HSV locality

[tfe]

Hi Doctor,

Thank you for your time answering questions. I was wondering if the specific site that a person contracted herpes (penis and surrounding area, rectum, etc) is where the virus will recur in the future?

Also, a lot of resources say that people experience a delay in primary infection (or don't experience it all) and some people get very severe flu-like symptoms.  Have you noticed that one is more common? For example, do most people get a primary infection within the 2-3 week period?

And lastly, for a male, if he was to get herpes in an area other than the penis or its immediate surrounding, would it still have the potential to cause problems urinating, discharge, etc?

Thank you.

- F.

[Csaw]

Just for clarification, which type of HSV could I have potentially contracted from receiving unprotected fellatio, 1 or 2?

[H. Hunter Handsfield, M.D.]

Your symptoms don't sound like herpes, but did either doctor do a blood test?  See numerous other threads about the right kind of test.  A negative HerpeSelect test for HSV-2 will confirm you definitely don't have it.

HHH, MD

[Csaw]

I had an encounter back in December, and since have seen my PCP 4 times and my dermatologist 2 times and either one of them have been able to confirm that I have HSV.  About once a month I go 3-4 day periods where the tip of my penis will get a "stinging/tingling" sensation and the skin will get a little "reddish" in color.  In some light, it looks like parts of the meatus are discolored.  I've never had a breakout of any kind and no unusual discharges.  At this point I don't know what to think.  Both Doctor's suggested I relax and the sensation will eventually subside.  It's been almost 5 months, I don't know how much longer I should wait to seek a third opinion...

[H. Hunter Handsfield, M.D.]

The evaluation you describe is not at all reassuring.  A digital rectal examination is worthless in detecting any STD.  Visual inspection is a little better, but requires a clinician who knows what to look for, and should include anoscopy, i.e. using a short tubular device to look inside.  Even so, visual inspection with anoscopy probably will pick up an abnormality in fewer than 20% of people with an anorectal STD.  You need specific laboratory tests for specific diseases.

Anal intercourse is inherently traumatic, more so early in gay men's sexual careers.  Over time, the sphincter accommodates and the potential for injury is lower, although anorectal trauma always remains a much higher risk than vulvovaginal injury through vaginal intercourse.   So, yes, your symptoms could be due to a fissure or other traumatic injury; hemorrhoids also are an "occupational" hazard associated with anal sex.  However, fissures and hemorrhoids probably WOULD have been seen or felt by your doctors.

I disagree with the reasoning of your sources "privy to STD knowledge", as you describe it.  Neither herpes nor the other possibilities are trivial in their import.  If nothing else, anyone with untreated rectal herpes, chlamydia, gonorrhea, or syphilis has a much greater risk of becoming infected with HIV if exposed.

So, yes, I would go to the STD clinic; or find another provider who knows a lot about STD in general and rectal problems in gay men in particular.  The odds are good your tests will be negative, but it would be a mistake to just assume it.

HHH, MD

[tfe]

Thank you yet again for more informative responses.

I had a urologist check me out, but he said because of the lack of any penile discharge/staining, discomfort urinating/ejaculating, swollen epidis, etc.., that I don't have anything. Since my last unprotected exposure was several months ago, he said anything would have manifested itself (and would have done so differently) by this point in the game. (I only asked about the symptoms of discharge, urination problems strictly rhetorically in my first post).

After my unprotected exposure around 10 weeks ago, I was checked out for lesions/STD symptoms by means of a digital exam within a few days of my exposure and was assured that there wasn't any sign of any lesions/openings, nor an STD infection (but this was visually and not via blood test, etc)

I had a protected (prolonged) anal exposure since my 10 week ago unprotected exposure, for the first time, without much lube (just spit) -- would a cut from that (or just hard stool) cause a tiny painless bump that won't go away? (I think you mentioned fissures in related posts)

I guess my only concern is herpes. I mentioned that I had rectal discomfort to my GP. He did a non-digital visual examination and said that there wasn't anything he could see as being wrong, and several people who are privy to STD knowledge said that based on the non-severity, persistent nature of the symptoms, plus the location of the bump, my stress and the timeframe from exposure, that herpes seems unlikely. (Esp since we only had unprotected skin-to-skin contact for 10-20 seconds; and the other protected exposure involved virtually no skin-to-unprotecte-dskin contact)

Given the lack of any problems but rectal discomfort and the assurance of my GP and urologist, should I go to a local STD clinic or just move on with life?


