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Psychotherapeutic management of herpes genitalis
I Drugs Psychotherapeutic management of herpes genitalis
G. R. B. Skinner
‘Then gently scan your brother man, Still gentler sister woman: Though they may gang a kennin wrang, To step aside is human. ’
advice concerning specific problems associated with the disease. Establishment of patient/doctor relationship
Address to the unto Guid, Robert Bums 1759-1796
Dificulties
This is critical and it may be useful to consider the possible difficulties towards establishment of such a relationship. Firstly, there are consultations where the doctor - working with the best will in the world - does not professionally ‘hit it off’ with the patients. In 20 years, there have been four or five patients with whom I felt inherently uncomfortable and that the patient would benefit from consulting a colleague which may be the way forward. It is important (particularly for young practitioners) to not feel a sense of failure in these circumstances. It must be admitted that some patients are intrinsically resentful of doctors - perhaps for good reason - and thus the relationship is strained ab initio; this represents a challenge and it is satisfying to transcend a background of resentment and establish a proper relationship. Secondly - at a more mundane level - it can be dificult to have the time and proper environment to properly manage a patient, for example a young patient who has recently contracted herpes genitalis, within the environment of a busy genitourinary clinic or family practitioner surgery. This is not a criticism of these clinics (I have done service there myself for many a long year). Time must be found to answer at least the most relevant questions and the services of a counsellor or nurse with professional experience of the disease is invaluable. In an ideal world, which it’s not, genitourinary clinics may be less appropriate than family practitioners’ surgeries or consultant
Introduction the last 2 decades it has been my privilege to have been consulted by over 10000 patients with primary or recurrent herpes genitalis. The privilege is two-fold; firstly, it is a privilege to be consulted on any problem by a patient and secondly, to be referred patients by colleagues for a disease where until the last 5 years there was no specific treatment. Management of patients with herpes genitalis requires resort to the art of medicine, and management is complicated by the patients’ perceptions - sometimes correct perceptions - of the disease; herpes genitalis is ‘incurable’ and will be with the patient for life, herpes genitalis is a venereal disease and may be associated with AIDS and the disease means a life time of socio-sexual ostracism. The benefit to the patient from sensible discussion of these aspects cannot be over-emphasised and I make no apology for devoting Part 1 of this two-part series concerning management of patients with herpes genitalis to psychotherapeutic strategies. This will be followed in Part 2 by investigation of chemotherapeutic and immunotherapeutic approaches. Psychotherapeutic management will be discussed under two general headings, namely establishment of a useful patient/doctor relationship and provision of During
Gordan R.B. Skinner, MD, DSc, FRCPath,
FRCOG,
of Infection, The Medical School, University Birmingham B15 2TH, UK Currenr Obstetrics 0 I993 Longman
and Gymecology Ltd
GroupUK
(1993) 3, I&-
169
in patient/doctor relationship
Department
of Birmingham,
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rooms as there is no specialised management which can be prosecuted only in genitourinary clinics. Thirdly, the patient’s pre-consultation psychological state can be less than favourable. She is often frightened and may never have been to a doctor never mind a genitourinary clinic; there may have been high ructions at home or with a sexual partner followed by an unsatisfactory medical consultation, which point is examined later in more detail. We are only human beings but it is vital to resist the temptation to reciprocate these negative attitudes by trying to make the consultation last for as little time as possible to get rid of this rather irritating patient; this will only compound the patient’s counterproductive emotional state and is unprofessional. As an aside, professionalism in medicine does not mean adopting an insufferably pompous demeanour or getting into a wee huddle with pals to decide on a minimum scale of fees (which is deemed to be professional but means running a cartel). Professionalism is doing what you consider best for the patient. Finally, the practitioners’ attitude can be unhelpful for reasons that are understandable but perhaps not entirely excusable. It’s a bind if there is no specific treatment and with a crowded waiting room, the previous patient a well-known hypochondriac and the next patient a well-known malingerer, it can stretch tolerance to deal in the middle of all this with a patient who wants to know why she keeps on having recurrent attacks of herpes genitalis. The most prevailing negative attitude is that it’s not a serious disease and a thousand worse things could befall a patient. I have gone full cycle on this one; originally, I noted with dismay the degree of systemic upset and local discomfort in (particularly) female patients with primary herpes genitalis. Some years later, as patients recover from a primary attack within 334 weeks, I tended to think - fuelled by the over-reaction and rather hysterical presentation by the media -~ that perhaps rather much was being made of the disease. After 20 years I do feel that, while herpes genitalis is not life-threatening, there is no doubt that it has seriously prejudiced the quality of life in a large number of patients quite out of proportion to the physical suffering but through its psychological sequalae. A second regrettable practitioner attitude finds expression in a sometime rather peremptory intimation to the patient that she should have gone to the genitourinary clinic. This is witless and nothing short of disastrous; the patient has sought help from a doctor in whatever specialty and the sense of rejection engenders a feeling of despair (and rightly so) in these patients. A third and (fortunately) less frequent response is the implicit and sometimes explicit censure that she has contracted the disease through immoral sexual practice. This is reprehensible on two grounds; firstly, extrapolation of a practitioner’s personal morality to the patient is improper, and, secondly, there is no good evidence
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that herpes genitalis is associated with promiscuity; indeed the number of patients who contract this infection within a monogamous relationship from oral-sexual contact is legion and, in my experience, the disease is not common in prostitutes. In short, any association of this disease with ‘loose’ behaviour or immoral goings-on is nonsense and it will do untold damage to make immoral imputation of this nature. The poor soul has enough worries without the doctor adding to them. Nature of relationship
The nature of the patient/doctor relationship is important in this disease. During or immediately following the primary attack, patients crave a sensible professional adviser whom they can consult without fear of ridicule or censure. It is a great comfort if patients know that the doctor is available - not at every hour of every day and night ~ but within reasonable limits and I have seldom found patients to exceed these limits. Some practitioners consider it a mortal affront if television watching is interrupted for as little as 1 minute to talk to a patient on the telephone, provide reassurance or answer quite sensible questions. I sincerely counsel to never rebuff or rebuke patients who telephone for medical advice. I well remember Professor Sir Hector McLennan - a distinguished gynaecologist who practised in Glasgow - pointing out that if you have to deal with a patient at an awkward time, do it with grace as you’ll have to do it anyway; pragmatic Presbyterianism. Patients with herpes genitalis are best managed in a down-to-earth, straightforward, commonsense fashion; it is important to be sympathetic and caring without pandering or overindulging which is good for private practice but bad for the patient. The importance of adequate time for consultation and for trying to ensure that the same practitioner sees the patient at each clinic visit is really helpful although this can be administratively difficult. In this instance, it’s nice if the deputising doctor can explain that the regular or usual doctor is unavailable rather than just fronting up without explanation and even displaying in front of the patient a woeful ignorance of the patient’s history and management to that point in time. Finally, I want to grasp a nettle which is usually ungrasped. I refer to payment by patients for consultations. There are patients who wish to come at unusual times which do not conform to usual working hours, for example evenings or Sundays. In these circumstances - and particularly if the patient is privately insured - I am not in the slightest squeamish to accept payment with the critical proviso that a patient who comes to a non-payment clinic has precisely, and I mean precisely, the same standard of care and attention and within the same timeframe. This seems a reasonable philosophy which is shared by the great majority of medical practitioners.
