Genital Herpes

What is genital herpes?

Genital herpes is an infection of the genitals (penis in men, vulva and vagina in women) and surrounding area of skin. It is caused by the herpes simplex virus. The buttocks and anus may also be affected. There are two types of herpes simplex virus:

• Type 1 herpes simplex virus is the usual cause of cold sores around the mouth. It also causes up to half of cases of genital herpes.
• Type 2 herpes simplex virus usually only causes genital herpes. It can sometimes cause cold sores.

The rest of this leaflet just deals with genital herpes. (See separate leaflet called 'Cold Sores' for details about herpes simplex infection around the mouth.) Herpes simplex infection can also affect other areas of the body. For example, herpes simplex infection that develops on the fingers is commonly called 'whitlow'.

How do you get genital herpes?

Genital herpes is usually passed on by close physical contact with someone who is already infected with the virus. The moist skin that lines the mouth, genitals and anus is the most susceptible to infection. This means that the virus is most commonly passed on by having vaginal, anal or oral (mouth-to-genitals) sex, or just close genital contact with an infected person.

Also, the herpes simplex virus can be passed on through contact with skin on another area of the body that is infected with the virus. For example, if you have a cold sore around your mouth, you may pass on the virus that causes genital herpes by having oral sex. Also, if you have a herpes infection on your finger, you may transfer the herpes infection to your own genital area.

What are the symptoms of genital herpes?

The first time you are infected with genital herpes simplex is called the primary infection. This may, or may not, cause symptoms (described below). Following a primary infection, the virus is not cleared from the body but lies inactive (dormant) in a nearby nerve. In some people the virus 'activates' from time to time, and travels down the nerve to the nearby skin. This causes recurrent symptoms of genital herpes if the primary infection was in the genitals, or recurrent cold sores if the primary infection was around the mouth.

It is common not to develop any symptoms

Most people never develop any symptoms when they are infected with the virus. At least 8 in 10 people with genital herpes simplex virus do not know that they are infected. (Or, they only have a short bout of very mild symptoms which is not recognised as genital herpes. For example, just a slight area of itch or a small red area which soon goes.) In such people, the virus stays inactive (dormant) in the root of a nerve that supplies the genitals, but never causes recurrent episodes of symptoms. However, even people who do not get symptoms may, on occasions, have virus in their genital area and therefore be infectious to sexual partners. In fact, this is how many genital herpes simplex infections are passed on.

A first episode of symptoms

At first you may feel generally unwell with a mild fever, and aches and pains. Groups of small, painful blisters then appear around your genitals and/or anus. They tend to erupt in crops over 1-2 weeks. The blisters soon burst and turn to shallow, sore ulcers. The glands in your groin may swell and feel like lumps at the top of your legs. It is common to have pain when you pass urine, especially in women.

In women, a vaginal discharge may occur. Women may also have blisters and ulcers on the cervix (the neck of the womb at the top of the vagina). The inside of the back passage may also be affected. The ulcers and blisters can last up to 10-20 days, and then gradually heal and go without scarring.

Sometimes less typical symptoms occur. For example, you may just have a small raw area, one or two small ulcers, or just an area of irritation with nothing to see. Sometimes symptoms last just a few days.

Note: sometimes a first episode of symptoms appears months or years after being first infected. This is why a first episode of symptoms can occur during a current faithful sexual relationship. You may have been infected months or years ago from a previous sexual partner who did not realise that they were infected.

It is not clear why some infected people develop symptoms, some don't, and some have a first episode of symptoms months or years after first being infected. It may be something to do with the way the immune system reacts to the virus in different people.

Recurring episodes of symptoms

After the first episode, further episodes of symptoms occur in some people from time to time. These are called 'recurrences'. It is not clear why the dormant virus 'erupts' from time to time. Recurrences tend to be less severe and shorter than the first episode. It is more usual to have 7-10 days of symptoms with a recurrence, unlike the 10-20 days of symptoms that may occur during the first episode. Most people do not develop a fever and do not feel particularly unwell during a recurrence. A tingling or itch in your genital area for 12-24 hours may indicate a recurrence is starting. The time period between recurrences is variable.

Recurrences tend to become less frequent over time. In people who have recurrences, their frequency can vary greatly. Some people have six or more a year. For others it is less frequent than this. On average, people tend to have 4 to 5 recurrences during the first two years after the first episode. Some people do not have recurrences at all after a first episode of symptoms.

