Overview

Genital herpes is one of the most common sexually transmitted infections worldwide, affecting millions of people. The World Health Organization estimates that approximately 13% of the world's population aged 15-49 has HSV-2 infection, while many more have genital HSV-1 infection.

The infection is caused by two types of herpes simplex virus: HSV-1 and HSV-2. While HSV-1 traditionally caused oral herpes (cold sores) and HSV-2 caused genital herpes, both types can now cause genital infections. In fact, HSV-1 now accounts for a significant portion of new genital herpes cases, particularly in young adults.

Once infected, the virus remains in the body for life, residing in nerve cells. It can become active periodically, causing outbreaks of symptoms. Many people with genital herpes experience mild symptoms or no symptoms at all, which is why the virus often spreads unknowingly.

Key Points

  • Affects 1 in 6 people aged 14-49 in the United States
  • Can be caused by both HSV-1 and HSV-2
  • Remains in the body for life but can be managed effectively
  • Many people have no symptoms or very mild symptoms
  • Can be transmitted even when no symptoms are present
  • Antiviral medications can reduce outbreak frequency and severity

Symptoms

Genital herpes symptoms can vary greatly from person to person. Some individuals may have severe symptoms, while others may have symptoms so mild they go unnoticed or are mistaken for other conditions.

Primary Outbreak Symptoms

The first outbreak (primary infection) is typically the most severe and may include:

Additional Primary Outbreak Symptoms

  • Flu-like symptoms (fever, body aches, swollen lymph nodes)
  • Headache and fatigue
  • Tingling or burning sensation before blisters appear
  • Pain in the legs, buttocks, or genital area

Recurrent Outbreak Symptoms

Subsequent outbreaks are usually milder and shorter in duration:

  • Fewer blisters that heal more quickly (7-10 days)
  • Less severe pain and discomfort
  • Prodromal symptoms (warning signs) before outbreak
  • Tingling, itching, or burning at the site

Asymptomatic Shedding

The virus can be transmitted even when no symptoms are present. This is called asymptomatic viral shedding and occurs when the virus is active on the skin surface without causing visible symptoms.

Causes

Genital herpes is caused by the herpes simplex virus (HSV), which exists in two types:

HSV-1 (Herpes Simplex Virus Type 1)

  • Traditionally associated with oral herpes (cold sores)
  • Increasingly common cause of genital herpes
  • Often transmitted through oral-genital contact
  • Generally causes fewer recurrent outbreaks when affecting genitals

HSV-2 (Herpes Simplex Virus Type 2)

  • Primary cause of genital herpes
  • Almost exclusively transmitted through sexual contact
  • More likely to cause recurrent genital outbreaks
  • Can also cause oral herpes through oral-genital contact

Transmission Methods

The virus spreads through:

  • Direct skin-to-skin contact during vaginal, anal, or oral sex
  • Contact with herpes sores, skin, saliva, or genital secretions
  • Asymptomatic shedding when no visible symptoms are present
  • Mother to baby during childbirth (rare but serious)

The Virus Lifecycle

  1. Initial infection: Virus enters through small breaks in skin or mucous membranes
  2. Replication: Virus multiplies in skin cells causing symptoms
  3. Latency: Virus travels to nerve cells where it remains dormant
  4. Reactivation: Various triggers cause the virus to become active again

Risk Factors

Several factors can increase your risk of contracting genital herpes or experiencing outbreaks:

Behavioral Risk Factors

  • Multiple sexual partners: Increases exposure risk
  • Unprotected sexual activity: Lack of barrier protection
  • Early age of first sexual activity: Longer lifetime exposure
  • History of other STIs: May indicate risk behaviors or biological susceptibility

Biological Risk Factors

  • Gender: Women are more susceptible to infection from men than vice versa
  • Weakened immune system: HIV/AIDS, chemotherapy, immunosuppressive drugs
  • Skin conditions: Eczema or other conditions that break skin barrier
  • Recent infection or illness: Temporary immune suppression

Outbreak Triggers

Factors that may trigger recurrent outbreaks include:

  • Physical or emotional stress
  • Illness or fever
  • Fatigue or lack of sleep
  • Menstruation
  • Sun exposure or sunburn
  • Friction from sexual activity
  • Compromised immune function

Diagnosis

Accurate diagnosis of genital herpes is important for proper treatment and prevention of transmission. Several testing methods are available:

Clinical Examination

A healthcare provider will:

  • Examine visible sores or lesions
  • Ask about symptoms and sexual history
  • Assess for other STIs

Laboratory Tests

1. Viral Culture

  • Sample taken from fresh sore
  • Most accurate when sores are new and open
  • Can identify HSV type
  • May have false negatives if sores are healing

2. Polymerase Chain Reaction (PCR) Test

  • More sensitive than viral culture
  • Can detect virus from sores, blood, or spinal fluid
  • Identifies HSV type
  • Preferred test when available

3. Blood Tests (Antibody Tests)

  • Detects HSV antibodies in blood
  • Can diagnose past or current infection
  • Type-specific tests available (HSV-1 vs HSV-2)
  • May take 12-16 weeks after exposure to be accurate

Differential Diagnosis

Conditions that may be mistaken for genital herpes:

  • Syphilis
  • Chancroid
  • Aphthous ulcers
  • Trauma or friction injuries
  • Yeast infections
  • Bacterial infections

Treatment Options

While there is no cure for genital herpes, effective treatments can manage symptoms, reduce outbreak frequency, and lower transmission risk.