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Advice on specific problems Primary herpes genitalis
Primary herpes genitalis can be most discommoding. The patient may be unable to walk or sit down, the walls of the vagina can be approximated by inflammatory exudate accompanied by extreme discomfort on urination or defecation, with urinary retention in approximately 5% of patients. The misery can be compounded by severe systemic upset, excessive sweating, joint pains, headache and feelings of extreme malaise, fatigue and depression. Appropriate medication includes antipyretic analgesics or pethidine (if required) bladder catheterisation and specific antiviral therapy instituted with expedition. Specific advice is critical; many patients feel tired and should be instructed, not advised, to go to bed and stay there until they feel better. ‘Fighting’ this fatigue will only prolong the primary attack; one of my patients attempted to run a half-marathon whereupon the primary episode continued for 3 months. The patient must be told and will welcome the information that the primary attack is unlikely to continue beyond 3 weeks and that she can expect complete recovery with resumption of normal health and sexual function. There is nearly always a major angst concerning the source of the infection which needs quite careful management. Some cases are clear-cut wherein the partner had overt penile herpes or labial herpes with an unequivocal history of oral-sexual contact and there is little point in fluffing around trying to find some other less contentious source of infection; the ramifications of this clear-cut episode on the relationship will have to be worked out willy-nilly and the whole thing might as well be faced at square one. A more difficult situation arises when a patient is convinced that she contracted the infection from her partner who denies of ever having herpes genitalis or ‘any kind of herpes for that matter’. There is usually aggravation with accusations flying right left and centre and everybody, including relatives and friends, get into the act. In this circumstance - and acknowledging that the advice might be tinged with expediency - it is useful to emphasise that the disease can certainly be contracted (the expediency part concerns our lack of knowledge of the frequency of this event) from objects, e.g. towels, face cloths or indeed from asymptomatic excretion from the patient’s own mouth; the patient could also have contracted the infection in the dim and distant past and the attack is essentially a recurrence. These situations occur although it is impossible to opine on their frequency in day-to-day practice. Some patients will interpret these intimations as support for the herpetic virginity of her consort or even that she has had another partner on which she is keeping mum. It can be hard work and needs effort, tact and patience. It is often reassuring for the patient to be told that in approxi-
mately 25-35% of cases - in my experience - it is impossible to identify the source of infection. A third common situation occurs when a single patient - who is not in a relationship - contracts primary herpes genitalis with the inevitable accompaniments of mystification and anxious incomprehension. It is brainless to suggest that the patient is not telling the truth and, in my opinion, it is quite rare for a patient to tell a whopper in this situation as she has little to gain and only genuinely wants to know the truth of the matter. Practitioners seem to have difficulty understanding that virus can be transmitted from (for example) a towel which might have been used on labial herpes and subsequently used on the genitalia; preliminary research in our laboratory has indicated the extraordinary stability of infectious virus contained within whole cells, particularly in a moist environment and, indeed, if our objective was to infect our genitals from cold sores on our mouth the most efficient way to achieve this objective would be to remove virus infected cells from the mouth by a towel and then inoculate them by repeated rubbing on the epithelia of the genitalia. It must also be remembered that children with herpetic cold sores on the mouth will use any towel then chuck it down without another thought whereupon the unsuspecting adult has a shower and inoculates themselves with that towel. In my opinion, contraction of disease from lavatory seats occurs although is relatively unusual. I remember a case where three members of a family contracted herpes genitalis on the posterior aspect of both thighs encouraging inculpation of lavatory seats rather than sexual practices which would be unusual by even today’s standards. In summary, as our knowledge of the mode and frequency of virus transmission is deficient, it is critical to not aggravate marital or interpersonal problems through this ignorance. The patient will usually ask about the likely pattern of disease. The usual frequency of recurrences is 2-8 per year although there can be less than one recurrence every 3 years and unfortunately some patients have recurrences every month or all the time _ ‘status herpeticus’. One patient under my care reported 11 years of continual recurrent herpes genitalis with no evidence of immune deficiency or other contributory cause. Most gratifyingly, this patient was finally improved by a plant extract (of which more in Part 2) and had no further recurrences for 9 months followed by a much reduced frequency at one every 3-4 months. The moral of this anecdote is to encourage you to read Part 2 of this series but perhaps more importantly to indicate that the pattern of herpetic recurrences can be altered and improved by a variety of strategies; indeed, I can only think of one patient in 20 years of practice where we have been unable to modulate - in some measure - the pattern of the disease. A frequent question concerns the possibility of there being no further recurrences following the
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primary attack. In my experience every (unvaccinated) patient with proven primary herpes genitalis has had at least one recurrence and the (quite frequent) intimation to patients that only 50% of patients have recurrences is patently ridiculous and arises (I think) from a rough ‘guestimate’ of numbers of patients who return to a clinic following their first visitation with primary herpes genitalis. Another fable teaches that recurrences will cease after 2 years. When this fails to realise, the patient is severely disappointed and quite reasonably loses faith in medical advice for ever after. The patient should be told that there may be few recurrences and they will almost certainly be less of a problem than the primary attack. It is always tempting to transcend the ‘uncomfortable moment’ with an overly optimistic opinion (which we know in our hearts is bull) but it’s not worth it - it will all come home to roost sooner or later in any case. Established recurrent herpes genitalis There are two aspects; namely the physical symptoms and the patient’s concern over the nature of the disease. its complications, the implications of transmission and a number of fundamental psychosocial problems which merit attention. Nature qf disease The main problem with herpes genitalis is seldom local lesion discomfort which is usually in the ‘irritating’ category (particularly in buttock herpes where sitting down is a constant irritation) but more the curiously unpleasant neuralgic symptoms which are described as aching, nauseating and generally horrible; patients are also distressed by accompanying symptoms of fatigue, depression and (more unusually) mental disorientation, headache and sometimes abdominal colic preceding or during recurrences. Fatigue and depression are interesting in that they do not appear to be an emotional response to ‘yet another recurrence’ as they usually precede recurrences. The hypothesis that these symptoms might be induced by a viral protein(s) has been partly substantiated by significant improvement in these symptoms by vaccination, suggesting neutralisation of such proteins by antibody formed in response to vaccination. ’ Patients frequently want to know what factors will induce recurrences. The following (in order) tend to stimulate recurrences, namely infection particularly influenza, cold, sore throat and food poisoning, a psychological upset particularly of an emotional or ‘heart’-type - I have a patient who starts herpetic recurrences within 6 h of quarrelling with her mother - fatigue and overwork, excessive exposure to sunlight _ which includes these strange devices called sunbeds that make white people brown - and local trauma which includes over-enthusiastic or prolonged sexual
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interplay or non-sexual trauma - for example a long bicycle ride or sitting astride the edge of a yacht, which is de rigueur in these circles. However, while there is correlation with these factors, there is no identifiable precipitating factor in a number of patients where recurrences come out of a clear blue sky in a patient in peak health and fitness. Personally, I do not believe that dietary control - for example avoiding nuts or chips or other major deprivations is of value apart (perhaps) from avoiding excessive sweet stuff which can encourage candidiasis which can stimulate herpetic recurrences; secondly, spices, chilli, peppers and curries reappear and irritate at t’other end and can thus be herpetogenic. However, its all a bit marginal and raises an issue in provision of advice to these patients. In general it’s better for the patient to do what she likes and ‘deil tak the hindmost’ rather than plotting a tortuous course avoiding enjoyable pursuits on the offchance of inducing recurrences which they might not anyway. I have seen patients give up scuba diving, five-a-side football, party-going and even alcohol (which is going a little too far) and (curiously) have continued the abstention in the face of incontrovertable evidence of no tangible result - neither having nor eating your cake. I doubt if its all worth it unless the pattern of disease is extremely troublesome and all else has failed. In summary, unless a specific aetiologic factor has been identified and the patient is in psychological need, its better to ‘allow’ enjoyable things - and patients enjoy things better once the doctor has ‘allowed’ them - which would even include sunbathing where the relaxation and comfort that some people seem to derive from this pastime may well outweigh the herpetogenic effect of ultraviolet radiation. Sociosexual implications; self-perception. infectiousness; partner communication These constitute the dominant preoccupation of almost every patient and devolve into concern over genera1 perception of the patient in the light of her having contracted the disease and secondly, how possible transmission of the disease will affect present or future relationships and social interaction with relatives and friends; the two aspects are inter-related and will be jointly discussed. Many patients feel that contraction of this disease has sullied the uprightness of their character and indicates to all and sundry that they are immoral, promiscuous and a ‘scarlet woman’. The practitioner must re-emphasise that the disease is frequently transmitted within a monogamous relationship often from oral/sexual contact - indeed I have encountered the disease in two celibate women within strict religious orders. Strangely, patients will resist this concept and repost that the world ‘does not see it that way’, and at the end of the day, one is obliged to indicate she will have to live as she sees herself
