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Genital herpes
Last reviewed: 23.04.2024
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For many years, genital herpes remained outside the area of attention of practitioners, which was primarily due to the inadequate capabilities of laboratory diagnostics of herpesvirus infection, the underestimation of the role of the herpes simplex virus (HSV) in human infectious pathology, and the lack of effective therapies.
[Epidemiology of genital herpes
Herpes is a common viral infection of a person and represents a serious medical and social problem. In the early 70s of the last century in the US and European countries, there was a sharp increase in the incidence of genital herpes, which by the 1980s increased 10-fold and amounted to 80 in England and France, and 178 cases per 100,000 in the United States . According to the WHO, the diseases transmitted by the herpes virus occupy the second place (15.8%) after the flu (35.8%) as the cause of death from viral infections.
It is now established that about 90% of the urban population in all countries of the world is infected with one or more types of herpes virus. Clinical manifestations of infection have 20% of them. Recurrent herpes infections are observed in 9-12% of residents of different countries. The highest incidence of genital herpes is registered in the age group 20-29 years and 35-40 years.
Causes of genital herpes
The causative agent of genital herpes are two serotypes of the herpes simplex virus: herpes simplex virus type (HSV-1) usually causes oral-labial herpes, herpes simplex virus type 2 (HSV-2) often causes genital lesions. Possessing neurodermatropism, HSV affects the skin and mucous membranes, the central nervous system, the eyes. HSV causes the pathology of pregnancy and childbirth, often leads to "spontaneous" abortion and fetal death. After infection, the virus is latent in a locally located sensitive ganglion and periodically reactivated, causing symptomatic lesions, or an asymptomatic but no less infectious virus release occurs. Infection with any of these viruses can cause an identical first episode of the disease. However, the frequency of subsequent recurrences is higher for infection with HSV-2 than with infection with HSV-1.
Infection occurs by contact, usually when the skin contacts the affected skin. The incubation period is from 2 to 12 days (an average of 6 days).
Given that during the incubation period and when the disease recurs, there is high contagiousness, it is necessary to refrain from having sexual intercourse at this time. The risk of transmission is higher from male to female. Primary infection with the HSV virus reduces the risk of seroconversion to HSV-2 in serodiscordant couples. Genital herpes is more common in women and in Negroes than in white. Genital infection caused by HSV-1 recurs much less frequently than with genital localization of the HSV-2 infection site, which is 95% of the total number of patients with recurrent genital herpes (RSH). For HSV is characterized by neurotropism (a tendency to live in nerve cells).
The main links in the pathogenesis of herpetic infection are:
- infection of sensory ganglia of the autonomic nervous system and lifelong persistence of HSV;
- tropism of HSV to epithelial and nerve cells, causing polymorphism of clinical manifestations of herpetic infection.
Under certain conditions, HSV multiplies in T- and B-lymphocytes of the patient.
In recent years, it has been established that HSV persists also in the epidermocytes of the skin, mucous membranes and secrets. Various clinical manifestations, the severity of the course of infection are explained by the peculiarities of local and general immunity.
Symptoms of genital herpes
50 -70% of patients infected with herpes simplex virus do not complain or complain of meager pain or burning. In the clinical course of HSV, it is customary to distinguish between primary and recurrent herpes.
Primary herpes is an acutely occurring disease in the first contact of a person with HSV in the absence of specific antibodies against it.
Primary genital herpes occurs predominantly in women in the form of vulvovaginitis, but the cervix can also be involved in the process. Primary herpetic vulvovaginitis is characterized by the appearance of pronounced edema and hyperemia of the large and small labia, the vaginal mucosa, the perineal region and, often, the inner surface of the thighs. There are pain, itching and dysuria, discharge from the vagina or urethra.
In men, primary elements are often located on the head, the body of the penis, the neck of the head, the scrotum, thighs and buttocks. Grouped bubbles appear first with a clear, and then cloudy content. After the opening of the vesicles, extensive erectile erosions are formed, having a round shape. Fusing, they form extensive ulcers with a wet surface. Defects of the epithelium heal in 2-4 weeks, leaving behind hyperpigmented spots. Scars usually do not happen.
When the urethral mucosa is affected, frequent urination appears and sometimes cystitis develops. At an atypical course, vesicles may be absent, and in the foreskin, hyperemia develops, burning, itching is observed. In severe course erosive and ulcerative lesions occur, swelling of the skin, severe intoxication, fever. Frequent relapses lead to lymphostasis and elephantiasis of the genital organs.