1. Antiviral Medications

The cornerstone of herpes treatment:

First-line Antivirals

  • Acyclovir (Zovirax): Original antiviral, requires frequent dosing
  • Valacyclovir (Valtrex): More convenient dosing, better absorption
  • Famciclovir (Famvir): Alternative option with good efficacy

Treatment Approaches

  • Episodic therapy: Taken during outbreaks to speed healing
  • Suppressive therapy: Daily medication to prevent outbreaks
  • Benefits: Reduces outbreak severity, duration, and transmission risk

2. Symptom Management

  • Pain relief: Over-the-counter pain medications (ibuprofen, acetaminophen)
  • Topical anesthetics: Lidocaine gel for local pain relief
  • Sitz baths: Warm water baths for comfort
  • Cool compresses: To reduce inflammation and pain
  • Loose clothing: To avoid irritation

3. Home Care Measures

  • Keep affected area clean and dry
  • Avoid touching sores to prevent spread
  • Wash hands thoroughly after contact
  • Use separate towels and washcloths
  • Avoid sexual contact during outbreaks

4. Lifestyle Modifications

  • Stress management: Meditation, yoga, counseling
  • Adequate sleep: 7-9 hours nightly
  • Healthy diet: Balanced nutrition supports immune function
  • Regular exercise: Boosts immune system
  • Avoid triggers: Identify and minimize personal outbreak triggers

5. Partner Management

  • Inform sexual partners about diagnosis
  • Partners should be tested
  • Discuss prevention strategies
  • Consider suppressive therapy to reduce transmission

Prevention

While no method is 100% effective, several strategies can significantly reduce the risk of contracting or transmitting genital herpes:

Primary Prevention (Avoiding Infection)

  • Barrier methods: Consistent condom use reduces risk by 30-50%
  • Limiting partners: Fewer sexual partners reduces exposure risk
  • Partner testing: Know your partner's STI status
  • Avoiding contact during outbreaks: Highest transmission risk
  • Dental dams: For oral-genital contact

Secondary Prevention (Reducing Transmission)

  • Daily suppressive therapy: Reduces transmission risk by 48%
  • Recognizing prodromal symptoms: Early warning signs
  • Communication: Open discussion with partners
  • Regular testing: Know your status

Special Considerations

Pregnancy Prevention Measures

  • Inform healthcare provider about herpes status
  • Suppressive therapy in third trimester
  • Cesarean delivery may be recommended during active outbreak

Limitations of Prevention

  • Condoms don't cover all affected areas
  • Asymptomatic shedding can occur
  • HSV can be transmitted through oral sex
  • No available vaccine currently

When to See a Doctor

Timely medical attention is important for proper diagnosis and treatment of genital herpes.

Seek Medical Care For:

  • First occurrence of genital sores or blisters
  • Painful urination with genital symptoms
  • Unusual vaginal or penile discharge
  • Flu-like symptoms with genital lesions
  • Symptoms that don't improve with treatment
  • Frequent or severe outbreaks
  • Questions about transmission or prevention

Urgent Medical Attention Needed:

  • Severe pain or inability to urinate
  • High fever with genital symptoms
  • Signs of secondary infection (increased redness, pus, red streaks)
  • Symptoms affecting the eyes
  • Confusion or severe headache (possible meningitis)

Special Situations

  • Pregnancy: Immediate consultation for outbreak management
  • Immunocompromised: Higher risk of complications
  • Newborns: Any suspected exposure requires immediate care
  • New partners: Discuss testing and prevention strategies

Related Conditions

Several conditions may be related to or confused with genital herpes:

Other Sexually Transmitted Infections

  • Syphilis: Can cause similar genital ulcers
  • Human Papillomavirus (HPV): Causes genital warts
  • Chlamydia and Gonorrhea: May cause discharge and pain
  • HIV: Increases susceptibility to HSV
  • Chancroid: Causes painful genital ulcers

Non-STI Conditions

  • Aphthous ulcers: Canker sores on genitals
  • Behcet's disease: Causes recurrent genital ulcers
  • Contact dermatitis: Allergic reactions
  • Lichen planus: Inflammatory skin condition
  • Psoriasis: Can affect genital area

Complications of Genital Herpes

  • Neonatal herpes: Transmission to newborns
  • Herpes encephalitis: Rare brain infection
  • Aseptic meningitis: Inflammation of brain lining
  • Urinary retention: Difficulty urinating during severe outbreak
  • Proctitis: Rectal inflammation from anal HSV

References

  1. Patel R, Kennedy OJ, Clarke E, et al. 2017 European guidelines for the management of genital herpes. Int J STD AIDS. 2017;28(14):1366-1379.
  2. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187.
  3. James SH, Sheffield JS, Kimberlin DW. Mother-to-Child Transmission of Herpes Simplex Virus. J Pediatric Infect Dis Soc. 2014;3(Suppl 1):S19-S23.
  4. Schiffer JT, Corey L. Herpes Simplex Virus. In: Bennett JE, Dolin R, Blaser MJ, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 9th ed. Philadelphia, PA: Elsevier; 2020.
  5. Gnann JW Jr, Whitley RJ. Genital Herpes. N Engl J Med. 2016;375(7):666-674.