Worried

[swatelite]

Dear Doctor,

I have a few questions, so I hope you can help.

Yesterday I noticed an irritated/red spot on the under shaft on my penis

[poster12]

Hi Worried.
I'm interested to hear if you got any answers to your problem. I have an identical problem which is has been very stressful.
The area on my penis just below the head (just below the 'hole') has a reddened area. When my penis is flaccid, it's less noticeable, However, during an erection it is more prominent and after masturbation it becomes very red. I take extra care to make sure I do not touch this area during masturbation to see if it still becomes red and it does. I had a handjob and anal massage from a massage parlor several weeks back and am wondering if this could be herpes as well? ANY HELP is welcome!
I had a full STD and Herpes test at 1 week but that only presents past incidents. I made an appt. to have another test at 5 weeks but this is practically driving me crazy. Among other things, unrelated or so, my nail beds have developed redness towards the tops.

[t1234]

Thanks,

I appreciate your help.

[windyh99]

t,

You make some good points. By your argument, we can't say that some percentage never shed, we can only say that they didn't shed during the study. If you look at several studies, you'll see the trend. Shorter studies find fewer shedders than longer studies. I don't recall how long the longest shedding study is. It might be about three months. BTW, the reference below cites another study that found 100% to shed when they looked for longer than 100 days. I haven't read that one, so I don't know the details.

I think I understood what you were asking for, and Mertz' study was the closest thing I could find. Proving that someone never has symptoms rather than misses their symptoms would be a difficult thing to do. Likewise, sampling for viral shedding on a daily basis for a year or two is impractical.

Most people who are seropositive DO have symptoms, but they don't have classic outbreaks that are unmistakeably herpes. And those minimal symptoms correlate with documented episodes of shedding. Once they know what to look for, they can identify their outbreaks, but even then, they still have some episodes of shedding that neither they nor the clinician can identify.

We do know from animal studies that frequency and severity of symptoms is related to the total amount of viral dna latent in the ganglia, so in theory, it might be possible to become infected with a small enough dose of virus to seroconvert but not enough to cause recurrences. That's a really hard one to prove.

Here's a good review of shedding studies. Very readable. And it contains a reference to another study on shedding in women who are unaware of their herpes status, but it probably doesn't adequately answer your question. It has some good discussion about definitions of asymptomatic/subclinical shedding and some of the practical problems related to applying these definitions.

Herpes simplex virus: the importance of asymptomatic shedding
Koelle and Wald
J Antimicrobial Chemo (200) 45, Topic T3, 1-8


I don't know how long we're gonna be allowed to keep this up on this board. If you want, you can email me at windyh99 at yahoo .

[t1234]

Crazy, the accuracy of these tests from STD clinics is not
96 PER CENT IN PRACTICE. BLOOD IS SENT FROM THE CLINIC TO THE LAB AND MAY BE TEMPERATURE SENSITIVE.  ALSO THE TESTING EQUIPMENT HAS TO BE CALIBRATED.

Some labs use their own versions which are non FDA approved.

ANYONE WHO TESTS POSITIVE WITHOUT A HISTORY OF SYMPTOMS SHOULD HAVE IT CONFIRMED BY ANOTHER TEST AT ANOTHER LAB.

YOU WOULDN'T BELIEVE THE "HORROR STORIES" OF FALSE POSITIVES.

[t1234]

Windy99

Thanks, I'll look at them.  In fact I think I've already
seen some of them, but will look again.

I think I mis-stated my question.

The studies I've seen were done with persons who are
sero-positive and with or had had clinical symptoms.  As you know most people who are sero-positive have no clinical symptoms.

I would define non-clinical as no past outbreaks of ulcerated
sores confirmed by periodic psychical exmaninations by a physican during the study for a period of more than 1 year.

It may follow that sero-positive people have the virus (maybe) or were exposed to it.  But it doesn't automaticly mean that they represent any health risk to their partners.  In fact the study Dr. Patel referrs to tends to show they do not if you want to view it from a different bias (55 per cent never shed inspite of the fact nearly all of this group had clinical symptoms).  You can make another assumptions if you were biased in the opposite direction. Since only people with clinical symptoms rarely shed then people that were sub-clinical would never shed.  See what I mean.  

