Venereal Diseases

Genital Herpes

Genital herpes is a common sexually transmitted disease that is caused by the herpes simplex virus. It is estimated that at least one in five adults in the United States is infected with the virus, but many people have no symptoms and do not realize that they are infected.

After getting infected, most people have recurrent episodes of genital ulcers for several years. Although the infection can stay in the body for years, symptom outbreaks become less and less common over time. The infection can be managed with medication and self-care measures.

People who have genital herpes are encouraged to talk to their sexual partner, use condoms, and take other preventive measures to prevent transmission (passing the virus to others). Genital herpes can be spread even when there are no visible ulcers or blisters.

Being diagnosed with genital herpes can be an emotional and distressing experience, and it is important to speak with your healthcare provider about how to manage symptoms and avoid passing the virus to sexual partners. Counseling and support groups can also be beneficial to individuals living with genital herpes infection.

The symptoms of genital herpes can vary widely, depending upon whether you are having an initial or recurrent episode. However, many people infected with genital herpes never experience symptoms.

Initial episode – For most people, the first herpes outbreak is the most severe, and symptoms tend to be more severe in women than men. The first outbreak usually occurs within a few weeks after infection with the virus. Symptoms tend to resolve within two to three weeks.

The signs of an initial (or primary) episode of genital herpes include multiple blisters in the genital area. For women, the sites most frequently involved include the vagina, vulva, buttocks, anus, and thighs; for men, the penis, scrotum, anus, buttocks and thighs may be affected. Signs and symptoms typically include blisters that become painful ulcers. Blisters on the penis or outer labia may crust over and heal. New lesions may develop for up to five to seven days after the first group appears.

There may also be tender, swollen lymph nodes in the groin, flu-like symptoms, such as joint pain, fever, and headache, and it may be painful to urinate.

A small percentage of people can develop headache, nausea and vomiting, or difficulty urinating. These symptoms occur when the herpes infection affects the nervous system.

People who have pain when they try to defecate may have proctitis (inflammation of the rectum or anus). Men who have sex with men are more prone to this complication than other patients.

Latent stage – After the initial outbreak, the virus travels to a bundle of nerves at the base of the spine, where it remains inactive for a period of time. This is called the latent stage. There are no symptoms during this stage.

Recurrent episodes – Many people experience recurrent episodes of genital herpes, which occur when the virus travels through nerves to the skin’s surface, causing an outbreak of ulcers. These recurrent episodes tend to be milder than the initial outbreak.

Ulcers may develop in the same area as those of the first outbreak, or may appear in other areas. It is possible to develop lesions in areas where there was no direct contact; for example, it is possible to have lesions around the anus without having had anal sex.

Likelihood of recurrence – Genital herpes recurs frequently in many patients, especially in those with HSV type 2. Over time, recurrences generally become less frequent and less severe. However, it is also possible to have a recurrence a few years after the initial HSV infection was acquired. This type of delayed herpes outbreak can be especially distressing if you never had symptoms during the initial infection, leading you to worry about the sexual activities of your past or present sexual partner(s).

Prodrome – As many as 50 percent of people with a recurrent outbreak experience mild symptoms before ulcers develop. These are called prodromal symptoms, and may include itching, tingling, or pain in the buttocks, legs, or hips. Recurrences tend to become less frequent and less severe after the first year.

Triggers for recurrence – Illness, stress, sunlight, and fatigue can trigger recurrent herpes outbreaks. In women, menstrual periods may trigger an outbreak.

The first time a person has noticeable signs or symptoms of herpes may not be the initial episode. For example, it is possible to be infected for the first time, have few or no symptoms, and then have a recurrent outbreak with noticeable symptoms several years later. For this reason, it is often difficult to determine when the initial infection occurred, especially if a person has had more than one sexual partner. Thus, a current sexual partner may not be the source of the infection.

The diagnosis of genital herpes is based on an individual’s medical history, their signs and symptoms, and the results of tests. It is important to distinguish genital herpes from other sexually transmitted diseases, particularly those that also produce genital ulcers, such as syphilis and chancroid.