- F

[H. Hunter Handsfield, M.D.]

One of the consistent characteristics of herpes is its recurrent nature, i.e. intermittent symptoms with complete normality between outbreaks.  Nevertheless, the initial episode can last as long as 6 weeks, and anal or rectal herpes is very common in gay men.  Your symptoms are suggestive of gonorrhea or chlamydial infection as well as herpes, and syphilis also is a fair bet.  You need to be tested for all of these.  (Rectal testing for chlamydia can be a problem; tests accuate for rectal specimens are not widely available, although that likely will change over the next 1-2 years.)  Your local health department STD clinic likely has the greatest expertise in such problems.

Best wishes--  HHH, MD

[HHH,MD]

I meant to be more specific in my challenge your "sources" on their reasoning about herpes.  Unchanging mild symptoms for several weeks is an argument against herpes, not for it; but is more suggestive of gonorrhea or chlamydia.

HHH, MD

[tfe]

Thanks for the diagnosis. Not the most ideal thing in the world to hear, though, but the truth hurts sometimes. I'll head to the state STD clinic tomorrow.

The "big two" I'm afraid of are HIV/HSV. I got HIV tested at 6 weeks, which is conclusive enough, but will get another this week at the 11 week mark, which should allay most doubts.

Then the big one is just HSV. It's reassuring that your evaluation (or at least suggestions, as evaluative as one can be over the internet to someone not capable of describing conditions with medical precision) seems to point away from that. I should add that I recall removing a strip of bloody skin from the itchy area (which may suggest a fissure perhaps?)

I'm hoping that with my lack of clear, definitive symptoms, the brevity of my single exposure and the odds in general are in my favor.

Thank you. What's worse is that this issue was non-consensual, so I hope I don't have to carry around scars from it forever. Prozac, here I come...

[tfe]

(My above post was made before your response, this was made after it)

Thank you very much for your detailed response. I only asked the above post because I think I might have acquired something perenially. Would a case of rectal/perennial herpes manifest itself  just inside the rectum and persist without pain (beyond an occasional mild 'itch') for many weeks unchanged?

Thank you again!

[tfe]

Also, was wondering if at either primary or "recurrent" stage if herpes would present itself as one "raised" area devoid of "clear fluid" that persists for roughly a month without bursting, scabbing over and healing

[H. Hunter Handsfield, M.D.]

Recurrent herpes emanates from persistent infection in a nerve ganglion.  The nerve associated with each ganglion serves a modestly broad area, and recurrent herpes can be anywhere in the distribution of skin or mucous membranes served by that nerve.  Therefore, it is common to acquire herpes, for example, in the vaginal area and have reucrrences, say, near the anus; or to acquire the infection on one part of the penis but have recurrences in a different spot.  But once a pattern of recurrent outbreaks is established, all subsequent symptomatic outbreaks generally occur in more or less the same spot.

The severity of the initial infection, including whether or not there are flu-like symptoms, is highly variable and not all the reasons are known.  One important factor is the presence of prior HSV infection.  This usually involves someone who already has HSV-1 then gets genital HSV-2:  they tend to have milder initial episodes, and less commonly have fever an flu-like symptoms, than those who have not had HSV-1.  Another factor may be the inoculum (i.e. the "dose" of virus received from one's partner), with higher doses meaning more symptoms and severity.  But most of the time there is no clear explanation; some people are just less lucky than others.

On the whole, out of every 100 people with newly acquired genital herpes due to HSV-2, about 20% will have fairly severe disease, with multiple painful lesions, swollen lymph glands, fever, and muscle aches; about 40% will have milder disease, without the flu-like symptoms; and 40% will have no symptoms.  Of the latter, most nevertheless develop symptomatic recurrrent outbreaks in the future.

Herpes almost never causes the symptoms you describe.  Once in a while, a male will first acquire herpes that involves the meatus (urethral opening) or the inside of the urethra itself.  This is excrutiatingly painful, but happily does not generally occur with recurrent herpes.  In other words, even with initial herpes that involves the penis, very few men would have recurrent symptoms of discharge or urinary pain; and it would be even more rare (virtually nonexistant) if the inital herpes were acquired some distance from the penis.

I hope that helps.  Best wishes--   HHH, MD