Assuming that if the test had been continued for another six months more people would have shed is not a valid assumption or is based on facts not in evidence.  

This is the problem assuming results from this tests that they just don't factually show. We don't know if more people would have shed by continuing the test unless we in fact continue the test.  

Also my understanding is that HSV1 and HSV2 are not the only virus in the herpes family that are sexually transmitted or widely distributed in the population.  They are just considered not a health risk except in very rare cases.  At one time HSV1 was not considered a health risk either.  At least until oral antivirals became widely available.

Also, just because a virus is present don't mean the viral load is a the level that's transferrable. Otherwise we'd all have Aids.

Will the above in mind I will look at the studies.

Thanks again.

[CRAZY BRAIN]

Man this is soo stupid. I AM SICK OF THIS! THE BLOOD TESTS CAN't TELL YOU 100% WHERE THE F___N DISEASE IS! ORAL SEX, HSV is possible.  THAT IS THE WHOLE POINT! AND YOU WANT TO DESTROY PEOPLE OVER THAT ****. IT DESTROYS PEOPLE! AND NO IF SOMEONE DOES NOT HAVE SYMPTOMS THEY SHED VIRUS LESS THAN SOMEONE THAT DOES!!!!! STOP THE BULLSHIT! F___THIS BS YOU GUYS ARE CRAZY!!! TELL PEOPLE THE SYMPTOMS!!! TELL THEM ABOUT PAIN, ABOUT ITCHING ABOUT RASHES,BLISTERS AND CUTS! TELL THEM THAT ! YOU GUYS ARE MESSING WITH LOTS OF PEOPLE AND IT IS WRONG. I AM MAKING SURE THE PEOPLE I KNOW THIS! ALSO WHAT DO BLOOD TESTS MEAN ANYWAY. SOME PEOPLE HAVE DIFFERENT BLOOD LEVELS SO WHAT?

[robert in atlanta]

I decided to write Ms Warren in an email and asked your question about practicing under docs.  She wrote back that in Oregon where she lives nurse practitoners don't practice under docs at all - nurse practitioners can have hospital priviledges on their own, prescribes meds, order labs and xrays, set up totally seperate practices from docs.  There is no relationships between them, unless they want to be related.  She said it varies from state to state but said lots of states are like that now.  She said she actually employs two docs in her practice and trains medical residents in her clinic.  Guess we all learned something new about those nurse practitioners today, at least I did!

I also think we might be looking at two different Anna Wald studies - the one I looked at definitely had men in it and 52 out of 53 asymptomatic folks who enrolled either recognized an outbreak or shed the virus during the study time.

[t1234]

Robert,

Thanks, Can you provide a link to the Dr. Wald study
you reference that has men.  I looked at a lot of them
but so far haven't found any that definitely shows
confirmed sub-clinical sero positive persons have or
shred the virus.

But am open minded and looking. Did you read the article from
my link?

Crazy, I think you are right.

Still, I don't understand what Ms. Warren as a nurse adds to a team of PHD's who are medical doctors, and experts in viral
research.  Why would they elevate her to their status? Don't they have on staff nurses?

Is she involved somehow in the funding of this research?

I just think these are fair questions so we know where everyone
is coming from?

[CRAZY BRAIN]

Exactly teach people how to recognise infection as most of the time it can be recognised. Why do they promote blood tests that are not %100 and don't teach the varied symptoms? That is the question you need to ask people. Also if you are not symptomatic you do not shed the virus as much so you are NOT AS CONTAGIOUS! Tell people that fact. This is what pisses me off for some reason they make this disease amorphous.

[windyh99]

About blood tests -
No blood tests are 100% accurate. Laboratory data has to be taken in context with the history and clinical findings. Sensitivity of 96% is considered very good.

About the number of people who shed -
The percentage of people found to shed without symptoms is proportional to the length of the study. The longer you look, the more you'll find.

Question for t1234 - Who's saying that seropositive for HSV doesn't mean that you're infected? I realize that may be the case for hepatitis and other viruses, but herpesviruses establish permanent latency in sensory ganglia. It only takes a few hours for the virus to find its way there upon inoculation.