Several diagnostic tests may also be used to diagnose genital herpes. These tests can usually confirm infection and identify which virus (HSV-1 or HSV-2) is responsible. The choice of testing will depend on your symptoms and whether you have any blisters or ulcers at the time you see your doctor. Polymerase chain reaction (PCR)-based testing and culture are the preferred tests for a patient presenting with active ulcers.

Polymerase chain reaction (PCR) test – The PCR test is a very sensitive test for identifying the herpes virus in cells and secretions from the urinary and genital tracts. The PCR test is more sensitive than the culture test, but is not always used due to its higher cost.

Culture test — A culture test determines if herpes simplex virus is present in blisters or ulcers. However, a herpes culture detects the virus in only about 50 percent of individuals with genital ulcers. The culture is more likely to detect the virus when ulcers are new and open, as compared to when they are older and healing. Therefore, it is important to see a healthcare provider within 48 hours of the first symptoms. The test is also more sensitive in individuals experiencing an initial episode of genital herpes than in individuals experiencing a recurrent episode.

Blood test – Blood tests are often used when a person has no visible ulcers at the time of the patient visit, but has a history of genital ulcers or believes he or she may have been exposed to the herpes virus in the past. However, routine screening for herpes simplex virus-1 or 2 (HSV-1 or HSV-2) is not recommended in asymptomatic adolescents and adults.

The blood test can detect antibodies (proteins that are produced by the body in response to a foreign substance) to HSV type 1 and type 2. Having a positive test for these antibodies indicates that the person was infected with the virus at some time in the past, although it is usually not possible to know when or from whom the virus was transmitted.

The results of antibody testing may be negative early on during the initial episode of infection since antibody formation takes a few weeks. The antibody test remains positive for life.

Blood tests may be helpful for couples if one person has a history of genital herpes and the other does not. If the partner has not been infected, then it is important to discuss ways to prevent transmission.

Although there is no cure for genital herpes, the infection can be managed with antiviral drug therapy and self-care measures.

Antiviral medications — Three antiviral medications are used to treat genital herpes: acyclovir (Zovirax®), famciclovir (Famvir®), and valacyclovir (Valtrex®). They are usually taken by mouth (in pill form). Acyclovir (Zovirax®) is the oldest and least expensive antiviral medication. It usually requires more frequent dosing than famciclovir and valacyclovir.

Treatment is most likely to be effective if it is started within 72 hours of the first symptoms. People with a history of recurrent genital herpes are often advised to keep a supply of antiviral medication in their home, which they can initiate at the first signs of a recurrence (eg, pain or tingling symptoms or at the sign of their first blister).

Suppressive therapy — Suppressive therapy is low dose antiviral treatment that is taken every day to prevent outbreaks.

The advantage of suppressive therapy is that it decreases the frequency and duration of recurrences, and can reduce the risk of transmitting HSV to an uninfected sex partner.

Suppressive therapy may be recommended if you have six or more recurrences each year or have a weakened immune system due to the human immunodeficiency virus (HIV), use of immune-suppressing drugs, or other factors.

Because all sexually active people are at some risk of acquiring genital herpes, it is important to communicate with a sexual partner before the first sexual encounter. Discussing herpes can be uncomfortable and embarrassing, but it ensures that both partners understand the possibility of transmitting the infection through sexual activity. Regular testing for sexually transmitted diseases is also recommended, especially if one or both partners have other sexual partners.

After being diagnosed with genital herpes, it is still possible to have a safe and healthy sex life; however, it is important to take precautions.

  • Using a latex condom with every sexual encounter can reduce the risk of herpes transmission when only one member of a couple has the virus. The more often you use latex condoms, the lower the risk of transmission.
  • Even when a person has no ulcers or blisters, use of a condom is recommended.
  • Sex should be avoided any time genital ulcers are present. Oral sex should be avoided if there are ulcers or blisters around the mouth because a person with the oral form of herpes can give a partner genital herpes by performing oral sex.