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and not how she erroneously believes the world at large views the issue. The second repost is that she ‘cannot help feeling like this’. It is important to ‘gently’ indicate that she can help it, her mental state offers no advantage to her or her family and that she, as a citizen, has a duty to contribute to society rather than wallowing and bewailing a fate which is not catastrophic on the grand scale of things. Certain patients - particularly homosexual females in my experience - take somewhat unkindly to this kind of counselling but someone has to say it and the vast majority of patients seem to absorb the message into the subconscious which reaps benefit over the next few months while adjusting to the problem. The second negative self-perception is that she is now a ‘carrier’ and virtually a leprous outcast who must be avoided even socially. In some ways, I am quite pleased when this is a significant feature of a patients anxiety as most patients will respond to certain undisputable facts and after some time will usually ditch the ‘carrier’ nonsense. As this relates closely to the likelihood of virus transmission in a sexual setting, I will now present the background of what is known and not known to put the whole question of ‘infectiousness’ into perspective. There are two situations - when lesions are present or when there are no lesions as detected by looking or by feeling in accessible areas of the genital tract. The former is straightforward; patients must be advised to avoid intercourse at these times, not only to avoid transmission but also as the friction of intercourse will often aggravate lesions and encourage spread to related areas of epithelium. Patients do have intercourse when lesions are present. This is an under-recognised factor in virus transmission and the importance of asymptomatic transmission may have been over-emphasised from rather optimistic assessment of patient disinclination at these times; indeed, our own survey has indicated this to be an equal folly of both lay and professional patients, including us lot.2 The following is often forgotten. Patients may have lesions on sites which do not generate discomfort at intercourse; these include extra-introital areas - for example outer labia, clitoris or even the perineum with posteriorly placed lesions. Secondly, lesions can be undetectable, for example high in the vagina or can be minute, painless lesions noticed only at or after intercourse. Thirdly, circumstances of decreased awareness from alcohol, drugs or sleepiness on awakening in the morning are contributory factors and finally, but quite rarely, intercourse can take place in the full awareness of one or both partners. I emphasise the rarity of this last possibility as much aggravation, dislike and distrust can develop where one partner assumes (nearly always wrongly) that the other did not disclose lesions. This happens but in almost every case, lesions were undetectable at intercourse or developed following intercourse. Transmission in the presence of lesions has been discussed in some detail to underscore the notion
that in association with auto-transmission (usually from the mouth) and by inanimate objects (usually towels) the risk of asymptomatic excretion between recurrences is unknown and I question if the increased statistical risk (if any) justifies the psychological burden carried by some of these patients. Thus, a patient should not be advised against intercourse between recurrences; at a more pragmatic level, if the patient is not having intercourse between recurrences, she’s not having intercourse at all which isn’t much fun and is certainly not justified by epidemiological data presently at our disposal. Specific advice on minimising the risk of virus transmission must be included in the practitioner’s check list. As stated, risk of virus transmission is most significantly reduced by avoiding intercourse when lesions are present or if the patient is experiencing symptomotology in the absence of lesions where, a priori, there is more likelihood of infectious virus in secretions. Condoms are protective but not completely, particularly from female to male where virus in vaginal secretions or at extra-introital sites can circumvent the condom; penile lesions, particularly towards or on the glans penis, will not transmit virus given that the condom stays on and does not tear. Contraceptive creams are useful. They contain detergent which kills virus, and if inserted into the vagina prior to intercourse, will kill a significant proportion of infectious virus and, pari passu, reduce the risk of virus transmission. This is a quite popular strategy with ladies who are keeping mum as, excepting the extravagant ramblings of popular American fiction, most people have some inkling of the likelihood of intercourse within the next two or three hours and thus can take this necessary precaution; in addition, there is little chance of being found out as most men haven’t the faintest idea what goes on in the female vagina although it is well to remember that in the event of oral sexual contact, detergent may not be caviar to most palates. Cold sores on the lips, mouth or nose are potent sources of transmission and an episode of oral sex when sores are present will almost certainly transmit type I and I have encountered three cases where there was incontrovertable evidence that the patient had infected her genitalia from sores on her own lips. Kissing in the presence of cold sores followed by oro-genital contact or oro-genital contact followed by genital contact can all ‘passively’ transmit virus to the genital area. Thus, if cold sores are present, sexual contact should be confined to genital or digital-genital contact. A quite frequent mode of transmission arises from lesions on the buttocks or upper thighs - not necessarily from sexual intercourse but from lying together with prolonged approximation of lesions providing ample opportunity, particularly in a warm perspiring situation, for the virus to penetrate the skin of the partner. Weeping lesions should be covered with a waterproof plaster and underclothing or pyjama bottoms although
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vesicular fluid can still be absorbed and soak through to a partner. Lesions should be covered with a plaster prior to intercourse where there can be approximation of skin surfaces or transmission of virus from the hands of a partner to the genital area in the course of love-making. Finally, advice in a contraction emergency - for example when a couple realise post facto that there have may been a lesion present or a condom comes off when lesions are thought to be present is important. As it is quite conceivable that there is virus absorbed but has not yet penetrated the recipient’s cells, the risk of the productive infection being established can certainly be reduced by washing with warm (not hot) soapy water. In our laboratory we have conducted model experiments whereby the earlier and more extensive the washing of tissue surfaces, the lower the proportion of tissue explants that become infected and it is not unreasonable to extrapolate this analogy to the in vivo situati0n.j The practitioner should not dodge issues; a number of women are abashed to ask if, when no lesions are present, she can be touched or receive oral sex without proceeding to unprotected sexual intercourse. In my opinion, this does not constitute a meaningful statistical risk and in 25 years of practice I have only once felt convinced that a patient transmitted virus from the genital area (in the female) to the face of a male; in this particular case, the patient had gross vulva1 herpes and the male was a mentally retarded youth - an unfortunate case. Now to the $64000 question(s) - namely, whether, when and how to disclose herpes genitalis to a new partner. ‘Whether’ is a major dilemma as it would seem the ‘right thing to do’ but the prospective partner might ‘do a runner’ and bang goes a nice relationship. Certain comments will help but still duck the issue. Most (I repeat most) relationships will not be aborted on the wings of this news but there will be catastrophes and the unpalatable possibility remains until there is reduced hysteria and more specific measures to deal with the disease. It’s also true (I suppose) that if the putative relationship cannot withstand this complication then it is foredoomed in any case but, as the patient will frequently point out there may not be a relationship to be foredoomed. In my experience, approximately 85% of patients discuss the problem prior to onset of sexual relations, approximately 5% only once the couple decide to no longer use barrier contraception and the remaining 5% of patients keep mum. Interestingly, none of the last group - who took a conscious decision to not disclose - have subsequently transmitted the infection as far as can be reasonably adjudged. This may relate to increased awareness and caution on their part as a kind of moral quid pro quo for non-disclosure. I recall a female patient who reported transmission to her unknowing boyfriend, assured him that she would nevertheless continue the relationship which impressed her boyfriend to
