc. are all easily available pain medications.

Vaccinations

HSV vaccinations are being researched to potentially lessen the intensity of symptoms and speed up apparent lesion healing. Furthermore, lowering shedding may lessen the severity, as demonstrated with the Varicella-zoster vaccination. There is currently no HSV vaccination available.

Differential Diagnosis

• Infectious genital ulcerative conditions 

1. Syphilis
2. Chancroid
3. Lymphogranuloma venereum
4. Granuloma inguinale

• Non-infectious genital ulcerative conditions

1. Crohn disease
2. Behcet syndrome
3. Fixed drug eruptions
4. Psoriasis
5. Sexual trauma

HSV-2 infection in the genital tract is linked to an increased risk of HIV infection. As a result, be aware that testing for HIV infection may modify HSV-2 therapy.

Genital herpes vs warts 

Because they both present in the vaginal region, genital warts and herpes can be difficult to differentiate. However, genital warts are little, flesh-colored lumps, but herpes sores resemble blisters or open wounds.

Skin-on-skin contact can spread both genital warts and genital herpes. When genital warts or herpes are swollen or irritated, distinguishing between the two can be very difficult.

The underlying viruses are what distinguish genital warts from herpes. Genital warts are a frequent word for a human papillomavirus (HPV) infection, while herpes is a common term for a herpes simplex virus (HSV) infection.

Prognosis

Although there is no treatment for HSV-2, early detection of symptoms and rapid initiation of medication can result in early viral replication inhibition. Abstinence during known virus shedding can reduce the probability of seronegative partner transmission. The Herpesviruses as a group cause severe neurological morbidity, and regrettably, HSV-2 remains in the seropositive individual for life.

Genital herpes prevention

Living with frequent outbreaks or even the first outbreak of genital herpes can damage the lifestyle and mental health of a patient. A few home remedies and lifestyle modifications are essential for absolute treatment and management of the disease.

• Talking to the partner about it: When one of the partners is frequently getting outbreaks it is essential that the other partner is also tested for HSV-2 virus. Virus shedding in one of the partners can cause the other to easily catch it. Prophylactic treatment becomes essential in such cases.
• Avoid itching and scratching: Blisters and lesions formed in this disease are extremely itchy and patients often complain about unintentional itching of blisters especially during nighttime. It is essential that topical creams and soothing ointments are applied at those hours so as to avoid scratches. Fluid exuded from one badly scratched blister will form clusters of other blisters wherever it touches the skin.
• Keep the area clean and dry: One extremely painful complication with herpes lesions is stinging and burning whenever it gets wet with water, urine, or sweat. It is advised to clean the area with water and pat dry with clean wipes.
• Look out for cold sores: It is wrongly assumed that cold sores do not spread herpes. Even though it is often true, if one of the partners is experiencing cold sores then it is best to avoid any sexual activity, especially oral type.

Complications

Viral diseases tend to lower the body's immune response thus making it more susceptible to other infections and complications. Following complications are likely to occur with HSV-2 infection.

• HIV and other STDs: Decreased immunity along with genital blisters can increase the risk of contracting other sexually transmitted diseases such as HIV- AIDS, etc.
• Difficulty urinating and UTIs: swelling and blisters cause profound difficulty in urination. This may lead to severe bladder and urinary infection that may require medical intervention and antibiotics
• Neonatal Herpes: infected mothers can pass the virus onto the newborn during the delivery process called neonatal herpes. This is one of the more severe and rapidly acting types and can lead to blindness, mental disorders, or even death among newborns.
• Brain and spinal cord infection: viral and non-viral meningitis are some of the less frequent complications of herpes simplex. Meningitis affects 36% of women and 13% of men, resulting in a proportion of infected people being hospitalized. As previously noted, during the prodrome of genital herpes and herpetic eruption, infected persons may have more systemic symptoms such as headaches, neck stiffness, and low-grade fever. Such symptoms should prompt an emergency lumbar puncture and CSF investigation, which frequently reveals lymphocytic pleocytosis. While CSF can be submitted for viral culture, PCR is the preferred diagnosis method.
• Acute retinal necrosis "is characterized by unilateral or bilateral red eyes, periorbital discomfort, and decreased visual acuity. The examination reveals episcleritis or scleritis, as well as necrosis and retinal detachment. It is possible that HSV-2 meningoencephalitis will arise.
• Psychological impact: herpes-like other STDs also affect the mental health of the patient, diminish confidence and mental stability.

Frequently asked questions about Genital Herpes

1. Is Herpes a lifelong condition?

Yes, there is no 100% cure of the disease and recurrent episodes of outbreaks can occur at any time, it is safe to say genital herpes, once acquired can come back at any time.  

2. What is the effect of topical alcohol application on the virus?

According to CDC, ethyl alcohol has virucidal (virus killing) properties at a concentration of 75-80%. This, however, can not be set as a hard and fast rule since different viruses have different lipophilic properties that vary with the environment.

3. What is the effect of Epsom salt on Herpes blisters?

Epsom salts are widely used as bath salt for both relaxation and disinfection. People who enjoy the use of such salts can soak their bodies for 5-10 minutes in an Epsom salt bath and pat dry afterward. It will help to decrease itching, redness, and swelling for a few hours.

Conclusion

Herpes genitalis is one of the most prevalent sexually transmitted viruses, and the psychological morbidity it causes is a significant, largely underappreciated medical concern. It is caused by the herpes simplex virus type 2 (HSV-2) and, in an increasing number of cases, the herpes simplex virus type 1 (HSV-1) (HSV-1). Both organisms are DNA viruses with envelopes that are susceptible to disinfectants and environmental factors.

The typical clinical symptoms include macular or papular skin and mucous membrane lesions that appear 4–7 days after a sexual encounter and proceed to vesicles, pustules, and ulcers that can persist up to 3 weeks. 12. Sensation, particularly severe inflammatory swelling of the vulva in women, searing pain, and dysuria are other common symptoms. Lymphadenopathy, fever, and cervicitis in women, or proctitis in males, are some of the most prevalent accompanying symptoms.

Genital herpes can present atypically, especially in the female genital tract, making clinical identification much more challenging. In the absence of symptoms, signs of herpes lesions of the cervix are rather prevalent, although urethral manifestations are frequently linked with severe micturition difficulties. Direct viral detection is used in the laboratory to make the diagnosis of acute genital HSV infection or asymptomatic virus shedding. 

Acyclovir is the first-line treatment for herpes genitalis and other HSV infections. Oral administration, on the other hand, has a bioavailability of just 15–30%. In immune-competent persons, infections of the skin and mucous membranes, including herpes genitalis, are treated orally.

Severe HSV infections should be treated with intravenous (i. v.) acyclovir, especially in immunocompromised individuals. The dose of acyclovir for the treatment of herpes genitalis is determined by the patient's infection status, immunological competence, and whether or not she is pregnant.

The medical care of people with herpes genitalis is frequently inadequate. It can be considerably improved with professional patient counseling and the proper application of existing diagnostic, therapeutic, and preventative strategies. Nonetheless, current antiviral therapy and prevention have flaws, particularly in the management of frequent recurrences.