Genital herpes in women. Features of the course of urethritis depending on the pathogen Herpetic urethritis in men symptoms

Bacterial urethritis. The causative agents are: staphylococci, streptococci, Escherichia coli, gardnerella, etc. The infection can enter the urethra through sexual contact, as well as due to its spread from the genitourinary tract with pyelonephritis, prostatitis, vesiculitis, urethral injury. More than 230 strains of bacteria have been isolated, which, under a certain situation, are able to recognize inflammation of the urethral mucosa.

The average duration of the incubation period for bacterial urethritis is 12-14 days (from 2 to 20 days). More often their clinical course is asymptomatic, sluggish. Less commonly, bacterial urethritis becomes acute.

Urethritis caused by diplococci, similar to gonococci (pseudogonococci), usually occurs as an acute urethritis.

Gardnerella, as a rule, cause oligosymptomatic urethritis, often ending in self-healing.

Bacterial urethritis often (in 30% or more) ends with complications (balanoposthitis, epididymitis, prostatitis, cystitis, etc.).

Chlamydial urethritis.

Caused by obligate intracellular bacteria, which are the most common cause occurrence of urethritis in men. According to various researchers, 1.5 million people fall ill with urogenital chlamydia every year in Russia.

Chlamydia go through extracellular and intracellular stages of development. A mature extracellular infectious form is an elementary body that can penetrate intracellularly. Intracellular elementary bodies are transformed into reticular bodies capable of growth and division. Elementary bodies are resistant, and reticular bodies are susceptible to antibiotic therapy.

The average duration of the incubation period is 3-4 weeks. The source of infection is a patient with an asymptomatic form of an acute or chronic disease.

Transmission occurs by contact (sexual) through genital-genital, genital-anal and oral-genital contacts, as well as non-sexually - through the placenta, during childbirth, by household means, due to contamination (from the genitals to the eyes with hands, in violation of hygiene rules).

In men, chlamydial urethritis in 70% of cases proceeds as an asymptomatic or asymptomatic inflammation (with scanty mucopurulent discharge), which can last for several months. Much less often (in 5%), urethritis can be acute, while inflammation is not much different from gonococcal lesions. In 25% of cases, chlamydial urethritis can have a subacute course, not much different from chronic, except perhaps more abundant discharge from the urethra, especially in the morning. In the initial stages of the disease, the anterior urethra is affected; in the chronic course, the inflammation passes to the posterior urethra and becomes total. In 30-40% of observations, symptoms of prostatitis, vesiculitis, epididymitis, funiculitis join.

Chlamydial infection does not cause permanent immunity, therefore reinfection is possible due to the exchange of infection with partners. In 2-4% of cases, Reiter's disease develops against the background of chlamydial urethritis.

Reiter's disease. It is characterized by systemic lesions of the genitourinary organs, eyes, joints (like asymmetric reactive arthritis), as well as damage to the skin, mucous membranes and internal organs. It develops as a complication of untreated chlamydia.

Trichomonas urethritis.

Trichomonas is transmitted sexually. Domestic transmission is rare. It can persist in urine for up to 24 hours, in semen for several hours, and survive in damp laundry. The incubation period for Trichomonas urethritis averages 5-15 days. There are the following forms of trichomoniasis: acute, subacute, chronic, trichomonas-denunciation.

In the acute form, the inflammatory process proceeds rapidly with abundant muco-foamy on the first day and with muco-purulent discharge from the urethra from the second day with frequent and painful urination.

With subacute urethritis, the symptoms are less pronounced, discharge from the urethra occurs in small amounts, purulent. The first portion of urine contains purulent flakes.

In chronic trichomonas urethritis, itching, burning, crawling in the urethra, and frequent urination come to the fore. Urethral discharge scanty. Since in chronic urethritis the inflammatory process passes to the posterior urethra, complications develop in the form of prostatitis, vesiculitis, epididymitis, with a long course, the formation of urethral strictures is possible.

Mycoplasmal urethritis.

They are caused by bacteria that have a plastic shell and contain DNA and RNA. The ability of mycoplasmas to take any shape allows them to penetrate bacterial filters.

Infection with mycoplasma infection occurs mainly through sexual contact. Intrauterine infection of the fetus was also established during its passage through the infected birth canal. Mycoplasma attaches to the epithelium of the urethra, can be carried by spermatozoa; in addition, it colonizes the foreskin. The incubation period lasts from 3 to 5 weeks.

