Genital Herpes

What is genital herpes?

Genital herpes is a common, long-term infection of the genital and anal area caused by the herpes simplex virus (HSV). There are two types of this virus. HSV-2 is the type most often linked with genital herpes, while HSV-1 is the type that usually causes cold sores around the mouth but can also infect the genital area, most often through oral sex. Once the virus enters the body it stays in the nerve cells for life. Much of the time it is inactive, but it can become active again and cause new outbreaks of sores or blisters.

Genital herpes is a sexually transmitted infection (STI), meaning it spreads mainly through sexual contact. It affects adults of all ages, genders and backgrounds, and it is one of the most widespread STIs in the world. Many people who carry the virus do not know they have it because their symptoms are mild, are mistaken for something else, or never appear at all. Although genital herpes cannot be cured, it can usually be managed well with medicine, and most people who have it live full and healthy lives.

Genital herpes symptoms

Genital herpes symptoms vary widely. Some people have painful, obvious outbreaks; others notice only slight irritation or nothing at all. Symptoms may appear a few days to a few weeks after the virus is passed on, though in some cases the first noticeable outbreak happens months or even years later.

Common symptoms during an outbreak include:

• Small blisters or sores on the genitals, buttocks, thighs, anus or, less often, the mouth
• Blisters that break open, leave shallow open sores (ulcers) and then crust over and heal
• Itching, tingling, burning or pain in the affected area before or during an outbreak
• Pain or stinging when passing urine, especially if urine touches a sore
• Unusual vaginal or penile discharge
• Swollen, tender lymph nodes (small glands that help fight infection) in the groin
• Flu-like symptoms such as fever, headache, body aches and tiredness

First outbreak. The first episode is often the most severe. It may last two to four weeks and is more likely to include flu-like symptoms, multiple sores and swollen glands. Some people, however, have a very mild first episode that they barely notice.

Recurrent outbreaks. Later outbreaks are usually shorter and milder, often lasting about a week, with fewer sores and little or no fever. Many people notice warning signs called prodromal symptoms, such as tingling, itching or shooting pain in the legs, hips or buttocks, hours or days before sores appear. The number of recurrences tends to fall over time, and genital HSV-1 infections generally recur less often than HSV-2 infections.

No symptoms. Many people carrying the virus never notice symptoms. The virus can still be present on the skin and passed to a partner during these periods, which is called asymptomatic shedding. This is one reason genital herpes spreads so easily.

Causes and risk factors

Genital herpes causes come down to one thing: infection with the herpes simplex virus, most often HSV-2 and increasingly HSV-1. The virus passes from person to person through direct skin-to-skin contact with an infected area, usually during vaginal, anal or oral sex. It can be transmitted even when no sores are visible, because the virus can be present on normal-looking skin.

Common ways the virus spreads include:

• Vaginal or anal sex with a partner who has genital herpes, with or without visible sores
• Oral sex from a partner with a cold sore or oral HSV-1 infection, which can cause genital HSV-1
• Genital-to-genital skin contact without penetration
• Rarely, from a mother to her baby during childbirth (neonatal herpes), which is a serious condition

The virus does not survive long outside the body, so it is very unlikely to spread through toilet seats, towels, bedding or swimming pools.

Factors that may increase the risk of getting genital herpes include:

• Having sex without condoms or dental dams (thin latex sheets used during oral sex)
• Having several sexual partners, or a partner who has other partners
• Starting sexual activity at a young age
• Having another sexually transmitted infection, which can make the skin more vulnerable
• Having a weakened immune system, for example from HIV, cancer treatment or medicines that suppress immunity
• Being female, because the virus passes more easily from men to women than the other way round

Factors that may trigger a recurrence in someone who already has the virus include illness, fever, stress, tiredness, menstruation, friction from sex, sunburn and a weakened immune system. Triggers differ from person to person, and outbreaks sometimes happen without any obvious cause.

Genital herpes diagnosis

Genital herpes diagnosis begins with a doctor or nurse examining the affected area and asking about symptoms, sexual history and any previous outbreaks. Because herpes sores can look like other conditions, such as ingrown hairs, syphilis, yeast infections or allergic reactions, a physical examination alone is often not enough, and laboratory tests are usually recommended to confirm the diagnosis.