Genital Warts

Condyloma acuminata (genital warts) is a sexually transmitted infection that causes small, skin-colored or pink growths on the labia, at the opening of the vagina, or around or inside the anus. Genital warts are the most common sexually transmitted infection in the United States. Although warts affect both genders, more women than men are diagnosed with warts.

Genital warts are caused by the human papillomavirus (HPV). There are over 100 different types of HPV, which can cause different types of problems. HPV types 6 and 11 are the major causes of warts, and types 16 and 18 are the major causes of cervical cancer. The wart-producing strains of HPV do not typically cause cancer.

HPV is spread by direct skin-to-skin contact, including sexual intercourse, oral sex, anal sex, or any other contact involving the genital area (eg, hand-to-genital contact). It is not possible to become infected with HPV by touching a toilet seat. Most people with the virus do not have visible warts, but can still transmit the virus. Treating the warts may not decrease the chance of spreading the virus. Therefore, all people who are sexually active should be regarded as potential sources of HPV, not just those with visible warts.

Warts may appear weeks to a year or more after being exposed to the virus; it is not usually possible to know when or how you became infected.

Warts are skin-colored or pink, and may be smooth and flat or raised with a rough texture. They are usually located on the labia or at the opening of the vagina, but can also be around or inside the anus.

Most women with warts do not have any symptoms at all. Less commonly, there may be itching, burning, or tenderness in the genital area.

Genital warts are diagnosed based on an exam. If your doctor or nurse is not certain that the area is a wart, he or she may perform a biopsy (remove a small piece of tissue).

There are many ways to treat genital warts: some involve using a medicine and some involve a procedure. Even with treatment, it is possible that the warts will come back within a few weeks or months. This is because treating the warts does not necessarily get rid of all of the virus (HPV) causing the warts. Some cells in the normal-appearing genital skin and vagina may remain infected with HPV. There is currently no treatment that will permanently get rid of HPV in all infected cells, but most people will clear the virus and the warts with their own immune systems within two years. The “best” treatment for warts depends on how many warts you have, where they are located, and you and your doctor preferences. Warts do not necessarily need to be treated, especially if they are not bothersome.

Medical treatments – Medical treatments include creams or liquids that you or your doctor or nurse must apply to the wart. All of these treatments must be used one or more times per week for several weeks, until the wart(s) goes away.

Podophyllin – Podophyllin is a treatment that destroys the wart tissue. A doctor or nurse applies the solution directly to the wart(s) with a cotton swab, and you should wash the area one to four hours later. The treatment is repeated weekly for four to six weeks, or until the lesions have cleared. Side effects range from mild skin irritation to pain and skin ulcers. Podophyllin is not used in pregnant women.

Podofilox – Podofilox is similar to podophyllin, but you can apply podofilox (Condylox) at home. Using a cotton swab, you apply a gel or liquid solution to the wart(s) twice daily for three days in a row. Then you use no treatment for the next four days. You can repeat this cycle up to four times until the warts have gone away. Podofilox is not used in pregnant women. Side effects of podofilox are similar to those of podophyllin.

Bichloroacetic acid and trichloroacetic acid – Both bichloroacetic acid (BCA) and trichloroacetic acid (TCA) are acids that destroy the wart tissue. TCA is used most commonly, and must be applied by a doctor or nurse. The provider applies the acid to the wart once per week for four to six weeks, or until the warts go away. Side effects of TCA include pain and burning. TCA is safe for use during pregnancy.

Imiquimod – Imiquimod (Aldara) is a cream that triggers the immune system to get rid of the wart. You can apply the cream directly to the wart (generally at bedtime), and then wash the area with water six to 10 hours later. You use the cream three days per week for up to 16 weeks. Mild irritation and redness are normal while using imiquimod, and mean that the treatment is working. Imiquimod is not recommended during pregnancy.

Interferon – Interferon is a medication that causes an immune response. It is available in several treatment forms (injection, topical gel), but studies have shown that it most effective when given as an injection into the wart.

Side effects of interferon include flu-like symptoms, fatigue, lack of appetite, and pain. Interferon is not usually recommended as a first-line treatment. It may be used in combination with surgical and/or other medical treatments, especially with warts that do not improve with other treatments. Interferon is not safe during pregnancy.