Such prodromal phenomena with recurrent genital herpes like burning or tingling precedes the appearance of rashes. With recurrent genital herpes, the elements of the rash are the same as in the primary herpes, they are less pronounced. Hyperemic plaque 2 cm in diameter covered with vesicles. After the opening, erosions are formed, which heal after 1-2 weeks. In case of relapse, the lesions are located in men on the body and the head of the penis, in women - on the large and small labia, in the perineum and on the inner thighs. The regional lymph nodes in the second or third week become enlarged, dense, painful, there is no fluctuation, the lesion is usually one-sided. When the pelvic lymph nodes are affected, there is pain in the lower abdomen. The disease is often accompanied by headache, fever, malaise and myalgia. In atypical forms of genital herpes, one of the stages of development of the inflammatory process in the outbreak (erythema, blistering) or one of the components of inflammation (edema, hemorrhage, necrosis) or subjective symptoms (pruritus), which give the corresponding name atypical form genital herpes (erythematous, bullous, hemorrhagic, necrotic, itchy, etc.).
In women, atypical forms are more common than in men. In most patients, genital herpes is atypical and is accompanied by signs that can easily be mistaken for signs of other genital infections or dermatoses.
The course of genital herpes
In the course of recurrent genital herpes, there are 3 degrees of severity:
- mild - exacerbation 3-4 times a year, remission not less than 4 months;
- medium-severe - exacerbation 4-6 times a year, remission - 2 3 months;
- severe - monthly exacerbations.
Reactivation of the virus after primary infection during the year occurs in 50-80% of patients. Antiviral drugs only reduce the titer of the virus, which the patient secretes into the external environment, and reduce the risk of transmission of infection 100-1000 times.
Histopathology
Pathomorphological changes are the same as with simple bubble dyspepsia.
What tests are needed?
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Treatment of genital herpes
Antiviral therapy should be used in all cases of diagnosis of genital herpes. Its objectives are to alleviate the symptoms of the disease, prevent complications and relapse.
Sex partners of patients with herpetic infection of the urogenital tract are subject to active detection. Treatment should be performed with clinical manifestations of herpes. It should be recommended to abstain from sexual intercourse or use condoms during exacerbations.
Treatment of the primary episode of genital herpes is performed with aciclovir, valaciclovir or famciclovir.
At the initial episode of genital herpes, aciclovir (ulcaryl, herpesvir, etc.) is used 400 mg 3 times a day or 200 mg orally 5 times a day for 7-10 days (in the USA) or 5 days (in Europe). At the same time, the duration of virus isolation and clinical manifestations is reduced. In addition, acyclovir may affect the course of neurological complications, such as aseptic meningitis and urinary retention.
In practice, proteflasitis, which exerts antiviral and immunocorrective action, is widely used. The drug is prescribed for 15-20 drops 2 times a day. The effectiveness of therapy increases with the application of proteflasitis to the lesion.
In severe cases, accompanied by neurological complications, acyclovir is administered intravenously at 5-10 mg / kg 3 times a day. A comparative study of the use of a high oral dose of acyclovir (4 g / day) and a standard dose (1 g / day) for the treatment of genital herpetic infection did not reveal any clinical advantages of a higher dose.
In the US, valaciclovir is approved for the treatment of a primary episode of genital herpes at a dose of 1000 mg twice a day for 7-10 days.
The use of 250 mg of famciclovir 3 times a day for 5-10 days is just as effective in the primary episode of genital herpes, as is the use of acyclovir.
During recurrences of the disease, acyclovir is administered orally 400 mg 3 times daily or 200 mg 5 times daily for 5 days. Although this treatment results in a reduction in the duration of virus isolation and manifestations of symptoms of individual episodes, the removal of the interval between relapses does not occur.
Valacyclovir is recommended for occasional treatment of recurrent genital herpes at 500 mg twice daily for 5 days.
Famciclovir is used as a means of episodic treatment of recurrent genital herpes at a dose of 125 mg orally twice a day for 5 days.
Preventive treatment of genital herpes
Preventive (preventive, suppressive) treatment of genital herpes consists in the use of acyclovir, valaciclovir or famciclovir in a continuous continuous regime. Such treatment is indicated to patients with a frequency of exacerbations from 6 episodes a year.
Daily intake of 400 mg of acyclovir orally 2 times a day prevents the development of recurrences of genital herpes. With this use, the frequency of exacerbations decreases by 80%, and in 25-30% of patients during the entire period of acyclovir, they do not occur at all.
Valacyclovir is recommended for suppressive therapy at a dose of 500 mg orally once a day (for patients who have no more than 10 relapses per year) or once a day (for patients who have more than one relapse per year).
Famiyclovir is also effective in suppressing recurrent genital herpes at a dose of 250 mg orally 2 times a day.
External treatment is the same as with simple vesicle abscess.
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