Genital Herpes

What genital herpes is

HSV infects the skin and mucous membranes, then travels up nerve fibers to clusters of nerve cells near the base of the spine (the sacral ganglia), where it stays dormant for life. From time to time it reactivates, travels back down the nerve, and either causes sores or is shed silently from normal-looking skin.

• HSV-2 almost always causes genital infection and recurs more often.
• HSV-1, the usual cause of cold sores, now causes a large share of new genital infections, often through oral sex. Genital HSV-1 recurs much less often and sheds less.

For an overview of both virus types and other sites they infect, see herpes simplex.

Genital herpes symptoms

The first outbreak

The first episode is usually the worst. It appears 2 to 12 days after exposure, about 4 days on average:

• tingling, itching or burning in the genital area
• small clusters of fluid-filled blisters that burst into shallow, painful ulcers, then crust and heal
• pain when urinating, as urine touches the sores
• tender, swollen lymph nodes in the groin
• fever, headache, muscle aches and tiredness
• vaginal discharge or urethral discharge in some cases

Sores take 2 to 4 weeks to heal without treatment. Many people infected never have a noticeable first outbreak, and their first symptoms come months or years later. That does not mean the infection is new.

Genital herpes in women and men

Recurrent outbreaks

Recurrences are shorter (about 5 to 10 days), with fewer sores and usually no fever. Many people feel a prodrome hours to a day beforehand: tingling, itching or shooting pain in the buttocks, hips or legs. HSV-2 recurs about 4 to 5 times in the first year on average, then less often. Genital HSV-1 often recurs once or not at all after the first year. Triggers can include illness, stress, friction, menstruation and sunburn.

How genital herpes is spread

Herpes spreads through direct contact with infected skin or mucous membranes during vaginal, anal or oral sex, or genital skin-to-skin contact.

• Most transmission happens when the person has no visible sores, through asymptomatic shedding.
• It is not spread by toilet seats, towels or swimming pools.
• Oral sex with someone who has a cold sore can cause genital HSV-1.
• Herpes sores make HIV easier to catch and pass on.

Diagnosis

1. PCR swab of a sore: the most accurate test. Swab a fresh blister or ulcer before it crusts. A culture is less sensitive.
2. Type-specific blood test (IgG): shows past infection with HSV-1 or HSV-2. It helps when someone has recurrent symptoms with negative swabs, or a partner has herpes. A positive HSV-1 result cannot tell oral from genital infection. Low-positive HSV-2 results can be false and may need confirmation.
3. IgM tests are not useful and should not be used.

The CDC does not recommend routine herpes blood testing for people without symptoms. Anyone with a new genital sore should also be tested for syphilis and HIV, because sores from different infections can look alike.

Genital herpes treatment

Antivirals (acyclovir, valacyclovir or famciclovir) stop the virus multiplying. They do not remove it from the nerves.

• First episode: a 7 to 10 day course, started as soon as possible, even if symptoms began a few days before.
• Episodic treatment: a short course of 1 to 5 days started within a day of a recurrence or at the first prodrome tingle. Keep a supply at home.
• Suppressive therapy: a daily pill that cuts outbreaks by 70 to 80% and roughly halves the risk of passing HSV-2 to a partner. Useful for frequent outbreaks, a partner without herpes, or psychological distress.

Easing an outbreak

• Sit in a warm, shallow salt-water bath.
• Pour water over the area while urinating, or urinate in the bath, to reduce stinging.
• Wear loose cotton underwear and keep the area clean and dry.
• Take acetaminophen (paracetamol) or ibuprofen at the label dose.
• A topical anesthetic such as lidocaine gel can help. Avoid other creams, which can slow healing.

Genital herpes in pregnancy

Most people with herpes have healthy babies. The greatest risk to the baby is when the mother catches herpes for the first time in the third trimester, because she has not yet made protective antibodies. Babies can get neonatal herpes, a severe infection, during birth.

• Tell your obstetric provider if you or a partner have herpes.
• Daily antivirals from 36 weeks reduce outbreaks and cesarean births.
• A cesarean is recommended if there are sores or prodrome symptoms at the start of labor.
• If your partner has herpes and you do not, avoid sex (including oral sex) in the third trimester or use suppression and condoms consistently.

Reducing the risk of spreading herpes

• Avoid sex from the first prodrome tingle until sores have fully healed.
• Use condoms every time. They lower, but do not eliminate, risk because they do not cover all skin.
• Daily suppressive antivirals for the partner with herpes.
• Tell partners before sex. Many couples where one partner has herpes never pass it on.

Complications

• Urinary retention and constipation from nerve involvement, mainly in the first episode
• Viral (aseptic) meningitis, usually with HSV-2, which typically resolves
• Spread to fingers or eyes from touching sores
• Higher risk of acquiring HIV
• Neonatal herpes
• Anxiety, shame and relationship stress, which counseling and support groups can help

Frequently asked questions

What does a first herpes outbreak look like?

It usually starts with tingling or burning, then clusters of small blisters that break into shallow, painful sores on the genitals, buttocks or anus. Many people have fever, aches and swollen groin glands. Sores crust and heal over 2 to 4 weeks. Antivirals started early shorten it.

Can you have genital herpes and not know it?

Yes. Most people with HSV-2 do not know they have it. Symptoms can be absent, so mild they are mistaken for ingrown hairs, razor burn or a yeast infection, or delayed for years. The virus can still be passed on during silent shedding.

Is genital herpes curable?

No. The virus stays in the nerves for life. Antiviral medicines control it well: they shorten outbreaks, prevent most recurrences when taken daily, and cut transmission. Outbreaks usually become milder and less frequent over the years even without treatment.

How do I know if I have HSV-1 or HSV-2?

A PCR swab of an active sore identifies the type. This matters because genital HSV-1 usually recurs much less often than HSV-2. Blood tests show past exposure to each type but cannot show where on the body the infection is.

Can you get genital herpes from oral sex?

Yes. Oral sex from someone with HSV-1, which causes cold sores, can cause genital herpes. It can be passed even when no cold sore is visible, although the risk is highest when there is an active sore or tingling.

Can I have a normal sex life with genital herpes?

Yes. Telling partners, avoiding sex during outbreaks, using condoms and taking daily suppressive therapy together greatly reduce the risk of passing it on. Many long-term couples where only one partner has herpes never transmit it.