Here's an early case study that documents an asymptomatic transmission. The source partner was enrolled in a study of acyclovir therapy and was examined by a clinician the day before and the day after the transmission occurred.

Acquisition of genital herpes from an asymptomatic sexual partner.
Rooney JF, Felser JM, Ostrove JM, Straus SE.
N Engl J Med. 1986 Jun 12;314(24):1561-4.


And here's a study of source partners that documents transmission from those with no history of symptoms (23 out of the 66 source partners.)

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2988143&dopt=Abstract
Sex Transm Dis. 1985 Jan-Mar;12(1):33-9.
Frequency of acquisition of first-episode genital infection with herpes simplex virus from symptomatic and asymptomatic source contacts.
Mertz GJ, Schmidt O, Jourden JL, Guinan ME, Remington ML, Fahnlander A, Winter C, Holmes KK, Corey L.


Here are some studies on shedding in men. These were published later than the Patel article, I think.

Herpes Simplex Virus Type 2 Shedding in Human Immunodeficiency
Virus-Negative Men Who Have Sex with Men: Frequency, Patterns,
and Risk Factors
Krone, Wald, et. al.
Clin. Infect. Dis. 2000;30 (February)

Genital Shedding of Herpes Simplex Virus among Men
Anna Wald,  Judith Zeh,  Stacy Selke,  Terri Warren,  Rhoda Ashley, and Lawrence Corey
JID 2002;186 (Suppl 1)

Frequency of Symptomatic and Asymptomatic Herpes Simplex Virus Type 2 Reactivations among Human Immunodeficiency Virus Infected Men
Timothy Schacker, Judith Zeh, Hui-lin Hu, Edgar Hill, and Lawrence Corey
The Journal of Infectious Diseases 1998;178:1616-1622

You can find the abstracts for these (and maybe full-text) at PubMed. Just put a few keywords in, like the author's name and the word herpes and they should come up.


windy

[robert in atlanta]

Darn if I can find in the CDC material that says the tests are not clear cut.  Crazy, could you help me with that one? I did find in Anna Wald's papers that over 98% of people who test positive for HSV 2 by that western blot will shed virus from the privates or have outbreaks down there, in 3 months time.  I did find another place in the CDC guidelines, while looking for your statement, that "additionally, these tests can be used to diagnose unrecognized infection and manage the partners of people with genital herpes".  It does say there are a few false positives, and I've read Terri Warren's statements saying that many times on WebMD.  I guess my thinking is that if I had herpes.  (like one in four adults in the USofA), then I would sure as heck rather find out through a blood test than infecting someone else. Course I already know I do!  But then I guess some people would rather live in ignorance until they do infect someone else, or infect a pregnant woman and then have her infect her baby.  That fella from England that writes in support of testing pregnant women at the IHMF site sure convinced me.  Seems its just a matter of personal preference for people - find out through a stick in the arm or using another person as the incubator.  Guess I'm just not big on science experiments involving unsuspecting folks, even if I'm real upset instead.  But then, that's just me.

[CRAZY BRAIN]

Go to the FACT SHEET for Herpes at CDC for the "clear cut". Also look at the blood test facts they are NOT 100% and they can cost a pretty penny that many people that have HSV don't have! Just b/c you have HSV 2 it does not mean you will transmit it. The risk is so small you are acting like it is a DEFINATE that you will. Plus the risks are lower than if you are syptomatic. In addition Mrs. Wald was stating facts on the research she did with her population. Hey man you could have HPV and transmit it to others. Do you know if have that? Also rememeber Western Medicine has reccomended things in the past like lets say for example Hormone Therapy for women. This was big in the 70's and well look at what they say about it now, causes cancer,they where wrong etc. I do not think that research based on small groups of people as in many of these HSV studies is appropriate. Most tests or medicines are not allowed to be released unless larger and more extensive studies have been done.  Once again HSV 2 blood test cannot tell you for 100% where it is located just that it probably is! Tell people the symptoms not that it could be any zit on your penis. Stop the maddness it is clearly upsetting many people! That is all I am asking. Just look at how many people are distressed by this un-clear information on this website alone. Ask Dr. Rockoff how many Herpes questions he has answered. You tell me this is not distressful the information that people are providing on the internet. Then you tell me that a blood test used alone, by itself for diagnosis that is not 100% SURE IT IS ON YOUR PENIS is useful. Think abou it! NP and MD are very often wrong.