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the extent that he brought forward the marriage date by 6 months; 1 month following marriage, the lady had a recurrence whereupon the new husband assumed he had transmitted this to his new wife and was even more moved by her loyalty and stoicism. The final outcome was actually favourable as each considered the other a saint and the herpes problem is now a dead duck; even the devil works in wondrous ways. This is all jolly interesting but the patient is still waiting to hear what to do. While in the last analysis the patient must decide for herself, my general advice would be that the situation should be disclosed prior to unprotected sexual intercourse but if the patient has decided to not disclose, she should not be condemned or censured by the practitioner as the risk in a patient with a bit of nouse who knows the risks and how to minimise them (vide supra) offers a quite low risk of transmission in comparison to the base or background risk of contracting the infection. A second question is when to raise the issue. There seems little need prior to onset of sexual relations as, until then ones’ genitals are ones’ own business. This allows time to assess the likely future of the relationship and if the relationship is a non-starter a big rigmarole about herpes is neither needed nor desirable. This leads to the third question, namely how to introduce and discuss herpes genitalis with a new or an established partner who is as yet unaware of the problem. Patients (and us) tend to believe what they hear and there is no doubt that the more the patient makes of it the more the partner will make of it. A low-key delivery is best without preannouncement that there is ‘something we should talk about over dinner’; it will be something of an anticlimax when a partner launches into a tale of genital herpes over a candle-lit dinner. A sometime difficulty is that sexual relations have been proceeding without disclosure and in this instance patients often downplay the frequency of recurrences or even the certitude of the diagnosis towards ameliorating anticipated partner aggravation and in truth this seems to be a useful - if not pristine pure - approach to the problem. The patient should certainly be told that once the issue has been aired and the relationship is proceeding (as it will usually do) to not go on about it. The patient agonises that if intercourse is not ‘herpetically possible’, the relationship will collapse (which is nonsense) and I cannot think of a relationship which foundered purely on the rocks of deprivation of unprotected sexual intercourse for intervals throughout the year. Certain patients will get to enjoy being centre stage and often cannot understand why their partner is not more interested in their ‘herpes’ and, in fact, they are taking the whole thing rather lightly or even indifferently. The point must be made that genitals are rather akin to haemorrhoids, corns, discharges and periods which are of limited general interest and there is a danger _ which I have observed in an alarming number of
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cases - that the relationship will founder - not because of herpes or sex or anything to do with genitals per se - but because the patient has become the big bore and ascribes all past, present and future failings in life to the disease. This syndrome can arise spontaneously and then be fuelled by family, friends, medical attendants and especially by the sexual partner particularly where there is some suspicion that he was the source of infection and now must atone by excessive attention to the person he infected with the disease. This situation requires diplomacy and tactful firmness but does represent a situation where the practitioner - having got the feel of the couple - can make an important contribution towards their future happiness. Herpes neonatorum
The third most prevalent anxiety concerns the possible effect on herpes genitalis on a baby. This aspect has been handled quite irresponsibly by certain sections of the media particularly in the USA. There is no evidence of transplacental virus transmission nor hazard to the foetus within intact uterine membranes. The patient can be told quite categorically that in the absence of any other complications, if there is no clinical or laboratory evidence of herpes genitalis during labour or when the membranes have ruptured, then Caesarean section will not be necessary. If a patient happens to be in hospital prior to delivery, it makes sense to test for virus in the genital tract remembering to ask the laboratory to provide an (albeit) provisional report prior and not following delivery(!) The whole problem has been exaggerated in the public perception and I have never encountered a case of herpes neonatorum in the infant of a mother who entered pregnancy with recurrent herpes genitalis. Nevertheless, there is no point in being too tense about everything - an occupational hazard of obstetrics - and if an elderly primagravid patient is set fair to spend the entire pregnancy agonising over herpes genitalis, then there may be a case for abandoning obstetrical purity and deciding on Caesarean section at an early stage, telling the patient the plan, whereupon patient, her family and her medical attendants will have a more tranquil pregnancy. Advice is frequently sought concerning contraction of herpes during the postnatal period. It is rare for a serious disseminated herpetic infection to develop in by an infant beyond the first 3 weeks of life and it is ridiculous to try to prevent Granny kissing the baby because she was noted to have herpes on her face a couple of years ago. At the same time, it is wise to avoid kissing babies (or anyone else for that matter) when there are obvious cold sores on the mouth. In summary, a patient should be toid there is no bar to becoming pregnant on account of recurrent herpes genitalis but that she should advise her medical attendants of this condition. It is most unlikely that
she will require a Caesarean section solely on account of a recurrence of herpes genitalis but if she does, it’s not the end of the world. Carcinoma of the cervix
An association has been proposed between type 2 herpes simplex virus infection and carcinoma of the uterine cervix; this association has arisen from epidemiological studies and from in vitro studies where the virus disabled in some way - most usually by ultraviolet radiation - has induced oncogenic transformation in a non-oncogenic cell line; the cells then given rise to tumours in homogenic animal species. 3-7 Koch’s postulates have not been entirely satisfied; some epidemiological studies have not confirmed this relationship and, at a commonsense level, there are patients with carcinoma of the cervix who have never had herpes simplex virus type 2 and patients with herpes virus type 2 who (thankfully) have not and will not develop cancer of the cervix. A decline in belief in this association did not arise from such reasonable observations but from recent evidence that human papilloma virus (HPV) might be associated with pre-invasive or invasive changes in the cervix. This is somehow taken to make HSV a less likely agent as if HSV and HPV were competing for the glory of being the cause of cancer while the truth is that if one virus can induce carcinomatous change, this increases the likelihood that an agent of similar anatomy and physiology could do likewise or act synergistically in an oncological role. In summary, it has never been postulated that HSV2 is the exclusive aetiological agent(s) of cervical cancer but may be associated with increased risk of pre-invasive or invasive changes. If the patient introduces the subject, it should be pointed out that there may be a small increased risk of cervical cancer which is eliminated by regular cervical cytology; additionally, if the question of hysterectomy arises for other indication, then it is not unreasonable that foreknowledge of the history of herpetic cervicitis could just tip the balance in favour of that procedure. Finally, it is worth considering perceived complications of this disease which can be thoroughly put to rest in discussion with the patient. Herpes genitalis is not life-threatening and does not decrease life expectancy. Healing lesions can leave scars which are more marked in lesions which have become secondarily infected with pyogenic bacteria but in my experience these scars fade with time and in one patient who had had virtually continuous penile herpes for 40 years there was no residual evidence of scarring or fibrosis. There is no evidence to associate the disease with infertility, impotence or other sexual dysfunction other than might be mediated via psychological processes associated with the disease. There is no evidence that the disease weakens resistence to other infections or more specifically to HIV related disease through a general depression of
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the immune system; recent evidence that treatment of AIDS patients with anti-herpetic drugs - mainly designed towards control of coincidence cytomegalovirus infection - is a different issue and does not as some patients have interpreted - indicate that herpes simplex is a precedent of AIDS or that the patient is now more likely to contract the disease. Conclusion Herpes genitalis provides a unique opportunity to practice the art of medicine. The main strategies of management comprise talking to the patient, providing appropriate advice, answering questions from the patient or their partners and generally setting the right relationship between the patient and the profession. It is not a piece of cake; personal experience makes for more comfortable consultations without the gloomy foreboding while awaiting a patient who is still having frequent tiresome recurrences notwithstanding your best efforts. Avoid becoming ‘decisive’ and telling the patient that ‘no more can be done’ which you can’t possibly know anyway and is the last straw for the patient who now feels totally rejected. Relax, it’s alright to say you don’t know what to do but you wiI1 keep trying and working with the patient. She won’t be angry or think the less of you; it is not the end but the beginning of a journey together towards a destination of improving
