Genital or rectal herpes is an acute inflammatory infection caused by the herpes simplex virus. Most infections are caused by herpes simplex virus type 2 (HSV-2), but some cases are caused by herpes simplex virus type 1 (HSV-1). Symptomatic cases may represent either primary infection with HSV or recurrent disease, since the herpes viruses have the ability to remain latent in the involved nerve root between outbreaks, and when activated cause recurrent infections.
HSV-2 is usually sexually transmitted by genital-genital or oral-genital contact. Transmission of the virus occurs when the genital or oral mucosa of the uninfected person comes in contact with virus shed by an actively infected person. The infected person may have a symptomatic infection, or more commonly, asymptomatic genital or oral shedding of the virus.
The occurrence of herpes simplex virus is widespread. The Centers for Disease Control and Prevention (CDC) estimates that 31 million people in the United States are infected with HSV-2 and that there are 200,000 to 500,000 new cases a year. Incidence of the infection is highest in sexually active persons.
The incubation period for herpes is from 2 to 7 days; in most cases, the incubation period is closer to 7 days. Persons with primary herpetic lesions are infectious for about 7 to 12 days. Genital, rectal, or oral herpes recurs in 60 to 80 percent of persons whose primary infection was symptomatic. These recurrent episodes of herpes are milder and of shorter duration than the initial outbreak. Treatment of acute outbreaks or suppressive therapy with acyclovir will decrease the symptoms of herpes or the frequency of outbreaks, but will not cure the infection.
Patients should be counseled to abstain from sexual activity while lesions are present. In addition, condoms should be used during sexual contact since asymptomatic shedding may transmit the virus.
The risk of neonatal infection should be explained to all patients - male and female - with genital herpes. Women of childbearing age should be advised to inform their physician of any history of infection if they become pregnant.
Primary herpes infection may be asymptomatic or symptomatic. In women, the primary infection is usually more severe than in men. Any area of the female genitalia may be involved. Herpes simplex infection causes characteristic blister-like vesicular lesions that quickly rupture and leave shallow, exquisitely tender ulcers with a gray discharge and red base. New lesions may continue to develop for about 1 week.
In men, the primary infection usually involves the penis with the same vesicular lesions.
Both men and women may have dysuria and inguinal lymphadenopathy, as well as flu-like symptoms including fever, headache, malaise, and muscle aches during the first few weeks of infection.
Herpes can also involve the perirectal area or the oral cavity.
The diagnosis of herpes may be made by examination of the characteristic lesions. The simplest technique for diagnosing herpes is the examination of cells scraped from the base of an ulcer or vesicle using the Tzanck smear or, for cervical or vaginal lesions, the Papanicolaou (Pap) smear or Tzanck smear.
Other diagnostic tests include an enzyme-linked immunoabsorbent assay (EIA), direct fluorescent antigen (DFA), or viral cell culture.
The recommended treatment for herpes infection is acyclovir. Treatment with acyclovir hastens healing and decreases viral shedding, but does not eradicate the virus. Table 1 presents recommended treatment regimens.
Persons with herpetic lesions should be instructed to keep the area clean and dry in order to prevent secondary bacterial infections. They should also avoid touching the lesions and, if they do touch them, should wash their hands.
Persons with known prior genital or rectal herpes should avoid sexual contact when they have active lesions or have the prodrome of pain, tenderness, burning, tingling, or itching prior to the appearance of active lesions.
Since asymptomatic shedding of infectious virus may occur, persons with known herpes should always use a condom and inform their sexual partner(s).
For HIV-infected and other immunocompromised persons, the herpes infection may be more severe and less responsive to therapy. Some persons may require higher and longer doses of acyclovir. Cases of acyclovir-resistant herpes infections are now reported primarily in HIV-infected or other immunocompromised persons. Treatment of severe cases of acyclovir-resistant herpes requires hospitalization and treatment with intravenous foscarnet.
Most neonates who are infected with herpes simplex virus at the time of passage through the birth canal are born to mothers with no history of clinically apparent genital herpes. As a result, routine viral cultures during pregnancy to detect viral shedding are not appropriate.
At the onset of labor, all women should be carefully examined for the presence of active lesions. If the woman has signs or symptoms suggestive of active genital herpes, the baby should be delivered by caesarean section.
Infants exposed to herpes simplex virus at the time of delivery may develop disseminated infection with disease involving the skin, eyes, and mouth, or herpes simplex encephalitis. Peripartum or congenital (intrauterine) infection may result in the death of the infant or lead to serious neurologic or ophthalmic complications.
Herpes simplex virus (HSV) infection. In: Sexually Transmitted Diseases. Clinical Practice Guidelines--May 1991. Atlanta, GA: U.S. Department of Health and Human Services, 1991. pp. III-19-III-20.
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