[t1234]

Sorry, but I just read you post in detail.


If you know of a study that proves that subclinical people who are Sero Positive to HSV2= Infection or that they are in fact
contagious "post a link"  I am most interested.

I've been all over the web and can't find one frankly to my surprise.

Personally I am a "lay person", HSV2 negative, 60 years old, and as a matter of practice will not get sexually involved with anyone without a blood test for STD's including HSV2.  But I've seen first the trama this causes people when they find they are seropositive and told they have the disease.

I had always been told and assumed what you are saying is true.
But after the last women almost committed suicide, and several
front line Doc's said Seropositive did not mean infection, I started looking into it for myself

Therefore, I was very interested in the debate between Ms. Warren and Doctor Rockoff who until redirected by Ms. Warren didn't advise that subclinical sero-positive was meaningful.

Then searching some other sites, I found Ms. Warren was apparently not a physician.  In fairness, looking at her
post again, I think she used R.N. after her name.

But I felt "had".  I think Ms Warren's work may be beneficial, but do we really want nurses "counter-manding" doctors.  The public has been taught only licensed persons in the professional
fields of medicine, law etc can give advice.  I realize Nurse
practioners are a special case, but the last time I checked state law requires them to work under the direction of a licensed physician.  But in any case, any person who perports themselves as an expert and based on that expertise countermands a licensed physician in public view should clearly
identify themselves as what they are.

Frankly, I am still curious as the whether Ms. Warren has done
any consulting work or affiliated with any drug companys.  There's nothing wrong with.  A lot of Doctors are paid consultants.  But it's still a fair question.


Sorry you have contracted HSV2.

Thanks for your comment to my post.

[t1234]

I think there is a good article by Doctor Patel at the
following link.  You can view it there.

http://bmj.bmjjournals.com/cgi/content/full/314/7074/85#R14

As he  points out 55 per cent of the people in Dr. Wald's
study did not shed the virus.

Also you get click on the footnotes and get an copy of
the study.

For me, it raises a lot of questions.

One. This was done exclusively with women.  
Two. Almost all if not all of these people
were symtomatic (Women they assumed were
sub-clinical turned out to have symptoms).

Even then only 45 per cent of these women had the virus
in vaginal fluids and then then only on rare occassions.

From these study, I can't get to the point that Sero-positive
without clinical symtoms == contagious or even infection vrs.
exposure.

The only thing I can get from it is that on rare occassions 45 per cent of HSV2 symtomatic women have the virus present in vaginal fluids when then are not symtomatic.


Read it and let me know what you think.


Note:  an example of what Crazy is talking about is a recent study to determine the effectiveness of a certain antiviral in
perventing transmission of HSV2.  A "TV DOC" got on national TV, pointed out that of all the births in the U.S. 2000 babies get genital herpes from the birthing process and 80 per cent of the mothers don't even know they have the virus.

But never fear, "ACME" drug to the rescue. This drug is effective in preventing transmission in 40 per cent of the cases.

You can imagine the phones of managed care providers were ringing off the wall from scared mothers demanding HSV2 blood
tests and this drug.  With 20 per cent of white women and 45
oer cent of black women seropositive to HSV2 "ACME" sold a lot of drugs.


If you look back in the comments you will see a scared mother with a 2 year old with HSV1. Do you really want to socially
isolate a two year old in the family unit on what is at
best speculation.

Of this would be okay, as long as we're sure that people who  are Sero Positive and subclinical to HSV2 either are at  risk of transmission or actually have the desease.

Just having the anti-bodies may or may not = infection.  For example if I take Hepatitus A + B vaccine I will be positive
for Hepatitus anti-bodies, but don't have or will ever have the
desease.  All these depends on the disease, and to make that
determination for HSV2 a large study limited to persons who are proven to be subclinical via periodic medical examinations performed over a adequate period of time is needed. In additon, a control group woud be required.  Of course, it would probably be hard to get it funded because it won't sell any drugs.