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her wellbeing. During the last 2 decades I have embarked on many such journeys and it has been a rare pleasure to meet, befriend and care for so many nice ladies. References Turyk ME, Wilbanks GD, Benson C, et al. Therapeutic efficacy of Skinner vaccine against herpes genitalis in prospective double-blind placebo-controlled trial. 1993: in preparation Pate1 S, Skinner GRB. Prolonged survival of herpes simplex virus within cells outwith the human body. 1993; in preparation Skinner GRB. Thouless ME, Jordan JA. Antibodies to type I and type 2 herpes virus in women with abnormal cervical cytology. Journal of Obstetrics and Gynaecology of the British Commonwealth 1971; 68: 1031-1038 Skinner GRB. Transformation of primary hamster embryo fibroblasts by type 2 simplex virus: evidence for a ‘hit-andrun’ mechanism. British Journal of Experimental Pathology 1976; 57: 361-376 Skinner GRB, Whitney JE, Hartley CE. Prevalence of typespecific antibody against type 1 and type 2 herpes simplex virus in women with abnormal cervical cytology: evidence towards pre-pubertal vaccination of sero-negative female subjects. Arch Viral 1977; 54: 21 l-221 Coleman DV, Moore AR, Beckwith P, et al. Prognostic significance of HSV antibody status in women with dysplasia of uterine cervix (CIN 1 or 2). Br J Obstet Gynaecol 1983; 90: 421-427 Chen Min-Hui, Dong Chang-Yuan. Liu Zhi-Hui, Skinner GRB, Hartley CE. Prevention of type 2 herpes simplex virus induced cervical carcinoma in mice by prior immunisation with a vaccine prepared from type 1 herpes simplex virus vaccine. Vaccine 1983; I: 13-17
G. R. B. Skinner
‘Then gently scan your brother man, Still gentler sister woman: Though they may gang a kennin wrang, To step aside is human. ’
advice concerning specific problems associated with the disease. Establishment of patient/doctor relationship
Address to the unto Guid, Robert Bums 1759-1796
Dificulties
This is critical and it may be useful to consider the possible difficulties towards establishment of such a relationship. Firstly, there are consultations where the doctor - working with the best will in the world - does not professionally ‘hit it off’ with the patients. In 20 years, there have been four or five patients with whom I felt inherently uncomfortable and that the patient would benefit from consulting a colleague which may be the way forward. It is important (particularly for young practitioners) to not feel a sense of failure in these circumstances. It must be admitted that some patients are intrinsically resentful of doctors - perhaps for good reason - and thus the relationship is strained ab initio; this represents a challenge and it is satisfying to transcend a background of resentment and establish a proper relationship. Secondly - at a more mundane level - it can be dificult to have the time and proper environment to properly manage a patient, for example a young patient who has recently contracted herpes genitalis, within the environment of a busy genitourinary clinic or family practitioner surgery. This is not a criticism of these clinics (I have done service there myself for many a long year). Time must be found to answer at least the most relevant questions and the services of a counsellor or nurse with professional experience of the disease is invaluable. In an ideal world, which it’s not, genitourinary clinics may be less appropriate than family practitioners’ surgeries or consultant
Introduction the last 2 decades it has been my privilege to have been consulted by over 10000 patients with primary or recurrent herpes genitalis. The privilege is two-fold; firstly, it is a privilege to be consulted on any problem by a patient and secondly, to be referred patients by colleagues for a disease where until the last 5 years there was no specific treatment. Management of patients with herpes genitalis requires resort to the art of medicine, and management is complicated by the patients’ perceptions - sometimes correct perceptions - of the disease; herpes genitalis is ‘incurable’ and will be with the patient for life, herpes genitalis is a venereal disease and may be associated with AIDS and the disease means a life time of socio-sexual ostracism. The benefit to the patient from sensible discussion of these aspects cannot be over-emphasised and I make no apology for devoting Part 1 of this two-part series concerning management of patients with herpes genitalis to psychotherapeutic strategies. This will be followed in Part 2 by investigation of chemotherapeutic and immunotherapeutic approaches. Psychotherapeutic management will be discussed under two general headings, namely establishment of a useful patient/doctor relationship and provision of During
Gordan R.B. Skinner, MD, DSc, FRCPath,
FRCOG,
of Infection, The Medical School, University Birmingham B15 2TH, UK Currenr Obstetrics 0 I993 Longman
and Gymecology Ltd
GroupUK
(1993) 3, I&-
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in patient/doctor relationship
Department
of Birmingham,
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rooms as there is no specialised management which can be prosecuted only in genitourinary clinics. Thirdly, the patient’s pre-consultation psychological state can be less than favourable. She is often frightened and may never have been to a doctor never mind a genitourinary clinic; there may have been high ructions at home or with a sexual partner followed by an unsatisfactory medical consultation, which point is examined later in more detail. We are only human beings but it is vital to resist the temptation to reciprocate these negative attitudes by trying to make the consultation last for as little time as possible to get rid of this rather irritating patient; this will only compound the patient’s counterproductive emotional state and is unprofessional. As an aside, professionalism in medicine does not mean adopting an insufferably pompous demeanour or getting into a wee huddle with pals to decide on a minimum scale of fees (which is deemed to be professional but means running a cartel). Professionalism is doing what you consider best for the patient. Finally, the practitioners’ attitude can be unhelpful for reasons that are understandable but perhaps not entirely excusable. It’s a bind if there is no specific treatment and with a crowded waiting room, the previous patient a well-known hypochondriac and the next patient a well-known malingerer, it can stretch tolerance to deal in the middle of all this with a patient who wants to know why she keeps on having recurrent attacks of herpes genitalis. The most prevailing negative attitude is that it’s not a serious disease and a thousand worse things could befall a patient. I have gone full cycle on this one; originally, I noted with dismay the degree of systemic upset and local discomfort in (particularly) female patients with primary herpes genitalis. Some years later, as patients recover from a primary attack within 334 weeks, I tended to think - fuelled by the over-reaction and rather hysterical presentation by the media -~ that perhaps rather much was being made of the disease. After 20 years I do feel that, while herpes genitalis is not life-threatening, there is no doubt that it has seriously prejudiced the quality of life in a large number of patients quite out of proportion to the physical suffering but through its psychological sequalae. A second regrettable practitioner attitude finds expression in a sometime rather peremptory intimation to the patient that she should have gone to the genitourinary clinic. This is witless and nothing short of disastrous; the patient has sought help from a doctor in whatever specialty and the sense of rejection engenders a feeling of despair (and rightly so) in these patients. A third and (fortunately) less frequent response is the implicit and sometimes explicit censure that she has contracted the disease through immoral sexual practice. This is reprehensible on two grounds; firstly, extrapolation of a practitioner’s personal morality to the patient is improper, and, secondly, there is no good evidence
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that herpes genitalis is associated with promiscuity; indeed the number of patients who contract this infection within a monogamous relationship from oral-sexual contact is legion and, in my experience, the disease is not common in prostitutes. In short, any association of this disease with ‘loose’ behaviour or immoral goings-on is nonsense and it will do untold damage to make immoral imputation of this nature. The poor soul has enough worries without the doctor adding to them. Nature of relationship
The nature of the patient/doctor relationship is important in this disease. During or immediately following the primary attack, patients crave a sensible professional adviser whom they can consult without fear of ridicule or censure. It is a great comfort if patients know that the doctor is available - not at every hour of every day and night ~ but within reasonable limits and I have seldom found patients to exceed these limits. Some practitioners consider it a mortal affront if television watching is interrupted for as little as 1 minute to talk to a patient on the telephone, provide reassurance or answer quite sensible questions. I sincerely counsel to never rebuff or rebuke patients who telephone for medical advice. I well remember Professor Sir Hector McLennan - a distinguished gynaecologist who practised in Glasgow - pointing out that if you have to deal with a patient at an awkward time, do it with grace as you’ll have to do it anyway; pragmatic Presbyterianism. Patients with herpes genitalis are best managed in a down-to-earth, straightforward, commonsense fashion; it is important to be sympathetic and caring without pandering or overindulging which is good for private practice but bad for the patient. The importance of adequate time for consultation and for trying to ensure that the same practitioner sees the patient at each clinic visit is really helpful although this can be administratively difficult. In this instance, it’s nice if the deputising doctor can explain that the regular or usual doctor is unavailable rather than just fronting up without explanation and even displaying in front of the patient a woeful ignorance of the patient’s history and management to that point in time. Finally, I want to grasp a nettle which is usually ungrasped. I refer to payment by patients for consultations. There are patients who wish to come at unusual times which do not conform to usual working hours, for example evenings or Sundays. In these circumstances - and particularly if the patient is privately insured - I am not in the slightest squeamish to accept payment with the critical proviso that a patient who comes to a non-payment clinic has precisely, and I mean precisely, the same standard of care and attention and within the same timeframe. This seems a reasonable philosophy which is shared by the great majority of medical practitioners.