• Swab test (viral culture or PCR). A sample of fluid is taken from a blister or sore with a cotton swab. The sample is sent to a laboratory to look for the virus. PCR (polymerase chain reaction) is a very sensitive test that detects the virus’s genetic material and can also tell HSV-1 from HSV-2. Swabs work best when taken from fresh sores within the first few days of an outbreak; older, healing sores may give a false negative result.
• Blood test (type-specific serology). This looks for antibodies, the proteins the immune system makes in response to the virus. It can show whether someone has been infected with HSV-1 or HSV-2 at some point, but it cannot tell where on the body the infection is or when it happened. Antibodies can take several weeks to appear, so a test done too soon after exposure may be negative. Doctors usually reserve blood tests for specific situations, such as when a person has symptoms but a negative swab, or when a partner has herpes.
• Testing for other infections. Because STIs often occur together, your doctor may suggest testing for other infections such as HIV, syphilis, chlamydia and gonorrhea at the same time.

Imaging scans are not used to diagnose genital herpes. In hospitals, this condition is generally managed by infectious disease specialists, dermatologists (skin doctors), gynecologists, urologists or sexual health clinics. At Acibadem, care for herpes and other sexually transmitted infections is coordinated through the Infectious Diseases Department.

Genital herpes treatment options

There is currently no cure for genital herpes, because no medicine can remove the virus from the nerve cells where it rests. However, genital herpes treatment can shorten outbreaks, ease symptoms, reduce how often outbreaks happen and lower the chance of passing the virus to a partner. Treatment is tailored to each person, and your doctor will discuss which approach fits your situation.

Observation and self-care. Mild outbreaks sometimes heal on their own within one to two weeks without prescription medicine. Self-care measures that may ease discomfort include keeping the area clean and dry, wearing loose cotton underwear, taking warm baths, applying a cool compress or petroleum jelly to sores, taking over-the-counter pain relievers such as acetaminophen or ibuprofen if suitable for you, and passing urine in the bath or shower if it stings. Avoid touching sores, and wash your hands afterwards if you do.

Antiviral medication. The main treatment is a group of medicines called antivirals, which stop the virus from multiplying. The three most commonly prescribed are acyclovir, valacyclovir and famciclovir, taken as tablets. They are used in two main ways:

• Episodic treatment means taking a short course of tablets, usually for a few days, as soon as an outbreak begins or when warning signs appear. Starting early, ideally within the first day, gives the best chance of shortening the outbreak.
• Suppressive treatment means taking a tablet every day to prevent outbreaks before they start. Doctors may suggest this for people who have frequent or severe recurrences, who find outbreaks distressing, or who want to reduce the risk of passing the virus to a partner. Daily suppressive therapy significantly reduces but does not completely remove the risk of transmission. Treatment is usually reviewed after a period of time to see whether it is still needed.

For the first outbreak, doctors generally recommend a course of antiviral tablets regardless of how severe it seems, because the first episode is often the longest. Antiviral creams are not usually recommended for genital herpes, as they are much less effective than tablets. Antivirals are generally well tolerated; side effects, when they occur, are usually mild, such as headache or nausea. People with kidney problems may need adjusted doses.

Severe or complicated infections. In rare cases, for example in people with very weak immune systems or when the infection spreads beyond the skin, hospital treatment with antiviral medicine given through a vein may be needed. Very rarely, the virus becomes resistant to standard antivirals, and alternative medicines may be used.

Pregnancy. Genital herpes in pregnancy needs careful management, because the virus can be passed to the baby during birth. Pregnant women with a history of herpes are often offered daily antiviral tablets in the final weeks of pregnancy to reduce outbreaks at the time of delivery. If sores are present when labor begins, a cesarean (surgical) delivery may be recommended. Women who develop a first-ever infection late in pregnancy face a higher risk and are monitored closely.

Surgery and rehabilitation have no role in treating genital herpes itself, apart from cesarean delivery in the situation described above.

Living with genital herpes and outlook

Learning that you have genital herpes can be upsetting, and feelings of shock, shame or worry about relationships are very common. It may help to know that the infection is extremely widespread, that it does not reflect on anyone’s character, and that for most people it becomes a minor, occasional inconvenience rather than a major health problem.

The long-term outlook is generally good. Genital herpes does not usually cause serious complications in otherwise healthy adults. Sores heal without scarring in most cases, and outbreaks tend to become less frequent and less severe over the years. In many people, recurrences eventually stop or become very rare, although this cannot be predicted for any individual. Herpes does not cause infertility and does not cause cancer.