Some people can identify some things that may trigger an episode of recurrence. Such triggers include sunlight, physical illness, excess alcohol, or stress. If you can identify a trigger, it may be helpful to try to avoid this in the future, if possible.

Do I need any tests?

Yes. A blister can be swabbed by a doctor or nurse to obtain a small sample to send to the laboratory. This can confirm the infection is due to the herpes simplex virus. Tests to look for other sexually transmitted infections may also be done at the same time.

These swab tests may be done in a genito-urinary medicine (GUM) or sexual health clinic and your GP may refer you to such a clinic. You can also make an appointment at most GUM clinics yourself without needing a referral from your GP.

What is the treatment for genital herpes?

General measures that may help to ease symptoms when they occur

• Painkillers such as paracetamol may help to ease pain.
• If it is painful when you pass urine, it is often less painful if you pass urine whilst sitting in a warm bath or with water flowing over the area.
• Anaesthetic ointment that you can buy at pharmacies (such as lidocaine 5%) may relieve itching or pain. Some people also apply ointment about five minutes before passing urine if this is painful. Note: some people are sensitive ('allergic') to anaesthetic ointments, and the ointment sometimes makes skin symptoms worse in such people. Applying Vaseline® before passing urine may be a helpful alternative to anaesthetic ointment.
• An ice pack (ice wrapped in a tea towel) placed over the sores for 5-10 minutes may be soothing. Do not put ice directly on to skin as this may cause an 'ice burn'.
• Have lots to drink. This can help to make your urine more dilute and may make passing urine less painful.
• Do not use scented soaps, bubble bath, etc, as these may irritate. Gentle cleaning of the sores with just cotton wool and plain or salt water is best. Gentle drying with a hair dryer on its lowest setting may be more comfortable than with a towel.
• Some people say that placing cold, used tea-bags against the sores is soothing.
• Tight clothing may irritate the sores and blisters so is best avoided.
• You should avoid sharing towels or any sponges or face cloths with other people, as this may pass on the infection.
• You should avoid having sex until the sores and blisters have cleared and/or you have seen a doctor for follow-up.
• When you resume sexual activity after an episode has cleared, a lubricant may help as some people find the friction of having sex may trigger a recurrence.

Antiviral medication

Antiviral medication does not clear the virus from the body. It works by stopping the virus from multiplying. Antiviral medicines include: aciclovir, famciclovir and valaciclovir. Antiviral medication is most useful for a first episode of symptoms. It reduces the severity and duration of symptoms if it is started within five days of symptoms starting. A five day course of treatment is usual, but may be extended by a few days if blisters are still forming.

Antiviral medication may not be needed to treat recurrences. This is because symptoms are often much milder than the first episode, and usually last just a few days. However, if you tend to get bad symptoms during recurrences, then a five day course of medication can be useful. To reduce the duration and severity of a recurrence, start the medication as soon as symptoms begin. Some doctors prescribe antiviral medication that you can keep at home and can start at the first sign of a recurrence. Starting treatment early can help to reduce the severity of your symptoms.

If you have frequent recurrences, an option is to take antiviral medication every day. In most people who take medication every day, the recurrences are either stopped completely, or their frequency and severity are greatly reduced.

See separate leaflet called 'Genital Herpes - Antiviral Medication' for more detail.

Should I have sex if I have genital herpes?

When you have symptoms (during a primary episode or recurrence)

Herpes simplex virus is very contagious when blisters are present. There is a high chance of passing on the virus if you have sex. You should not have sex from the time symptoms first start until they are fully over. If you do have sex, using a condom may not fully protect against passing on the virus, as the condom only protects the area that is covered.

When you do not have symptoms (which is most of the time)

It is less likely that you will pass the virus on when you have sex. However, some virus will be present on the genital skin surface from time to time, although infrequently. So, there is still a small chance that you may pass on the virus when you have sex when you do not have symptoms. It is best to discuss things with your sexual partner. Using a condom each time you have sex is thought to reduce the chance further. However, using a condom cannot completely stop the chance of passing on the virus. Also, people who take antiviral medication long-term to prevent recurrences have a reduced risk of passing on the virus.

Note: If your sexual partner already has the same virus then you cannot re-infect each other. Your partner may be infected but may not have symptoms. It may be helpful to discuss things with a doctor or nurse at a GUM clinic.