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Advice on specific problems Primary herpes genitalis
Primary herpes genitalis can be most discommoding. The patient may be unable to walk or sit down, the walls of the vagina can be approximated by inflammatory exudate accompanied by extreme discomfort on urination or defecation, with urinary retention in approximately 5% of patients. The misery can be compounded by severe systemic upset, excessive sweating, joint pains, headache and feelings of extreme malaise, fatigue and depression. Appropriate medication includes antipyretic analgesics or pethidine (if required) bladder catheterisation and specific antiviral therapy instituted with expedition. Specific advice is critical; many patients feel tired and should be instructed, not advised, to go to bed and stay there until they feel better. ‘Fighting’ this fatigue will only prolong the primary attack; one of my patients attempted to run a half-marathon whereupon the primary episode continued for 3 months. The patient must be told and will welcome the information that the primary attack is unlikely to continue beyond 3 weeks and that she can expect complete recovery with resumption of normal health and sexual function. There is nearly always a major angst concerning the source of the infection which needs quite careful management. Some cases are clear-cut wherein the partner had overt penile herpes or labial herpes with an unequivocal history of oral-sexual contact and there is little point in fluffing around trying to find some other less contentious source of infection; the ramifications of this clear-cut episode on the relationship will have to be worked out willy-nilly and the whole thing might as well be faced at square one. A more difficult situation arises when a patient is convinced that she contracted the infection from her partner who denies of ever having herpes genitalis or ‘any kind of herpes for that matter’. There is usually aggravation with accusations flying right left and centre and everybody, including relatives and friends, get into the act. In this circumstance - and acknowledging that the advice might be tinged with expediency - it is useful to emphasise that the disease can certainly be contracted (the expediency part concerns our lack of knowledge of the frequency of this event) from objects, e.g. towels, face cloths or indeed from asymptomatic excretion from the patient’s own mouth; the patient could also have contracted the infection in the dim and distant past and the attack is essentially a recurrence. These situations occur although it is impossible to opine on their frequency in day-to-day practice. Some patients will interpret these intimations as support for the herpetic virginity of her consort or even that she has had another partner on which she is keeping mum. It can be hard work and needs effort, tact and patience. It is often reassuring for the patient to be told that in approxi-
mately 25-35% of cases - in my experience - it is impossible to identify the source of infection. A third common situation occurs when a single patient - who is not in a relationship - contracts primary herpes genitalis with the inevitable accompaniments of mystification and anxious incomprehension. It is brainless to suggest that the patient is not telling the truth and, in my opinion, it is quite rare for a patient to tell a whopper in this situation as she has little to gain and only genuinely wants to know the truth of the matter. Practitioners seem to have difficulty understanding that virus can be transmitted from (for example) a towel which might have been used on labial herpes and subsequently used on the genitalia; preliminary research in our laboratory has indicated the extraordinary stability of infectious virus contained within whole cells, particularly in a moist environment and, indeed, if our objective was to infect our genitals from cold sores on our mouth the most efficient way to achieve this objective would be to remove virus infected cells from the mouth by a towel and then inoculate them by repeated rubbing on the epithelia of the genitalia. It must also be remembered that children with herpetic cold sores on the mouth will use any towel then chuck it down without another thought whereupon the unsuspecting adult has a shower and inoculates themselves with that towel. In my opinion, contraction of disease from lavatory seats occurs although is relatively unusual. I remember a case where three members of a family contracted herpes genitalis on the posterior aspect of both thighs encouraging inculpation of lavatory seats rather than sexual practices which would be unusual by even today’s standards. In summary, as our knowledge of the mode and frequency of virus transmission is deficient, it is critical to not aggravate marital or interpersonal problems through this ignorance. The patient will usually ask about the likely pattern of disease. The usual frequency of recurrences is 2-8 per year although there can be less than one recurrence every 3 years and unfortunately some patients have recurrences every month or all the time _ ‘status herpeticus’. One patient under my care reported 11 years of continual recurrent herpes genitalis with no evidence of immune deficiency or other contributory cause. Most gratifyingly, this patient was finally improved by a plant extract (of which more in Part 2) and had no further recurrences for 9 months followed by a much reduced frequency at one every 3-4 months. The moral of this anecdote is to encourage you to read Part 2 of this series but perhaps more importantly to indicate that the pattern of herpetic recurrences can be altered and improved by a variety of strategies; indeed, I can only think of one patient in 20 years of practice where we have been unable to modulate - in some measure - the pattern of the disease. A frequent question concerns the possibility of there being no further recurrences following the
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primary attack. In my experience every (unvaccinated) patient with proven primary herpes genitalis has had at least one recurrence and the (quite frequent) intimation to patients that only 50% of patients have recurrences is patently ridiculous and arises (I think) from a rough ‘guestimate’ of numbers of patients who return to a clinic following their first visitation with primary herpes genitalis. Another fable teaches that recurrences will cease after 2 years. When this fails to realise, the patient is severely disappointed and quite reasonably loses faith in medical advice for ever after. The patient should be told that there may be few recurrences and they will almost certainly be less of a problem than the primary attack. It is always tempting to transcend the ‘uncomfortable moment’ with an overly optimistic opinion (which we know in our hearts is bull) but it’s not worth it - it will all come home to roost sooner or later in any case. Established recurrent herpes genitalis There are two aspects; namely the physical symptoms and the patient’s concern over the nature of the disease. its complications, the implications of transmission and a number of fundamental psychosocial problems which merit attention. Nature qf disease The main problem with herpes genitalis is seldom local lesion discomfort which is usually in the ‘irritating’ category (particularly in buttock herpes where sitting down is a constant irritation) but more the curiously unpleasant neuralgic symptoms which are described as aching, nauseating and generally horrible; patients are also distressed by accompanying symptoms of fatigue, depression and (more unusually) mental disorientation, headache and sometimes abdominal colic preceding or during recurrences. Fatigue and depression are interesting in that they do not appear to be an emotional response to ‘yet another recurrence’ as they usually precede recurrences. The hypothesis that these symptoms might be induced by a viral protein(s) has been partly substantiated by significant improvement in these symptoms by vaccination, suggesting neutralisation of such proteins by antibody formed in response to vaccination. ’ Patients frequently want to know what factors will induce recurrences. The following (in order) tend to stimulate recurrences, namely infection particularly influenza, cold, sore throat and food poisoning, a psychological upset particularly of an emotional or ‘heart’-type - I have a patient who starts herpetic recurrences within 6 h of quarrelling with her mother - fatigue and overwork, excessive exposure to sunlight _ which includes these strange devices called sunbeds that make white people brown - and local trauma which includes over-enthusiastic or prolonged sexual
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interplay or non-sexual trauma - for example a long bicycle ride or sitting astride the edge of a yacht, which is de rigueur in these circles. However, while there is correlation with these factors, there is no identifiable precipitating factor in a number of patients where recurrences come out of a clear blue sky in a patient in peak health and fitness. Personally, I do not believe that dietary control - for example avoiding nuts or chips or other major deprivations is of value apart (perhaps) from avoiding excessive sweet stuff which can encourage candidiasis which can stimulate herpetic recurrences; secondly, spices, chilli, peppers and curries reappear and irritate at t’other end and can thus be herpetogenic. However, its all a bit marginal and raises an issue in provision of advice to these patients. In general it’s better for the patient to do what she likes and ‘deil tak the hindmost’ rather than plotting a tortuous course avoiding enjoyable pursuits on the offchance of inducing recurrences which they might not anyway. I have seen patients give up scuba diving, five-a-side football, party-going and even alcohol (which is going a little too far) and (curiously) have continued the abstention in the face of incontrovertable evidence of no tangible result - neither having nor eating your cake. I doubt if its all worth it unless the pattern of disease is extremely troublesome and all else has failed. In summary, unless a specific aetiologic factor has been identified and the patient is in psychological need, its better to ‘allow’ enjoyable things - and patients enjoy things better once the doctor has ‘allowed’ them - which would even include sunbathing where the relaxation and comfort that some people seem to derive from this pastime may well outweigh the herpetogenic effect of ultraviolet radiation. Sociosexual implications; self-perception. infectiousness; partner communication These constitute the dominant preoccupation of almost every patient and devolve into concern over genera1 perception of the patient in the light of her having contracted the disease and secondly, how possible transmission of the disease will affect present or future relationships and social interaction with relatives and friends; the two aspects are inter-related and will be jointly discussed. Many patients feel that contraction of this disease has sullied the uprightness of their character and indicates to all and sundry that they are immoral, promiscuous and a ‘scarlet woman’. The practitioner must re-emphasise that the disease is frequently transmitted within a monogamous relationship often from oral/sexual contact - indeed I have encountered the disease in two celibate women within strict religious orders. Strangely, patients will resist this concept and repost that the world ‘does not see it that way’, and at the end of the day, one is obliged to indicate she will have to live as she sees herself
