Westover Heights Clinic - Symptoms

    Genital herpes infections are classified in three categories: primary, non-primary (initial), or recurrent. 

    A PRIMARY outbreak is defined as an outbreak that occurs in a person who has no prior antibody to herpes simplex virus meaning they have never had either HSV 1 or HSV 2.  Primary symptoms are sometimes more severe.  However, most individuals who experience a true primary outbreak have symptoms that they do not consider troublesome, or they may have no symptoms at all.

     Those people who do have symptoms with their primary outbreak may have whole body involvement: headache, aching joints, tiredness, fever, pain in the legs, and flu-like symptoms.  The lymph nodes in the groin often become enlarged and tender and may feel like large peas under the surface of the skin.  In this situation, when lymph nodes enlarge, it should be seen as a good thing.  It means the immune system is mounting an aggressive response to the herpes infection.  Lesions or sores also may appear in the throat or mouth. Genital symptoms may include sores (often on both sides of the genitals), painful urination, itching, and a discharge from the penis or the vagina. The sores begin as blisters, then break open and form ulcers in the skin. Women often do not notice the blister stage on the labia because the labia run together with movement and the blisters are rapidly broken.  Crusts or scabs form and eventually fall off.  Lesions on the inner labia do not form crusts, but instead, new skin replaces the sores. Women will usually have lesions on the cervix as well, and men may have them inside the penis in the urethra, hence the discharge described above as infected cells slough off from those areas.  Some women with primary herpes infections also get a yeast infection in the vagina that makes the itching and discharge more bothersome.  Frequently, a new crop of herpes lesions will appear five to seven days after the first batch appears.  The typical primary outbreak lasts from two to three weeks in those individuals who notice symptoms. 

    NON-PRIMARY (or initial) first episode infections occur when a person who has previously been infected with HSV 1 newly acquires HSV 2.  The existing antibody to HSV 1 keeps the HSV 2 infection mostly under control, and HSV 2 symptoms may be overlooked completely.  However, the antibodies to HSV 1 do not keep someone from getting HSV 2.  So, a person could have a history of cold sores caused by HSV 1 (or have been infected without knowing or remembering it) and still get genital herpes caused by HSV 2.   The symptoms for non-primary first episode infections are less severe than the primary infection and most go unnoticed.  The sores usually cover a smaller area, the whole-body symptoms described above are less likely to occur, and recovery time is typically shorter.  It is important to note that most people in this category have outbreaks that are minor enough to go unnoticed.  As much as 80-90% of first time genital outbreaks go unrecognized.

    RECURRENT infection occurs in people who have had a previous HSV infection at or near the same site on the body.  For those with genital herpes, that includes having outbreaks anywhere in the “boxer shorts” area.  A single group of nerves supplies the genitals, thighs, lower abdomen, rectum and buttocks.  A person need not have had sexual contact in any part of that area to have outbreaks there. For example, one need not have had anal sex to have an outbreak around the rectum. For some people, outbreaks occur in the same place every time, but sometimes outbreaks move to a new location.  During recurrent outbreaks, most people do not experience whole-body symptoms like headache, fever, etc.  The sores cover a still smaller area, and many people do not experience with their outbreaks.  The average recurrence lasts about 2-10 days. Fifteen to 30 percent of women have virus present on the cervix during recurrences. These are averages, and outbreaks can vary a great deal, even in the same person.  A person could have genital herpes for 30 years, not know it, and then have their first recognized recurrence.  When they finally do have an outbreak they recognize, it can cause unnecessary havoc in relationships if suspicions of infidelity arise.
 
    A FEW WORDS ABOUT ORAL HERPES: Because oral herpes can cause a genital sexually transmitted infection, it needs to be discussed briefly in this book.  However, it should be noted that the vast majority of oral infections (cold sores and fever blisters) are not sexually transmitted. Oral herpes is often acquired in childhood, and is frequently the result of an adult with a cold sore kissing a child. But many acquisitions happen totally without symptoms.  Adults who get an oral first infection can have symptoms that are both dramatic and painful.  Blisters can develop around the mouth, inside the mouth, and on other places of the face.  The lymph nodes in the neck and head may enlarge and become very tender. Like genital herpes, the infected person may feel like they have the flu.
    Most often, people infected with oral HSV 1 have recurrences that occur on the border between the lip and the face.  These are commonly known as cold sores or fever blisters. Herpes does not cause canker sores, ulcerated sores that occur inside the mouth.  When people have cold sores, they should not give oral sex to others.  Like with genital herpes, there is a risk of giving off (or shedding) the oral herpes virus without any symptoms being present. HSV 1 is shed from the mouth of people with recurrent cold sores on about 18 out of every 100 days sampled (when PCR is the testing method).  Though herpes outbreaks rarely occur inside the mouth, shedding of the virus can occur from inside the oral cavity.
    HSV 1 now causes about a third of first time genital herpes outbreaks. At the first outbreak, there is no difference between how type I and type 2 behave or look. However, if a person has been infected with type I genitally, they are far less likely to have recurrences. The recurrence rate for genital HSV 1 infection is about one outbreak every other year compared to HSV 2 genital infection that recurs four to six times per year.  It is very important that when herpes lab tests are done (either blood or swab tests) positive results are typed as HSV 1 or 2.  It is important to know the viral type because a person who has HSV 1 genitally can still acquire HSV 2 genitally (the reverse almost never happens), though some preliminary research indicates that they may be less likely to acquire HSV 2 genitally if they have HSV 1 genitally.  HSV 1 genital infection can happen in a relationship where neither person has ever had another sexual partner but the couple engages in oral sex and the virus is passed from mouth to genitals.  A cold sore does not need to be present for that to occur.

Prodrome
    About half the people with genital herpes experience something known as prodrome.  Prodrome is a set of symptoms that occur before an actual outbreak is present.  Itching, tingling, a crawling-under-the-skin feeling, pain down the back of the leg or in the buttocks, may all be signs of a recurrence on the way. Some people experience the prodrome signs but have no recurrence.  This is called an "aborted" outbreak. 
    Over time, a pattern may emerge that will help predict the onset of a herpes outbreak. The virus can certainly be transmitted during prodrome, so at that point one should stop having sexual contact with the infected area, be it the mouth or the genitals.  It may be helpful to keep a calendar of prodromes and outbreaks for a while to see how well one can predict a recurrence.  Developing an awareness of prodromal symptoms is one way to try to reduce the chances of transmitting virus to another person.
    "Triggering mechanisms" are those things that seem to be associated with the onset of an outbreak. Menstruation, sunlight, pregnancy, birth control pills, diet, friction (which includes prolonged or vigorous intercourse, oral sex or masturbation), stress, illness, and heat have all been identified as possible triggering mechanisms. Again, keeping a calendar of events associated with outbreaks may help to identify one's own triggering mechanisms, if indeed there are any. It is worth noting that only one study has shown that stress, and only extended duration stress, has any relationship to recurrences. Several other studies have not confirmed this connection.  Stressing out about having stress is not helpful. 
    People who have genital HSV 2 have an average of four to six outbreaks per year.  This varies greatly from person to person, with some having as many as two outbreaks per month to others having outbreaks only once every five years.  Men generally have one more outbreak per year than women. The first year of having herpes may not be a good measure of things to come; people may have more outbreaks in this first year than they do subsequently. Giving off the virus without symptoms is also more common during the first six to twelve months of having herpes.