Herpetic proctitis is primarily a problem of first-episode herpes, generally in someone who acquires the infection through receptive anal sex. Some cases of rectal or anal herpes may have episodic proctitis as the main manifestation of recurrent herpes, but it probably is rare; I have never seen such a case. Most likely this is even less common with HSV-1 than HSV-2. However, no data are available on either initial manifestations or recurrence pattern for anorectal (as opposed to genital) HSV-1 infection. That is, recurrent outbreaks are uncommon with genital HSV-1, but I am not aware of any available studies or data about anorectal infection.
The symptoms you describe mostly suggest anal (external) more than rectal (internal) inflammation, except for the constipation part--but that could be due to anal sphincter reflex due to anal pain. You don't describe the other common symptoms of procititis: anal discharge, mucus or pus mixed with feces, or bleeding. I don't recall your previous thread and recent exposure history, but the symptoms you describe make me wonder whether you have a new infection, perhaps now with HSV-2. If you have been at risk for new STD, you might need diagnostic testing to be sure.
To your specific questions:
1-3) See above.
4) By all means follow up with a health care provider, as planned; and see above about testing. Specifically, if you still have active sores when examined, they should be cultured for HSV and, if positive, for virus type; if negative or if the lesions have resolved, request a type-specific HSV-2 blood test.
5) With all anti-herpes drugs, the first response when control is less good than expected is to increase the dose. It should be up to your doctor, but increasing to 1.0 g of valayclovir may be worth a try.
6) Asymptomatic genital shedding is uncommon with HSV-1, just as for symptomatic outbreaks. However, some people with genital HSV-1 (fewer than 10%) have outbreaks just as frequently as those with HSV-2; it stands to reason that those persons may also have increased frequency of asymptomatic shedding, but this has not been studied. And as I said above, it is unknown how all this plays out with anorectal HSV-1. All of which is a long-winded way of saying I cannot predict the transmission risk. However, I am confident that risk would be substantially reduced (but probably not eliminated) by condoms and anti-herpetic therapy.
7) My guesss is that 1.0 g (1000 mg) of valacyclovir would be more effective in preventing transmission than 500 mg; in fact, I normally prescribe the higher dose. There is reason to be suspicious that the main research study would have shown greater prevention effectiveness had a higher dose been used.
Thanks for the thanks. Best wishes-- HHH, MD
Dr.
Thanks for your detailed comments. In response
- I do not have pus or blood, just fissures, red tenderness and small blisters forming in a perfect circle around the anus. It hurts when passing a bowel movement. The feces is also hard and very dark. I have had problems in my lower GI most of my life and fissure are not uncommen, even before Herpes. Question: Could this mean that this could not be h. prutitis, but could be herpetic lesions around my anus that is external?
- I do not, nor have never practiced anal sex.
- I was diagnosed (cultured with genital HSV-1 3 years ago) and have had two outbreaks since the primary. First recurrent outbreak, two lesions in perineum area. No anal problems. The second outbreak (last week) more mimiced the primary outbreak with constipation, hard dark stools, fissues, blisters, redness around anus, and also had genital blisters - I was covered front to back.
- I had a blood test last week (HerpeSelect) and it came back yesterday with postive HSV-1 and negative HSV-2. My doctor also did a culture last week of the fissures and blisters around the anus - this should come back today. My last sexual encounter with over 3 months ago (I had sexual relation with a man 3 times, all using condoms). Question is if cuture comes back postive for HSV-1 or no herpes found I should be in the clear correct?
- Would you consider two outbreaks frequent in a three year timeperiod? Also could herpes in the anal area be triggered by IBS/IBD? So that I could be experiencing two separate diseases at the same time?
Thanks sorry for so many questions. You would be amazed on how much most doctors do not know about this disease. I have been through three due to them not being able to answer basic questions. I find myself educating them after I have read your comments on this website.
It doesn't matter whether I or anyone else would classify such outbreaks as "frequent". It's a good bet you have recurrent perianal herpes due to HSV-1. I can't comment on a possible relationship to IBS/IBD--whether that's the cause instead of herpes, whether you have both problems, or whatever; that's an issue for you to address with your doctor. If uncertain, you could take suppressive therapy (and stick with it consistently and see how well it prevents recurrences.
HHH, MD