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and not how she erroneously believes the world at large views the issue. The second repost is that she ‘cannot help feeling like this’. It is important to ‘gently’ indicate that she can help it, her mental state offers no advantage to her or her family and that she, as a citizen, has a duty to contribute to society rather than wallowing and bewailing a fate which is not catastrophic on the grand scale of things. Certain patients - particularly homosexual females in my experience - take somewhat unkindly to this kind of counselling but someone has to say it and the vast majority of patients seem to absorb the message into the subconscious which reaps benefit over the next few months while adjusting to the problem. The second negative self-perception is that she is now a ‘carrier’ and virtually a leprous outcast who must be avoided even socially. In some ways, I am quite pleased when this is a significant feature of a patients anxiety as most patients will respond to certain undisputable facts and after some time will usually ditch the ‘carrier’ nonsense. As this relates closely to the likelihood of virus transmission in a sexual setting, I will now present the background of what is known and not known to put the whole question of ‘infectiousness’ into perspective. There are two situations - when lesions are present or when there are no lesions as detected by looking or by feeling in accessible areas of the genital tract. The former is straightforward; patients must be advised to avoid intercourse at these times, not only to avoid transmission but also as the friction of intercourse will often aggravate lesions and encourage spread to related areas of epithelium. Patients do have intercourse when lesions are present. This is an under-recognised factor in virus transmission and the importance of asymptomatic transmission may have been over-emphasised from rather optimistic assessment of patient disinclination at these times; indeed, our own survey has indicated this to be an equal folly of both lay and professional patients, including us lot.2 The following is often forgotten. Patients may have lesions on sites which do not generate discomfort at intercourse; these include extra-introital areas - for example outer labia, clitoris or even the perineum with posteriorly placed lesions. Secondly, lesions can be undetectable, for example high in the vagina or can be minute, painless lesions noticed only at or after intercourse. Thirdly, circumstances of decreased awareness from alcohol, drugs or sleepiness on awakening in the morning are contributory factors and finally, but quite rarely, intercourse can take place in the full awareness of one or both partners. I emphasise the rarity of this last possibility as much aggravation, dislike and distrust can develop where one partner assumes (nearly always wrongly) that the other did not disclose lesions. This happens but in almost every case, lesions were undetectable at intercourse or developed following intercourse. Transmission in the presence of lesions has been discussed in some detail to underscore the notion
that in association with auto-transmission (usually from the mouth) and by inanimate objects (usually towels) the risk of asymptomatic excretion between recurrences is unknown and I question if the increased statistical risk (if any) justifies the psychological burden carried by some of these patients. Thus, a patient should not be advised against intercourse between recurrences; at a more pragmatic level, if the patient is not having intercourse between recurrences, she’s not having intercourse at all which isn’t much fun and is certainly not justified by epidemiological data presently at our disposal. Specific advice on minimising the risk of virus transmission must be included in the practitioner’s check list. As stated, risk of virus transmission is most significantly reduced by avoiding intercourse when lesions are present or if the patient is experiencing symptomotology in the absence of lesions where, a priori, there is more likelihood of infectious virus in secretions. Condoms are protective but not completely, particularly from female to male where virus in vaginal secretions or at extra-introital sites can circumvent the condom; penile lesions, particularly towards or on the glans penis, will not transmit virus given that the condom stays on and does not tear. Contraceptive creams are useful. They contain detergent which kills virus, and if inserted into the vagina prior to intercourse, will kill a significant proportion of infectious virus and, pari passu, reduce the risk of virus transmission. This is a quite popular strategy with ladies who are keeping mum as, excepting the extravagant ramblings of popular American fiction, most people have some inkling of the likelihood of intercourse within the next two or three hours and thus can take this necessary precaution; in addition, there is little chance of being found out as most men haven’t the faintest idea what goes on in the female vagina although it is well to remember that in the event of oral sexual contact, detergent may not be caviar to most palates. Cold sores on the lips, mouth or nose are potent sources of transmission and an episode of oral sex when sores are present will almost certainly transmit type I and I have encountered three cases where there was incontrovertable evidence that the patient had infected her genitalia from sores on her own lips. Kissing in the presence of cold sores followed by oro-genital contact or oro-genital contact followed by genital contact can all ‘passively’ transmit virus to the genital area. Thus, if cold sores are present, sexual contact should be confined to genital or digital-genital contact. A quite frequent mode of transmission arises from lesions on the buttocks or upper thighs - not necessarily from sexual intercourse but from lying together with prolonged approximation of lesions providing ample opportunity, particularly in a warm perspiring situation, for the virus to penetrate the skin of the partner. Weeping lesions should be covered with a waterproof plaster and underclothing or pyjama bottoms although
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vesicular fluid can still be absorbed and soak through to a partner. Lesions should be covered with a plaster prior to intercourse where there can be approximation of skin surfaces or transmission of virus from the hands of a partner to the genital area in the course of love-making. Finally, advice in a contraction emergency - for example when a couple realise post facto that there have may been a lesion present or a condom comes off when lesions are thought to be present is important. As it is quite conceivable that there is virus absorbed but has not yet penetrated the recipient’s cells, the risk of the productive infection being established can certainly be reduced by washing with warm (not hot) soapy water. In our laboratory we have conducted model experiments whereby the earlier and more extensive the washing of tissue surfaces, the lower the proportion of tissue explants that become infected and it is not unreasonable to extrapolate this analogy to the in vivo situati0n.j The practitioner should not dodge issues; a number of women are abashed to ask if, when no lesions are present, she can be touched or receive oral sex without proceeding to unprotected sexual intercourse. In my opinion, this does not constitute a meaningful statistical risk and in 25 years of practice I have only once felt convinced that a patient transmitted virus from the genital area (in the female) to the face of a male; in this particular case, the patient had gross vulva1 herpes and the male was a mentally retarded youth - an unfortunate case. Now to the $64000 question(s) - namely, whether, when and how to disclose herpes genitalis to a new partner. ‘Whether’ is a major dilemma as it would seem the ‘right thing to do’ but the prospective partner might ‘do a runner’ and bang goes a nice relationship. Certain comments will help but still duck the issue. Most (I repeat most) relationships will not be aborted on the wings of this news but there will be catastrophes and the unpalatable possibility remains until there is reduced hysteria and more specific measures to deal with the disease. It’s also true (I suppose) that if the putative relationship cannot withstand this complication then it is foredoomed in any case but, as the patient will frequently point out there may not be a relationship to be foredoomed. In my experience, approximately 85% of patients discuss the problem prior to onset of sexual relations, approximately 5% only once the couple decide to no longer use barrier contraception and the remaining 5% of patients keep mum. Interestingly, none of the last group - who took a conscious decision to not disclose - have subsequently transmitted the infection as far as can be reasonably adjudged. This may relate to increased awareness and caution on their part as a kind of moral quid pro quo for non-disclosure. I recall a female patient who reported transmission to her unknowing boyfriend, assured him that she would nevertheless continue the relationship which impressed her boyfriend to