Possible complications, though uncommon, include bacterial infection of the sores, difficulty passing urine during a severe outbreak, spread of the virus to the eyes or fingers through touching sores, and, very rarely, meningitis (inflammation of the lining around the brain). People with genital herpes may also have a somewhat higher risk of acquiring HIV if exposed, because sores make it easier for HIV to enter the body. Neonatal herpes remains the most serious complication, which is why pregnancy care is so important.

Practical steps that many people find helpful include:

• Recognizing your personal warning signs so treatment can start early
• Avoiding sex from the first tingling until sores are fully healed
• Using condoms consistently, understanding they reduce but do not eliminate the risk of transmission
• Considering daily suppressive treatment if outbreaks are frequent or if a partner does not have the virus
• Telling sexual partners, ideally before sex, so they can make informed choices
• Managing known triggers such as stress, lack of sleep and illness where possible
• Seeking support from a counselor or support group if the diagnosis affects your mood or relationships

Frequently asked questions

Can genital herpes be cured?

No. At present there is no cure for genital herpes because the virus remains in the body’s nerve cells for life. However, antiviral medicines can shorten outbreaks, reduce how often they happen and lower the risk of passing the virus to others. Research into vaccines and new treatments is ongoing, but nothing that clears the virus is currently available.

What are the first signs of genital herpes symptoms?

Early genital herpes symptoms often include itching, tingling or burning in the genital or anal area, sometimes with pain shooting down the legs or buttocks. Within hours or days, small blisters may appear, break open into sores and then crust over. A first outbreak may also bring fever, headache, body aches and swollen glands in the groin, though some people notice very little.

What causes genital herpes outbreaks to come back?

After the first infection the virus rests in nerve cells and can reactivate from time to time. Common triggers include illness, fever, stress, tiredness, menstruation, friction from sex, sunburn and anything that weakens the immune system. Triggers vary between people, and outbreaks sometimes recur without a clear reason. Over time, recurrences usually become less frequent.

How is genital herpes diagnosis confirmed?

Doctors usually confirm genital herpes diagnosis by taking a swab from a fresh blister or sore and sending it for a PCR test or viral culture, which detects the virus directly and can identify the type. A blood test for HSV antibodies may be used in certain situations, but it cannot show where the infection is or when it occurred, and it may be negative in the first weeks after exposure.

Is genital herpes treatment needed if symptoms are mild?

Not always. Mild outbreaks may heal on their own with self-care, and some people choose not to take medicine for every episode. However, doctors generally recommend antiviral tablets for the first outbreak, and daily suppressive treatment may be advised if outbreaks are frequent, distressing, or if you want to reduce the risk to a partner. Your doctor can help you weigh the options.

Can I pass genital herpes to a partner when I have no sores?

Yes. The virus can be present on the skin without any visible signs, a process called asymptomatic shedding, and this is how many infections are passed on. Avoiding sex during outbreaks, using condoms and taking daily antiviral medicine all reduce the risk, but none of these steps removes it entirely. Open conversation with partners is an important part of managing this risk.

Can I have a healthy baby if I have genital herpes?

Most women with genital herpes have healthy pregnancies and babies. The main risk is passing the virus to the baby during birth, which is uncommon when the infection is known and managed. Tell your maternity team about your history so they can offer antiviral tablets in late pregnancy and check for sores when labor starts. If sores are present, a cesarean delivery may be recommended.

When to see a doctor

See a doctor or visit a sexual health clinic if you notice blisters, sores, unusual discharge or persistent itching or pain in the genital or anal area, especially after a new sexual contact. Early testing gives the most reliable result and allows treatment to start promptly. You should also seek advice if a sexual partner has been diagnosed with herpes, even if you have no symptoms, or if you have genital herpes and become pregnant or are planning a pregnancy.

Seek urgent medical care if you experience any of the following:

• Inability to pass urine, or severe pain that makes urinating impossible
• Severe headache, stiff neck, sensitivity to light, confusion or drowsiness during an outbreak
• High fever with widespread sores, or sores that are spreading rapidly
• Eye pain, redness or blurred vision after touching a sore
• Sores that become increasingly red, swollen, hot or pus-filled, which may signal a bacterial infection
• Genital sores or a first-ever outbreak during pregnancy, particularly in the final weeks
• A newborn baby with blisters, fever, poor feeding, unusual sleepiness or seizures, especially if the mother has a history of herpes
• Severe or prolonged symptoms if you have a weakened immune system, such as from HIV or cancer treatment