What are the possible complications of genital herpes?

In a small number of people the infection can spread to other areas of skin on the body. Occasionally, the blisters become infected by bacteria (other germs) to cause a spreading skin infection. Note: genital herpes does not damage the uterus (womb) or cause infertility. Nor does it cause cancer of the cervix.

Genital herpes and pregnancy

A specialist will normally advise about what to do if you develop genital herpes whilst you are pregnant, or if you have recurrent genital herpes and become pregnant. This is because there may be a chance of passing on the infection to your baby.

A first episode of genital herpes whilst you are pregnant

If you develop a first episode of genital herpes within the last six weeks of your pregnancy, or around the time of the birth, the risk of passing on the virus to your baby is highest (there is about a 4 in 10 chance). The baby may develop a very serious herpes infection if he or she is born by a vaginal delivery.

Therefore, in this situation your specialist is likely to recommend that you have a Caesarean section delivery. This will greatly reduce the chance that the baby comes into contact with the virus (mainly in the blisters and sores around your genitals). Infection of the baby is then usually (but not always) prevented.

However, if you decide against a Caesarean and decide to opt for a vaginal birth, the specialist is likely to recommend that you are given antiviral medication (usually aciclovir). This is given intravenously (into your veins) during your labour and birth. They may also suggest that antiviral medication is given to your baby after they are born.

If you develop a first episode of herpes infection during the earlier stages of your pregnancy, the risk of passing on the virus to your baby is much lower. Sores or blisters are likely to clear before childbirth, and a normal vaginal delivery is likely to be safe for the baby. The specialist may advise that you are treated with antiviral medication at the time of infection. This helps the sores to clear quickly. In addition, some doctors advise that you should take antiviral medication in the last four weeks of pregnancy to help prevent a recurrence of herpes at the time of childbirth. However, this is not routine and the advantages and disadvantages of taking antiviral medication in the last four weeks of pregnancy should be discussed with you by your specialist.

If you have recurrent genital herpes and become pregnant

If you have recurring episodes of genital herpes, the risk to your baby is low. Even if you have an episode of blisters or sores during childbirth, the risk of your baby developing a serious herpes infection is low. It is not clear why the risk is low, but it is probably because you pass on some antibodies and immunity to the baby during the pregnancy.

However, there is some debate as to what is best if you do have a recurrent episode of sores or blisters during childbirth. Some doctors may recommend a Caesarean section. However, the Royal College of Obstetricians and Gynaecologists does not routinely recommend a Caesarean section if there are blisters or sores due to a recurrent herpes episode at the time of childbirth. Again, this is because the baby is likely to have some immunity to the virus and the chance of the baby developing a serious herpes infection is low. If you do have a recurrent episode when you go into labour, you should discuss your options with your specialist and together decide the best way that your baby should be delivered.

Another debatable point is whether antiviral medication should be taken in the last four weeks running up to childbirth. This may help to prevent a recurrence of blisters during childbirth. Again, your specialist will be able to advise on the pros and cons.

In summary

A first episode of herpes around the time of birth can be serious for the baby and a Caesarean section is usually advised. In any other situation - an earlier primary infection or a history of recurrent episodes - the risk to the baby is low and your specialist will advise on possible options.

Further help and information

If you suspect that you have genital herpes or any other sexually transmitted disease, then see your GP or contact your local GUM clinic. You can go to the local GUM clinic without a referral from your GP. You can ring the local hospital or health trust and ask where the nearest clinic is. It may also be listed in the phone book under 'Genito-urinary Medicine'.

Another source of help and information is:

Herpes Viruses Association

41 North Road, London N7 9DP
Helpline (local rate) 0845 123 2305
Web: www.herpes.org.uk

References

• Herpes simplex - genital, Clinical Knowledge Summaries (September 2008)
• Management of genital herpes, British Association for Sexual Health and HIV (2007)
• Sen P, Barton SE; Genital herpes and its management. BMJ. 2007 May 19;334(7602):1048-52.
• Gupta R, Warren T, Wald A; Genital herpes. Lancet. 2007 Dec 22; 370(9605):2127-37. [abstract]
• Hollier LM, Wendel GD; Third trimester antiviral prophylaxis for preventing maternal genital herpes simplex virus (HSV) recurrences and neonatal infection. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD004946. [abstract]
• Management of genital herpes in pregnancy, Royal College of Obstetricians and Gynaecologists (2007)