Sinecatechins – Sinecatechins (eg, Veregen) is a botanical product that can be self-administered. The exact mechanism of action of catechins is unknown, but they have both antioxidant and immune enhancing activity. The ointment is placed on each external wart three times each day for up to 16 weeks. It should not be used in the vagina or anus, in immunocompromised women, or in women with active herpes. It should be washed off of the skin before sexual contact or before inserting a tampon into the vagina, and it can weaken the latex in condoms and diaphragms.

In trials of this therapy, 5 percent of users discontinued the drug due to side effects and almost 90 percent reported local application site reactions, some of which were severe (itching, redness, pain, inflammation, ulceration, swelling, burning, small blisters).

Surgical treatment – Surgical treatments include treatments that remove the wart (called excision) and treatments that destroy (freeze, burn) the wart. These treatments are often used in combination. Some surgical treatments can be done in the office while others are done in the operating room. Surgical treatments are considered safe in pregnancy, and may be recommended for:

  • Warts that do not respond to medical therapy
  • Large areas of warts, where medical therapy alone is often inadequate
  • Warts involving the vagina, urethra, or anus
  • Areas that have pre-cancerous changes in addition to warts

Cryotherapy – Cryotherapy uses a chemical to freeze the wart. The treatment can be done in the office, and does not usually require any anesthesia.

Cryotherapy often causes pain during the procedure; other side effects can include skin irritation, swelling, blistering, and ulceration. Cryotherapy can be used during pregnancy.

Electrocautery – Electrocautery uses electrical energy to burn away warts. Treatment is usually done in an operating room using local anesthesia to prevent pain.

Excision – Excision involves using surgery to remove the wart. Most people are treated in the operating room using anesthesia to prevent pain. Rarely, excision causes pain, scarring, and infection.

Laser – Lasers produce light energy, which destroys warts. Physicians who perform laser treatment require specific training and specialized equipment. Laser treatment is done in the operating room using local anesthesia to prevent pain.

Laser therapy may be recommended if you have multiple warts spread over a large area. Risks of laser surgery include scarring, pain, and changes in the skin (usually lightened color).

Because all sexually active people are at some risk of acquiring genital herpes, it is important to communicate with a sexual partner before the first sexual encounter. Discussing herpes can be uncomfortable and embarrassing, but it ensures that both partners understand the possibility of transmitting the infection through sexual activity. Regular testing for sexually transmitted diseases is also recommended, especially if one or both partners have other sexual partners.

After being diagnosed with genital herpes, it is still possible to have a safe and healthy sex life; however, it is important to take precautions.

  • Using a latex condom with every sexual encounter can reduce the risk of herpes transmission when only one member of a couple has the virus. The more often you use latex condoms, the lower the risk of transmission.
  • Even when a person has no ulcers or blisters, use of a condom is recommended.
  • Sex should be avoided any time genital ulcers are present. Oral sex should be avoided if there are ulcers or blisters around the mouth because a person with the oral form of herpes can give a partner genital herpes by performing oral sex.

HPV vaccine – Two vaccines, quadrivalent (commercial name Gardasil) and 9-valent (commercial name Gardasil 9), are available for prevention of genital warts. Gardasil helps prevent infection from four types of HPV (types 6, 11, 16, and 18), and Gardasil 9 adds five additional types of HPV prevention. These vaccines will help prevent most cases of genital warts (caused by HPV 6 and 11) and cervical cancer (caused by HPV 16, 18, and the other five HPV types). Only Gardasil 9 is available in the United States. The vaccines will not treat an HPV infection or warts that have already occurred.

Another vaccine, Cervarix, helps prevent infection from two types of HPV (types 16 and 18), thus it helps to prevent most cases of cervical cancer, but not genital warts.

All of these vaccines are safe. An article about the HPV vaccine is available separately.

