Herpes or Balanitis? Test or no test?

[Worrid Well]

Hi there,

I am a 45 year old uncircumsised male who has bouts of what I beleive to be balanitis since my 20's.  

My symptoms are as follows:

Small red spots between the head of my penis and the foreskin, usually with an odor.  Sometimes the red spots are splotchy and are on the head of the penis.  Sometimes there are raised white spots, which never scab over, but rather either go away or "tear" with vigouris washing. The skin below is generally pink, but fades quickly and there is never any fluid in these raised spots.

There are never any clear blister-like vesicules.

This red rash or spots happen only on the head or ares covered by the foreskin.  Never on the shaft and doubtdful it is on the same place twice

I generally try to either keep this area completely dry or use a anti-fungal like lotramin when these symptoms first occur and they generally dissappear whihtin a few days.  This treament seems to stop any further spread of the rash.

I was diagnosed as having Balanitis about 5 years ago, and since then have treated myself as above.

Symptoms generally occur after having sex and not cleaning my penis afterward or not showering for a few days.  I usually have symptoms once or twice a year.

This condition has never really bothered me (especially since it was diagnosed) until recently.

Recently I had my normal Balantis symptoms, and decided to have the same urologist who diagnosed me 5 years ago just confirm again that it was Balanitis.  He looked at it and said it was "non-specific" and told me to use lotramin.   He then said just to be sure, I should have a HSV-1 / HSV-2 test done.  I am fairly knowledagble in this field and asked some specifics.  This doctor was not sure what to tell me if it came back HSV-1, thought that an ELISA test could give me a titer..etc.  I was not impressed.

I  would only consider getting an HSV-2 test done, and only then would I get the HerpeSelect HSV 2.  I also know that this  product has a Positive Predictive Value of 85% (or a false positive rate of 15%) in a prevelance rate of about 15% (which is where I figure a 45 year old male would be). I also know that the prevelance in the generally population for me is about 17%.

I am extremly reluctant to have a test done that has a PPV value that is pretty much equal to the positivity rate in the general population. There is as much chance of getting a false positive as a true positive.

I am not at any high risk factors for Herpes other than having more than 5 sexual partners (in long term relationships) over the last 20 years, and I am recently married.

I to not want to put my wife in any risk at all for contracting HSV,and therefore have contimplated getting the HSV-2 test done, but I also do not want to have the tremendous stress of receiving a possible false postive result.

I plan on having another doctor examine me later today, and would really value your opinion on what I should do.        

[H. Hunter Handsfield, M.D.]

If you are happy with the conclusion in favor of balanitis and not herpes, I don't know why you posted your question in the first place.  You said you were concerned about the possibility of herpes and I advised you how that question can be resolved with greater certainty.  But I don't care in the slightest whether or not you get tested for HSV-2.  However, the performance characteristics of the test are not valid reasons not to do so.

This is my last reply on this thread.

[Worrid Well]

Dr. HHH and all,

Please understand that I am not questioning the rational for serological testing.....if it is based upon a proper examination and is consistant with history.

All diagnostic tests can have false positives and false negatives.  None are perfect.  That's why they should be done in the context described above.

In my case, I did get a second opinon from my own doctor yesterday who told me that the rash I had was not herpes, but instead Balanitis.  So in total, I have been diagnosed 3 times as having Balanitis from 2 different doctors, and 1 time as probably having Balantis,..... but just to be sure, get a HSV-1/ HSV-2 test (this from the same doctor who thought it was Balantis several years ago).  

Based upon no clinical history other than Balantis, and having no high risk behavior, I feel that being tested for HSV -2 would be the equivalant to being randolmy screened for HSV-2, which is clearly not indicated for the general puplic.

False positives do occur with the HerpeSelect product as in all tests, and while Dr. HHH and I probably don't agree on how often this happens, it occurs most of the time in patients with a low risk for having HSV-2.  

Confirmatory tests can be done as well, but again, Western Blots can be indeterminate and while I think PCR would provide a definitive diagnosis, it must be taken from an active lession, which I have never had.

Based upon the fact that my red spots and white spots never occur in the same place twice, respond very well to lotrim or similar antifungals, and never appear as lessions, and based upon 2 diagnosis of Balanitis and 1 diagnosis of 'probably" Balanitis, I am comfortable that this is in fact what I have.      

[t1234]

The problem I've seen is that many STD Labs (Clinics) and STD Testing Web Sites are in fact diagnosing people with genital herpes based on these these marginal numbers.  Some use inflammatory adds "YOU MAY HAVE HERPES AND NOT KNOW IT" which
scares people into testing.

I seems to me there should be strong warnings issued by either
the test manufacture or the CDC regarding the use of these tests.  There are a lot of people walking around thinking they have genital herpes when they don't.

[HHH,MD]

To clarify, with thanks to JustToBeSure in the thread just after this one (above):  The PPV as stated in the package insert is also affected by the optical density ratio cut-off for positive, negative, or indeterminate results.  FDA does not formally recognize "indeterminate", and at the time of the initial studies behind the package insert data, this was not known to be a problem.

My comment about never seeing a false positive result was meant to refer only to tests with OD ratios 3.5 and higher.  Results from 1.1 to 3.5 are not called positive (because many indeed would be false positive), but indeterminate.  Indeterminant results generally can be sorted out easily with additional testing.

My bottom line advice remains the same:  Blood testing for HSV-2 remains the only way to sort out your diagnostic dilemma.  The risk of a false positive result should not, in itself, dissuade you from being tested.

Sorry for any confusion--   HHH, MD

[H. Hunter Handsfield, M.D.]

Data in diagnostic tests' package inserts often are biased toward very conservative results.  In this case, the package insert information assumes the Western blot to always be accurate.  In fact, when HerpeSelect is postive but WB negative, almost always it is WB that is wrong.  But since WB was the designated standard for the analyses the company submitted for FDA approval, the regulations require such results to be classified as false positives.  I repeat that I have never seen a patient with a false positive result; and that when there is doubt about the meaning of a positive test, there are ways to sort it out.

Get tested.  I won't have any further comments unless/until youcome back to post the results.

HHH, MD

[Worrid Well]

Thanks for the reply doctor, however, the PPV values of the HerpesSelect product I quoted are from the Package Insert.  The PPV varies from 97.0% in 50% prevelance population (3 % false positives)to 62.8% in a 5% prevelance population (37.2% false positives.

If there are no other clinical symptoms, the thought of a false positive and then weeks or months waiting for a confirmation by a Western Blot or PCR seems tremendously stressful.  

[H. Hunter Handsfield, M.D.]

From your description, I agree herpes is not likely and you probably have recurrent nonspecific (or perhaps yeast) balanitis.  The way to sort this out is to go ahead with the HSV-2 blood test.  You mis-quote the positive predictive value, which is closer to 99%.  In 10 years using the Focus HerpeSelect assay in my clinic, including the years before it was FDA approved and on the market, I have never once seen a false positive result.  Every positive result was either clinically consistent with HSV-2 infection or was confirmed by additional testing.

But even if PPV were only 85%, you still can rely on a negative result, which is what you should expect.  In other words, if negative, you can be confident your problem is not genital herpes.  If positive, then you can address secondary diagnostic approaches, if your provider believes they are indicated.  Those can include confirmatory serological testing with Western blot, or awaiting the next apparent outbreak and getting examined promptely (within 1-2 days) for viral culture or PCR.

Bottom line:  Have the serological test.  Most likely it will be negative and you'll be home free.  And if positive, you definitely want to know it; the stress and inconvenience are trivial issues compared with potential herpes transmission to your wife.

Good luck--  HHH, MD