Symptoms questions

Dr.

Just some curiosity questions about herpes symptoms.  I've read so many different things online and wanted some more info.  I'm aware of the classic symptoms(prodrome, blistering, sores) but have read about other things that may indicate an infection-also read things about very mild symtpoms that may go ignored.  What might these be?  I've read flu like symptoms can occur on the first onset, painful urination and penile discharge, red rash, etc.  Are the painful urination and discharge from having sores inside the urethra?  I've read this can happen and since they're not outwardly visible, they can be missed and that if there are sores, they're near the opening of the urethra.

I'd appreciate any light you can shed on this sometimes confusing topic.  

PS This is a great forum and provides alot of useful info-thanks for helping!

[H. Hunter Handsfield, M.D.]

Wow--that's a big question--probably bigger than you know, because it is at the core of why people are frightened by this usually very mild disease.  I understand your uncertainty, but it's hard to shed much light briefly.  But here goes.

Simply put, herpes causes a breakdown in the skin or mucous membranes (the moist internal surfaces) of the genitals.  Symptomatic herpes occurs when the breakdown is painful or large enough to see easily.  But very small lesions or those inside certain organs--especially in the vagina or rectum--may not cause any symptoms.  Other lesions are outside, but are micrscopic and cause no visible abnormality or pain.  Still others may mimic other conditions, for example a "zipper burn" in men, a pimple in the genital area, etc; and still others may occur outside the usual areas, such as the buttocks or near the anus, and aren't noticed or the infected person doesn't consider them abnormal.  Some people are just more genitally aware than others.

The bottom line is that most people with genital HSV-2 infection are unaware of it.  If the diagnosis becomes apparent by blood test, or because a partner gets infected and there is only one possible source, many such persons come to recognize mild symptoms that they didn't notice before.  But some infected persons are truly asymptomatic and remain that way forever.  In addition, most people with symptomatic outbreaks of herpes also have non-symptomatic outbreaks, periods of "asymptomatic shedding" of HSV-2.  In other words, persons with overt recurrent herpes often can transmit the infection to their partners in between those outbreaks.

I know this isn't very reassuring.  The notion of having an asymmptomatic STD and being able to transmit it without awareness is one of the chief reasons genital herpes is so anxiety-producing and stressful, beyond the physical effects of the disease.  But remember the silver lining:  If you get herpes, it may be so mild you don't even know it.  In other words, most cases are not serious beyond the stress and anxiety that they cause.

Bottom line:  Many unexplained and very mild genital symptoms can be due to herpes.  To answer your specific question, yes, painful urination and genital discharge are among those symptoms.  Anybody with almost any genital symptoms that feel or look like irritation of the skin or mucous membranes should be tested for herpes, especially if tests for other obvious causes (e.g., chlamydia, gonorrhea, syphilis) are negative.

Finally, despite the difficulties in recognition and diagnosis, there still are many effective prevention measures.  These include being on the lookout for even mild symptoms and avoiding sex when they are present; using condoms; and using antiviral therapy to control symptoms and help prevent transmission.  [Only valacyclovir--Valtrex--has been proved to prevent transmission, and is the drug of choice for this purpose; but the odds are that the other oral drugs, acyclovir (Zovirax and others) and famciclovir (Famvir) would also help reduce the risk of transmission.]

For more comprehensive information about herpes, see the link at the top of this form (STD information from Public Health - Seattle & King County); or visit the American Social Health Association's website http://www.ashastd.org.  CDC, NIH, and numerous other agencies also have accurate herpes information on their websites.

Good luck--   HHH, MD

[DEANMACHINE]

Thanks for your candor-albeit kind of scary!  What is the best/most accurate blood test for herpes?  Is it alos true that any outbreaks would occur at the site the virus entered the body, i.e. you'd get them around the rectum from anal sex, on the genitals from normal intercourse, etc.

[H. Hunter Handsfield, M.D.]

Except in special circumstances, the only blood tests that are valid for diagnosing herpes simplex virus infection are those that measure antibody to HSV glycoprotein G, or gG.  (For those medically trained persons who might be reading this, I don't mean immunoglobulin G or IgG, which is entirely different.)  The only widely marketed gG test is the one produced by Focus Technologies.  So make sure your doctor orders the Focus blood test by name.  There are other accurate gG tests (e.g., using Western blot and other technologies) available in individual laboratories, but they are expensive and generally are used only for research or other special purposes.

Initial herpes usually is restricted to the site(s) of inoculation--e.g., penile sores if the penis was exposed.  But recurrent herpes can occur in sites not originally exposed.  For example, some heterosexual men with genital herpes, who have never had anal sexual exposure, can get recurrences around the anus.  Likewise, a woman can acquire herpes in the genital area but experience recurrences on the buttock or near the anus.  However, these are the exceptions.  Most recurrences for genitally acquired infection are on or immediately adjacent to the genitals.

Nothing is simple in herpes!

HHH, MD

[not_sure]

my health has always been perfect except this past week I noticed, in two areas near my anus, a strange almost sore sensation to touch-but nothing is visisble. I don't notice it, except when I inspect it I often rub the area, which seems to irritate the area and it becomes sore. I'm terrified now that I have herpes. HELP! does it sound like it is herpes, or is it possible that it is something else.