Sexual contact – Avoiding people who have genital warts or HPV can reduce your risk of becoming infected with HPV. However, from a practical standpoint this is difficult, as many people are infected with HPV and do not have any visible warts. Condoms do not provide complete protection against warts or HPV; areas not covered by the condom can spread HPV from one person to another.

If you have genital warts or HPV and you are worried about infecting your sex partner, have an honest talk before you have sex. Explain that you have HPV, that it is very common, and that most people are asymptomatic. There is no test for looking for HPV on the genitals. There is a test to find HPV on the cervix, but this does not check for the type of HPV that causes genital warts. Cervical HPV and external genital HPV are usually different.


Syphilis is a sexually transmitted infection. It is caused by a bacterium called Treponema pallidum.

You can catch syphilis when you have sex with someone who already has the infection. This can be by vaginal sex, oral sex or anal sex. Pregnant women can pass it to their baby. The infection is more common in men who have sex with other men, people who frequently change sexual partners and who do not use condoms during sex. Even if you have had syphilis before, you can still catch it again.

The signs and symptoms are the same in both men and women. There are 4 stages of infection.

  1. Primary syphilis An ulcer (chancre) develops where the bacteria enters the body, usually about 2 – 3 weeks after having sex with an infected person, but it may appear anytime up to three months later. There is usually one ulcer which is painless and this is most commonly on the penis in men, on the vulva or vagina in women, or on the anus. Depending on where the ulcer is, you may not notice it. The ulcer may take up to 6 weeks to heal and is very infectious to sexual partners. Occasionally there may be several ulcers, they may be painful, or in places such as the mouth and lips. 2 / 3
  2. Secondary syphilis Secondary syphilis develops 3-6 weeks after the appearance of the ulcer if you do not get treatment. This is caused by the bacteria spreading in your blood stream. You may notice a skin rash, often including the palms of the hands and soles of the feet, lumps in the genital area, white patches in the mouth, swollen glands, or less commonly, patchy hair loss, deafness, eye problems, inflammation of the liver, kidneys or brain. Secondary syphilis is very infectious to sexual partners. Without treatment, the rash and other symptoms from secondary syphilis usually disappear after severalweeks. However, the symptoms may ‘come and go’ for up to two years.
  3. Latent (hidden) syphilis After the symptoms of secondary syphilis have cleared, you may not have any symptoms for several years, but the infection can be found on a blood test.
  4. Tertiary syphilis About 1 in 10 people with untreated syphilis will develop serious damage of the nervous system, brain,bones, or heart. This may be many years later. Key pointsSyphilis is a sexually transmitted infection It is easily passed from one person to another during sex, including oral sex It often causes no symptoms Treatment is simple If syphilis is not treated it can cause serious long term health problems You can usually protect yourself by ALWAYS using condoms when you have sex

Yes, if you have an ulcer which might be caused by syphilis, it is possible to take a swab from the ulcer to make the diagnosis. A blood test will need to be taken too and sent to a laboratory where it will be tested for antibodies against the bacteria that cause syphilis. For some people syphilis will not show up on the test straight away so it might need to be repeated. If you think you have been in contact with syphilis or have symptoms that could be syphilis you should visit your family doctor or local sexual health or venereology/dermatology clinic. If you have syphilis, you should also be tested for other sexually transmitted infections, as you can have more than one infection at the same time. You should have a test for HIV infection.

It is important to receive treatment for syphilis as quickly as possible, as the infection can cause complications and serious health problems if it is left untreated. Syphilis is treated with a course of antibiotics, usually penicillin injections.

You should avoid sex until after both you and your partner(s) have finished all your treatment and your symptoms have gone.

Syphilis is unlikely to lead to any long-term problems if it is treated quickly. However, without treatment syphilis can spread to other parts of your body and cause serious problems. In 1 in 10 cases, where syphilis has been left untreated, it can spread through the bloodstream to cause infections in other parts of your body, such as your bones, heart and brain. This may not show up for several years. Once you have had treatment for syphilis, some of your blood tests will always be positive. This does not mean you need further treatment but you need to remember that you have been treated for syphilis (and keep a copy of you blood results) so you can tell doctors in the future if they ask you.