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the extent that he brought forward the marriage date by 6 months; 1 month following marriage, the lady had a recurrence whereupon the new husband assumed he had transmitted this to his new wife and was even more moved by her loyalty and stoicism. The final outcome was actually favourable as each considered the other a saint and the herpes problem is now a dead duck; even the devil works in wondrous ways. This is all jolly interesting but the patient is still waiting to hear what to do. While in the last analysis the patient must decide for herself, my general advice would be that the situation should be disclosed prior to unprotected sexual intercourse but if the patient has decided to not disclose, she should not be condemned or censured by the practitioner as the risk in a patient with a bit of nouse who knows the risks and how to minimise them (vide supra) offers a quite low risk of transmission in comparison to the base or background risk of contracting the infection. A second question is when to raise the issue. There seems little need prior to onset of sexual relations as, until then ones’ genitals are ones’ own business. This allows time to assess the likely future of the relationship and if the relationship is a non-starter a big rigmarole about herpes is neither needed nor desirable. This leads to the third question, namely how to introduce and discuss herpes genitalis with a new or an established partner who is as yet unaware of the problem. Patients (and us) tend to believe what they hear and there is no doubt that the more the patient makes of it the more the partner will make of it. A low-key delivery is best without preannouncement that there is ‘something we should talk about over dinner’; it will be something of an anticlimax when a partner launches into a tale of genital herpes over a candle-lit dinner. A sometime difficulty is that sexual relations have been proceeding without disclosure and in this instance patients often downplay the frequency of recurrences or even the certitude of the diagnosis towards ameliorating anticipated partner aggravation and in truth this seems to be a useful - if not pristine pure - approach to the problem. The patient should certainly be told that once the issue has been aired and the relationship is proceeding (as it will usually do) to not go on about it. The patient agonises that if intercourse is not ‘herpetically possible’, the relationship will collapse (which is nonsense) and I cannot think of a relationship which foundered purely on the rocks of deprivation of unprotected sexual intercourse for intervals throughout the year. Certain patients will get to enjoy being centre stage and often cannot understand why their partner is not more interested in their ‘herpes’ and, in fact, they are taking the whole thing rather lightly or even indifferently. The point must be made that genitals are rather akin to haemorrhoids, corns, discharges and periods which are of limited general interest and there is a danger _ which I have observed in an alarming number of
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cases - that the relationship will founder - not because of herpes or sex or anything to do with genitals per se - but because the patient has become the big bore and ascribes all past, present and future failings in life to the disease. This syndrome can arise spontaneously and then be fuelled by family, friends, medical attendants and especially by the sexual partner particularly where there is some suspicion that he was the source of infection and now must atone by excessive attention to the person he infected with the disease. This situation requires diplomacy and tactful firmness but does represent a situation where the practitioner - having got the feel of the couple - can make an important contribution towards their future happiness. Herpes neonatorum
The third most prevalent anxiety concerns the possible effect on herpes genitalis on a baby. This aspect has been handled quite irresponsibly by certain sections of the media particularly in the USA. There is no evidence of transplacental virus transmission nor hazard to the foetus within intact uterine membranes. The patient can be told quite categorically that in the absence of any other complications, if there is no clinical or laboratory evidence of herpes genitalis during labour or when the membranes have ruptured, then Caesarean section will not be necessary. If a patient happens to be in hospital prior to delivery, it makes sense to test for virus in the genital tract remembering to ask the laboratory to provide an (albeit) provisional report prior and not following delivery(!) The whole problem has been exaggerated in the public perception and I have never encountered a case of herpes neonatorum in the infant of a mother who entered pregnancy with recurrent herpes genitalis. Nevertheless, there is no point in being too tense about everything - an occupational hazard of obstetrics - and if an elderly primagravid patient is set fair to spend the entire pregnancy agonising over herpes genitalis, then there may be a case for abandoning obstetrical purity and deciding on Caesarean section at an early stage, telling the patient the plan, whereupon patient, her family and her medical attendants will have a more tranquil pregnancy. Advice is frequently sought concerning contraction of herpes during the postnatal period. It is rare for a serious disseminated herpetic infection to develop in by an infant beyond the first 3 weeks of life and it is ridiculous to try to prevent Granny kissing the baby because she was noted to have herpes on her face a couple of years ago. At the same time, it is wise to avoid kissing babies (or anyone else for that matter) when there are obvious cold sores on the mouth. In summary, a patient should be toid there is no bar to becoming pregnant on account of recurrent herpes genitalis but that she should advise her medical attendants of this condition. It is most unlikely that
she will require a Caesarean section solely on account of a recurrence of herpes genitalis but if she does, it’s not the end of the world. Carcinoma of the cervix
An association has been proposed between type 2 herpes simplex virus infection and carcinoma of the uterine cervix; this association has arisen from epidemiological studies and from in vitro studies where the virus disabled in some way - most usually by ultraviolet radiation - has induced oncogenic transformation in a non-oncogenic cell line; the cells then given rise to tumours in homogenic animal species. 3-7 Koch’s postulates have not been entirely satisfied; some epidemiological studies have not confirmed this relationship and, at a commonsense level, there are patients with carcinoma of the cervix who have never had herpes simplex virus type 2 and patients with herpes virus type 2 who (thankfully) have not and will not develop cancer of the cervix. A decline in belief in this association did not arise from such reasonable observations but from recent evidence that human papilloma virus (HPV) might be associated with pre-invasive or invasive changes in the cervix. This is somehow taken to make HSV a less likely agent as if HSV and HPV were competing for the glory of being the cause of cancer while the truth is that if one virus can induce carcinomatous change, this increases the likelihood that an agent of similar anatomy and physiology could do likewise or act synergistically in an oncological role. In summary, it has never been postulated that HSV2 is the exclusive aetiological agent(s) of cervical cancer but may be associated with increased risk of pre-invasive or invasive changes. If the patient introduces the subject, it should be pointed out that there may be a small increased risk of cervical cancer which is eliminated by regular cervical cytology; additionally, if the question of hysterectomy arises for other indication, then it is not unreasonable that foreknowledge of the history of herpetic cervicitis could just tip the balance in favour of that procedure. Finally, it is worth considering perceived complications of this disease which can be thoroughly put to rest in discussion with the patient. Herpes genitalis is not life-threatening and does not decrease life expectancy. Healing lesions can leave scars which are more marked in lesions which have become secondarily infected with pyogenic bacteria but in my experience these scars fade with time and in one patient who had had virtually continuous penile herpes for 40 years there was no residual evidence of scarring or fibrosis. There is no evidence to associate the disease with infertility, impotence or other sexual dysfunction other than might be mediated via psychological processes associated with the disease. There is no evidence that the disease weakens resistence to other infections or more specifically to HIV related disease through a general depression of
PSYCHOTHERAPEUTIC
the immune system; recent evidence that treatment of AIDS patients with anti-herpetic drugs - mainly designed towards control of coincidence cytomegalovirus infection - is a different issue and does not as some patients have interpreted - indicate that herpes simplex is a precedent of AIDS or that the patient is now more likely to contract the disease. Conclusion Herpes genitalis provides a unique opportunity to practice the art of medicine. The main strategies of management comprise talking to the patient, providing appropriate advice, answering questions from the patient or their partners and generally setting the right relationship between the patient and the profession. It is not a piece of cake; personal experience makes for more comfortable consultations without the gloomy foreboding while awaiting a patient who is still having frequent tiresome recurrences notwithstanding your best efforts. Avoid becoming ‘decisive’ and telling the patient that ‘no more can be done’ which you can’t possibly know anyway and is the last straw for the patient who now feels totally rejected. Relax, it’s alright to say you don’t know what to do but you wiI1 keep trying and working with the patient. She won’t be angry or think the less of you; it is not the end but the beginning of a journey together towards a destination of improving
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her wellbeing. During the last 2 decades I have embarked on many such journeys and it has been a rare pleasure to meet, befriend and care for so many nice ladies. References Turyk ME, Wilbanks GD, Benson C, et al. Therapeutic efficacy of Skinner vaccine against herpes genitalis in prospective double-blind placebo-controlled trial. 1993: in preparation Pate1 S, Skinner GRB. Prolonged survival of herpes simplex virus within cells outwith the human body. 1993; in preparation Skinner GRB. Thouless ME, Jordan JA. Antibodies to type I and type 2 herpes virus in women with abnormal cervical cytology. Journal of Obstetrics and Gynaecology of the British Commonwealth 1971; 68: 1031-1038 Skinner GRB. Transformation of primary hamster embryo fibroblasts by type 2 simplex virus: evidence for a ‘hit-andrun’ mechanism. British Journal of Experimental Pathology 1976; 57: 361-376 Skinner GRB, Whitney JE, Hartley CE. Prevalence of typespecific antibody against type 1 and type 2 herpes simplex virus in women with abnormal cervical cytology: evidence towards pre-pubertal vaccination of sero-negative female subjects. Arch Viral 1977; 54: 21 l-221 Coleman DV, Moore AR, Beckwith P, et al. Prognostic significance of HSV antibody status in women with dysplasia of uterine cervix (CIN 1 or 2). Br J Obstet Gynaecol 1983; 90: 421-427 Chen Min-Hui, Dong Chang-Yuan. Liu Zhi-Hui, Skinner GRB, Hartley CE. Prevention of type 2 herpes simplex virus induced cervical carcinoma in mice by prior immunisation with a vaccine prepared from type 1 herpes simplex virus vaccine. Vaccine 1983; I: 13-17