HSV-1 and Herpetic Proctitis

[9848]

Dr.,

I posted a query about a week ago and have a few follow up questions.  I contracted genital HSV-1 about three years ago.  I had a primary (very bad) that was cultured and positve for HSV-1.  I immediately went on valtrex (at the time I thought I might be able to give to my boyfriend who I contracted HSV from, he had a history of cold sores).  I did not have an outbreak until approximately a year later (I went off the valtrex approximately 5 months prior).  This outbreak was in the perineum area and on one side.  I was on and off valtrex (500mg) for the next year and a half and had one other outbreak recently (not on valtrex when this happened). This outbreak was like my primary, I had constipation, anal redness and irritation, fissures and small blisters that formed a circle around the anus, on both sides.  I have had a history of lower GI problems (IBS, constipation, loose bowels and occasionally anal irritation and fissures).  

This week I went in for a culture and had a HerpeSelect blood test done to make sure I did not have HSV-2.  Test was negative for HSV-2 and positive for HSV-1.  This test was done three months after my last sexual episode (in which protection was used). My questions are:

1.  Could I have herpetic proctitis?  I am a 38 year old female who has never had anal sex.

2.  If it is h. proctitis, is this rare (I have HSV-1)?  Is this any more serious than getting it on other parts of ones genitals?  Does this make me more contagious than having it on other parts of my genitals?

3.  I would not call have 2 outbreaks over the course of 3 years frequent, and hopefully I will fall under the percentages of the 50-60% of folks with genital HSV-1 who have a primary and 1 or 2 outbreaks over the course of a couple of years.  Do folks with h. proctitis tend to have more outbreaks?

4.  Should I continue to have any redness in the area cultured to see if it is in fact h. proctitis?  I do plan to make an appointment with a specialist to rule out other rectal conditions.

5.  While on valtrex (500mg) I would still get irritation in the anal area (redness around anus, feels like rug burn, although no blisters).  Not sure if these are mini breakouts.  Should I go on 1000mg dosage to see if these symptoms are wiped out?

6.  With genital HSV-1, if one has infrequent outbreaks (1 per 1.5 - 2 years), what is the likelyhood of transmission when one is on valtrex and uses condoms? Is there shedding of genital HSV-1 when outbreaks are not present?

7. Would a higher dose of valtrex (1000mg vs 500mg) provide more protection for a partner?

I am going crazy trying to pinpoint what is herpes and what is not.  The two recurrent episodes mentioned above looked like herpes and felt like herpes.  I am pretty good at noticing things on my body, but with these other digestive issues it is hard not to be paranoid.

Thank you for this service! No one else seems to be as knowledgeable about genital HSV-1....  

[H. Hunter Handsfield, M.D.]

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

[9848]

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.

[H. Hunter Handsfield, M.D.]

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