Another example of the "hyping of drugs" is the current interest
in male menopause now that testosterone is available in non-injectable versions.  

[CRAZY BRAIN]

Thanks for the info, they do say the tests can be helpful but not clear cut. HSV 2 can be even though it does not like to be in the oral area as well as anywhere else. The cdc says the results are NOT CLEAR CUT! You can't do blood tests for HPV but more people have that...so WHAT? The point is is the emoitional distress greater than the actual disease and for many people it is.

[robert in atlanta]

I believe that Ms. Warren and Dr. Wald are co-authors and co-researchers on a number of herpes papers. She is also a nurse practitioner, not just a nurse, and I think nurse practitioners have a really bigger role than regular nurses, like they can prescribe medicine and things. I did a literature search on PubMed to see what I could find, and found Ms. Warren to be an author on six different herpes papers in journals including New England Journal of Medicine (2 papers), Journal of the American Medical Association, Journal of Infectious Disease, the FDA Consumer Magazine.  Dr. Anna Wald is also an author on four of thsse same papers in these impressive journals.  Anna Wald has several other papers in addition to these. that I could find.   Dr. Lawrence Corey, head of Infectious Disease at the Fred Hutchinson Cancer Center in Seattle is also an author on three of the same papers.  From my reading, he is considered the country's leading guy on herpes, along with Dr. Wald. They are both at the University of Washington. Dr. Wald's papers, especially the one in JAMA, really do say that people who test positive by these tests, even without sores, are contagious.  Other authors that seem to be important in the area of herpes are Dr. Steve Tyring, Dr. Peter Leone, Dr. Hunter Handsfield, Dr. Lawrence Stanberry, Dr. Stephen Sacks and Dr. Rhoda Ashley Morrow.  Dr. Ashley Morrow is also an author on three of the papers with Ms. Warren.  Seems to me that Ms. Warren is in pretty fine company in terms of writing scientific papers.  I don't get why a couple of people here are so down on her, when all those authors are really saying the same things about testing with the blood tests.  I also looked up the CDC guidelines, and it does suggest type specific blood testing be available for use in setting where people have STDs or are at risk for STDs (whcih seems to me like everywhere).  It also says partners of people who have herpes might want to get the test to see if they are infected, and that the test should be available to anyone who wants them but they don't suggest it for the general population.  This reference is at cdc.gov, publications, STD treatment guidelines, herpes if you want to look at it.  So it seems to me that they are saying that the test is good for diagnosing herpes.  It  says "Because almost all HSV 2 infections are sexually acquired, type specific HSV 2 antibody indicates anogenital infection..."  To me that's pretty darn clear.  I also did some research at this website called IHMF.com, International Herpes Management Forum.  There are lots of discussions in there about testing, pros and cons, in regular folks and pregnant women.  No one seems to be saying that testing is bad because it can't figure out genital herpes infection.  They are saying things like what can you do, treat everyone? and it does upset people.  It also says that low risk people like kids shouldn't be tested because the test isn't that great in them.  But it also says that most people expect testing for herpes.  There are articles that say that herpes can be really light symptoms, and that lots of folks miss there herpes infections, but can still pass it on thru shedding.  If all of that is true, why wouldn't someone who has any risk get tested and just know the truth to protect someone else, either a lover or a baby?  All this reading really opened my eyes a lot.  Another good place to read is ASHA, the American Social Health Association, another place that gets slammed here on this board by a select few.  Seems they've been around for almost 100 years, giving out advice on STDs as a non-profit.  They are supported by the CDC grant money too.  So lets see here - the CDC, ASHA, FDA Consumer magazine, New England Journal, JAMA - vs. Crazy Brain and the non-believers (or maybe those in denial).  I know where I'm fixin' to put my trust in the testing issue.  I've already got genital herpes and so does my girlfriend, but if I didn't, I'd be down getting my test right now.

[t1234]

Crazy Brain

Thanks for trying to bring some sanity to the Herpes Scare.

You're right the CDC does not recommend general testing.

I recently read a comment by Dr. Wald in a popular magazine.
She used words like "possible" "but unlikely".

This language doesn't reflect the infamatory language used
by the people "hawking" this disease.

