Genital herpes is commonest sexually transmitted disease (STD) worldwide. The highest incidence is between 16 to 24 years of both sexes. Infection may be either primary or recurrent. Spread occurs at the time of close contact with a person who is shedding virus. Most of the genital herpes is due to type 2 infection. Genital contact with oral lesions affected by HSV-1 can also cause genital infection. Vulnerable mucous membranes are the genital tract, rectum, mouth and the oropharynx. The virus has the capability to set up latency in the dorsal root ganglia by ascending peripheral sensory nerves from the area of entry. It is this capability which allows them to attack recurrently.
Symptoms Genital Herpes infection
Asymptomatic infection though has been reported but in reality it is rare. Primary genital herpes is typically present by systemic symptoms of varying severity, which includes fever, myalgia and headache. Several painful shallow ulcers appears which may coalesce. Atypical lesions are also common. Tender inguinal lymphadenopathy (enlargement of the lymph glands at inguinal region) is usual. Over a period of 10-14 days the lesions form crusts and dry up. In women with vulval lesions the cervix is also almost always affected. Rectal infection may produce severe proctitis. Neurological complications may also appear e.g. aseptic encephalitis and/or involvement of the sacral autonomic plexus causing retention of urine. Recurrent attacks are common in many affected persons following the initial episode. Precipitating factors differ, as does the incidence of recurrence. A symptom prodrome is present in some patients before the appearance of ulcers. Systemic symptoms are not common in recurrent infections. The clinical manifestations in immune suppressed or, compromised patients (including patients with HIV infection) maybe more severe, asymptomatic shedding increased and recurrences occur with greater incidence. Systemic spread of HSV is also known.
Diagnosis of Genital Herpes Simplex Infection
History and examination themselves highly suggestive of HSV infection. A sure shot diagnosis can be made by isolation of virus from lesions only. Swabs are taken from the base of ulcers and placed in viral transport medium. Virus is most readily isolated from newest lesions. Type-specific immune responses can be seen 8 to 12 weeks after the primary infection and serological assays can be done. Though this method is not used in regular clinical practice.
Treatment of Genital Herpes Infection
Treatment of Primary infection
Bathing in Saltwater or bath on sitting in a tub of warm water is comforting and help the patient to pass urine with certain degree of comfort. Aciclovir 200 mg five times a day, famciclovir 250 mg three times in a day or valaciclovir 500 mg twice in 24 hours, all for 5 days, are helpful if taken while new lesions are still forming. When lesions are already crusting, antiviral therapy will not be of much help to change the course of the disease. Secondary bacterial infection sometimes occurs and treated with antibiotics. Rest, analgesics and antipyretics are prescribed to relieve symptoms. Rarely patients may need hospitalization and aciclovir given intravenously, particularly when HSV encephalitis is suspected.
Treatment of Recurrent Genital Herpes Infection
Recurrent attacks are usually less severe and can be treated with simple measures like saltwater bathing. Psychological morbidity is a problem with recurrent genital herpes and repeated recurrences cause strains on relationships; patients need substantial support. Long term suppressive treatment is advised to those with frequent recurrences. An initial course of aciclovir 400 mg twice a day or valaciclovir 250 mg twice in 24 hours for 6 to 12 months appreciably reduces the occurrence of attacks, although there may still be some breakthrough infections. Treatment is discontinued after one year and the incidence of recurrent infections is reassessed.
Genital Herpes Infection in pregnancy
The probable danger of infection to the unborn baby needs to be considered over and above the health of the mother. Infection occurs either via placenta or via the birth passage. If HSV is acquired for the first time during pregnancy, via placenta infection of the fetus is rare to occur. Treatment of primary HSV in the first or second trimester will depend on the woman's clinical symptoms and aciclovir can be given in normal doses. Aciclovir treatment during the last 4 weeks of pregnancy may help to prevent recurrence at the time of delivery. Primary infection acquired in the third trimester or at the time of delivery with high degrees of viral shedding usually needs delivery by caesarean section. For women with past history of infection, there is more chance that the baby may acquire HSV from the birth passage. For women with repeated infections, only those with genital lesions at the time of delivery are delivered by caesarean section.
Prevention and control of Genital Herpes Infection
Patients must be informed that they are infectious when ulcers are there; sexual intercourse should be avoided when there are ulcers or at prodromal period. Condoms will not be useful as ulcers may also be present outside the areas covered. Sexual partners should also be examined and information about prevention of infection is given.
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