Men's Health Education: Understanding the Symptoms, Recurrence, and Treatment of Genital Herpes (HSV-2)

Genital Herpes

Genus herpes is a sexually transmitted disease caused by the herpes simplex virus. Currently, its incidence is relatively high abroad. Initial symptoms are often severe.

(I) Pathogen
The pathogen of genital herpes is the herpes simplex virus, a type of herpesvirus. This virus has a DNA core at its center, surrounded by a capsid composed of 162 capsomeres, and a lipid-containing envelope. The virus particle size is 150–200 nm. Due to differences in antigenic properties, it can be divided into two types: HSV-1 and HSV-2. The former (over 99%) occurs in the mouth, pharynx, nose, eyes, and skin, i.e., herpes simplex; while the latter is commonly found in genital herpes. Statistics show that 90% of genital herpes cases are caused by HSV-2, and 10% by HSV-1. After a primary HSV infection, recurrence is common after a certain period of dormancy. Factors contributing to recurrence include fever, menstruation, psychological trauma, and food and medications may also be triggers.

(II) Transmission and Epidemiology
In recent years, reports of genital herpes cases abroad have shown a dramatic increase. In the UK, the number of cases was 9,576 in 1979, 10,801 in 1980, and 11,147 in 1981, increasing at a rate of 13% annually. In the US, the number of patients seeking treatment at private physicians rose from less than 30,000 in 1966 to 260,000 in 1979, an eightfold increase. It was estimated that by 1982, there were 500,000 primary cases and 5-14 million recurrent cases. Approximately 85% of primary and 98% of recurrent genital herpes cases were related to HSV-2. Recent reports estimate 300,000 to 500,000 new cases annually in the US, mainly related to direct sexual contact with infected individuals. However, asymptomatic individuals with a history of herpes are also being monitored, especially those who have not been exposed to HSV, as the virus is highly contagious. Statistics show that 80% of women become infected after sexual contact with male patients.

(III) Clinical Manifestations The incubation period for primary genital herpes is 2–7 days, usually 3–5 days. Initially, there is a burning sensation in the affected area. The primary lesion is one or more small, itchy red papules that quickly turn into vesicles. After 3–5 days, the vesicles become erosions or ulcers, crust over, and are painful. Systemic symptoms may occur at the onset of the disease and in the days preceding it, including fever, general malaise, neck stiffness, headache, and paresthesia in the S2–S4 segment. Lesions may be single or confluent. In men, they are located on the glans penis, coronal sulcus, scrotum, urethral opening, or penile shaft. In women, they are located in the perianal area, thighs, or buttocks. Approximately 90% of cases also involve the cervix. Some primary herpes cases only affect the cervix and are easily overlooked. Vaginal HSV lesions are uncommon. In male patients, HSV can be isolated not only from the urethra but also cultured from prostatic fluid or seminal vesicle fluid. Direct anal lesions may be asymptomatic or accompanied by itching, purulent discharge, and tenesmus. All primary genital herpes infections are generally accompanied by swollen and tender lymph nodes, which slowly subside over 1-2 months.

Recurrent genital herpes occurs within 1-4 months of the primary infection. Nearly 60% of patients relapse within one year of the first HSV-2 infection, and relapses can occur every year. There can be 4-6 relapses in the first year, decreasing in frequency thereafter. Recurrent cases typically have milder systemic symptoms and shorter durations. Skin lesions usually resolve in about 10 days. Patients with genital HSV-2 infection are more likely to relapse. Reeves et al. found a 14% relapse rate for HSV-1 infection and a 60% relapse rate for HSV-2 infection. Primary or recurrent genital herpes can be accompanied by urinary difficulties, acute urinary retention, herpetic gangrene, encephalitis, and endometritis. Patients with genital herpes are prone to psychological problems due to the difficulty in controlling recurrent attacks and sometimes severe pain. For example, they may experience decreased self-esteem, reluctance to interact with the opposite sex, fear of infection or cancer, sexual dysfunction, disruption of family harmony, and even depression.

HSV-2 infection in male homosexuals is second only to gonococcal anorectal inflammation. Clinical manifestations include severe anorectal pain, constipation, anal discharge, tenesmus, and fever. Some patients have perianal blisters or ulcers.

(IV) Diagnosis If the clinical presentation is typical, diagnosis is generally not difficult. Commonly used laboratory diagnostic methods for HSV infection include:

1. Virus isolation. This is usually confirmed by tissue culture, identification, and typing, but successful virus isolation requires obtaining suitable specimens and prompt inoculation. 1. **Specimen Collection:** Samples must be obtained from the base of the vesicle using a cotton swab from lesions within 1-3 days of onset. These samples should be rapidly sent to a laboratory for tissue culture and virus isolation. The positive rate is 75%-85%, but this method is expensive and generally unavailable in most laboratories.

2. Viral Inclusion Body Detection:Rapid diagnosis of HSV infection involves examining clinical specimens under a light microscope for HSV inclusion bodies, but the positive rate is lower than that of cell culture.

3. Cytological Diagnosis:Remove the vesicle top and use a curette to collect a sample from the newly exposed ulcer edge (not the vesicle base). If the lesion is crusted, apply a wet compress for at least half an hour, remove the crust, and collect a sample from the ulcer edge. Finding large, multinucleated giant cells with eosinophilic inclusion bodies within the nucleus is diagnostic of HSV infection, but the sensitivity is only 50%-80%, and the specificity is also poor. Similar changes are observed in varicella-zoster virus, making the two indistinguishable.

4. Immunocytochemical Examination:Typically, a fine smear of the lesion is prepared, fixed with acetone, and bright green fluorescence is observed in FITC-labeled anti-HSV-1 or HSV-2 infected cells.

(V) Treatment

1. General Treatment. This mainly includes the following:

① To prevent secondary bacterial infection, the vesicle walls should be kept intact and clean, and kept as dry as possible. For lesions on the thighs, buttocks, and genitals, gently wash with isotonic saline 2-3 times daily, pat dry, and take special care to prevent the vesicle tops from sloughing off.

② If secondary bacterial infection occurs, appropriate antibiotics are required.

③ Local analgesia can be achieved with local anesthetics, such as 5% lidocaine hydrochloride ointment, but some patients still require oral analgesics; provide psychological support and explain the treatment and management methods for recurrence.

④ Female patients with recurrent genital herpes require gynecological examination, including regular cervical smear tests for early cervical cancer.

2. The clinical efficacy of interferon is still under investigation. Recent reports indicate that a double-blind trial of interferon for acute recurrent genital herpes showed a shortened healing time in 81% of patients, but it did not delay recurrence. Literature recommends a single dose (6 × 10⁶ U) as more appropriate. Flu-like symptoms, mild transient leukopenia, and thrombocytopenia may occur after treatment.

3. Antiviral therapy: Acyclovir (ACV) selectively inhibits viral replication. In severe cases, intravenous injection is more effective than oral or topical application. The dosage is 2.5–7.5 mg/kg, every 8 hours. The currently recommended dose is 5 mg/kg/day for 5–7 days. Three days of injection can reduce the virus in the rash, alleviate pain, dry and heal lesions, and reduce inguinal lymphadenopathy. For general patients, the oral administration is 200mg five times a day (once every four hours during the day) for 7-10 days. This rapidly reduces the viral load, alleviates symptoms, and shortens healing time. Intravenous injection is generally not used. For recurrent cases, psychological therapy is also necessary in addition to medication. For cutaneous and mucosal herpes, topical application of 5% ACV ointment can rapidly reduce the viral load, alleviate pain, and dry out skin lesions.