I wish Dr. Wald would way in and tell us exactly what her
relationship with Terri Warren is and what her thoughts are.

I can't find any definite studies that prove people with "sub clinical" and only "Sero Positive" to anitbodies can transmit
the desease.

My information is that Terri Warren is an R.N. and not
an M.D.  If this is true, I don't understand how she can
lawfully give medical advice without a physican signoff. I quess it depends on the state.  Also is Terri a paid consultant for any of the drug companies who market the antivirals?

In my view there is a cost/benefit for everything.  For example we as a society have made the decision we will not quarantine
Aids infected people.  This view is not shared by our neighbor
to the South (Cuba) for example.

The public in the U.S> has also been educated you cannot get aids from saliva or kissing etc.

So in the example of HSV, a relatively harmless virus for the vast majority of people, do we really want to socially issolate Sero positive people or but them on antivirals to reduce the risk of transmission.

And what about the risk to people diagnosed as Sero Positive, go out and have sex with only known infected people
to keep from transmitting it, and suddenly have a primary herpes breakout??  This of course means that either the orginal
diagnosis was in error or the theory of sero positive to anitibodies= HSV is flawed.

Of course I'm just a lay person, but those are my thoughts.

Note: a definitive test would have to include statically significant numbers along with a control group.  Rememember the
transmission rate from female to male defined as having unprotected sex with an infected partner (defined as someone who is not only Sero Positive to Antibodies buy has periodic breakouts) only during the period they don't have symptoms for one year is only 4 per cent.  The error rate in the herpes select test I think is 4 percent under ideal conditions.  So without a control group I don't see how you make any definitive statements.

[JCREW]

Please help,

I have this pimple like bumpe on my left butt chik. Its very hard to sit anywhere and its been there now for about 7 days.
I tryed washing it with alchole and have been using neo sporine cream, but had no luck. When I feel it with my hand I feel a round suronding the size of 2 qurters. Can you please advise what it may be. Thanks

[CRAZY BRAIN]

No the cdc says the "results are not always clear cut" meaning lets say you have HSV 2 anti bodies with no symptoms does that mean you have gotten HSV on your legs, maybe your mouth from oral sex? They can't tell you 100% sure with a HSV anti body test the location of the disease. And if you have HSV 1 which most people due maybe you still have genital herpes. Antibody tests are in fact useful for HIV and other diseases that involve the whole human body, not skin condtions. But remember there are no tests for HPV and plenty of people have that too without knowing it, and it is much more prevalent. I and others just feel that as you see on this website promoting HSV antibody tests for people who never had a cut, blisters or rash is irresponsible medical care. It creates fear when there really is only a 10% annualized risk of transmission without symptoms, and even then NOT ALL patients are contagious. The cost of uncertainty when it comes to sex can be very deterimental to patients. 80% of HSV people are symptomatic. Why not say that to people and teach what the asymptomatic syptoms are instead of making it seem so amorphous? This is not working for people.

[CRAZY BRAIN]

another example of the HERPES SCARE thanks to Terri Warren and Asha. TELL THE PEOPLE THE COMMON THREAD JUTS LIKE EVERY OTHER MEDICAL DIAGNOSTIC TOOL PLEASE!

[swatelite]

What's the common thread? And why is there so much misleading information out there. Can you really have it with no symtoms as these websites claim? I have a little red spot on the winkly part of my penis and now all I can think is herpes even though it doesn't hurt when touched, there's no sore, there's no pain, and no itching.

[veryconcerned123]

I agree with you concerning this Herpes scare. They make it appear that everyone has it and no one knows it.

I don't buy it.  You really should tell this guy something since you have posted on HIS posting that he paid for.

Answer him and put his mind at ease.

[swatelite]

I also added that when it appeared before after masterbation, it went away in a day or two.

[Alan Rockoff, MD]

There's nothing in your description which reminds me of herpes.  This sounds like irritation.  You put it very well yourself: "I always question if it could be herpes, although there really is no reason to believe it is."

Have a doctor take a look, for reassurance.  Then consider counseling--if you're going to worry despite having "protected sex with a monogamous partner," then you may need to explore why this is so, and what you need to do to be able to deal with it.

Best.

Dr. Rockoff