There are no specific signs for mycoplasmal urethritis. As a rule, urethritis of mycoplasmal origin proceeds chronically. In this case, there are often lesions of the prostate gland, seminal vesicle, epididymis, which leads to infertility. Attaching to the head of the sperm, mycoplasma can reduce its fertilizing ability. Under certain conditions, mycoplasma infection can cause inflammation of the urinary organs (cystitis, pyelonephritis). Urogenital mycoplasmosis is often combined with intestinal damage (enterocolitis).

Herpetic urethritis.

Cause two serotypes of DNA containing herpes simplex viruses HSV-1 and HSV-2. Herpes is one of the most common human infections.

The disease is transmitted mainly sexually from a patient with genital herpes. Often, the genital virus is also transmitted from a herpes carrier who does not have symptoms of the disease. The method of infection with the virus can be genital-genital, oral-genital, genital-anal. There is a risk of neonatal infection of newborns, which can occur both during the passage of the birth canal and in the postpartum period with active herpetic manifestations in the mother or medical personnel.

During the initial infection with the herpes simplex virus, the virus enters the cells of susceptible mucosal or skin surfaces. It is then taken up by sensory nerve endings and transported to the nerve cells of the dorsal ganglion roots, where it is stored. Infection can be latent when the virus is present in the body without causing disease; and virulent when herpes is activated and causes local lesions. The disease in this case proceeds as chronic, relapsing, cyclic with localized, rarely generalized manifestations.

The initial symptoms of herpetic urethritis may be general complaints: fever, weakness, myalgia, headache. At the same time, there is a burning sensation in the urethra, which increases during urination, soreness of the lymph nodes. On the head, the skin of the penis, on the visible part (possibly on the invisible) of the mucosa of the urethra, a typical development of herpetic elements is noted, accompanied by a burning sensation, itching, and pain in the genital area. Initially, vesicles appear, which erode, become wet, then dry up, forming crusts, which fall off as epithelization progresses. Temporary hyperemia and pigmentation remain at the site of the lesion. A light yellow discharge may appear from the urethra.

Clinical manifestations of primary infection last about 3 weeks, local symptoms appear on the 2-14th day. Recurrent infection in the presence of antibodies to the virus is less pronounced. The clinical picture develops within 8-15 days. Stressful situations, overheating, hypothermia, a decrease in the body's defenses, etc. contribute to recurrence. Herpes, destroying the human immune system, can cause secondary immunodeficiency.

Some researchers note the connection of genital herpes with cervical cancer and prostate cancer.

Candida urethritis.

It is caused by opportunistic yeast-like Candida fungi, of which there are more than 150 species. 7 species are pathogenic for humans.

Candidiasis of the genital organs is more common in women, less often in men. An important role in the pathogenesis of the disease belongs to a decrease in immunity, dysbacteriosis, beriberi, hormonal disorders, diabetes, the condition of mucous membranes. skin! Candidiasis lesions are often combined with other pathogens of sexual infections (chlamydia, ureaplasmas, viruses, etc.).

The incubation period for candidal urethritis lasts from 2 weeks to 1 month, almost always proceeds torpid, rarely begins subacutely. The onset of the disease is accompanied by parasthesia, itching, burning, scanty discharge (thick, mucous). At the same time, diffuse and limited whitish-gray plaques appear on the mucous membrane of the urethra, under which a sharp hyperemia is determined. Candidal urethritis often occurs against the background of treated prostatitis, epididymitis vesiculitis, cystitis caused by other pathogens.

Often with candidal urethritis, there is a lesion of the head and foreskin of the penis. In this case, swelling, hyperemia of the foreskin and glans penis are observed, with areas of whitish-gray plaque, which, when removed, form surface erosion and cracks. Scarring of erosions and cracks in a chronic course can lead to the formation of cicatricial phimosis.

The presence of various types of urethritis pathogens requires timely treatment for a qualified medical care, for a comprehensive examination and the appointment of competent etiotropic treatment. On the basis of our medical clinics, a comprehensive diagnosis of infections transmitted through sexual contact is carried out. The equipment of our centers allows us to quickly and efficiently treat urethritis of any etiology

Our experts will be happy to help you!

Typical recurrent herpes on the skin and mucous membranes of the genital organs, usually in the same place, subjectively: burning, itching is manifested by repeated blisters.

Atypical forms of recurrent herpes, which greatly complicate the diagnosis .

At atypical forms either one of the stages of the development of the inflammatory process in the focus (erythema, blistering), or one of the components of inflammation (edema, hemorrhage, necrosis), or subjective symptoms (itching), which give the appropriate name to the atypical form (erythematous, bullous, hemorrhagic , necrotic, itchy, etc.).

Atypical forms of herpes of the external genitalia in women are more common than in men.

Subclinical (low-symptomatic) form manifested by microsymptomatics: short-term (less than a day) appearance of one or more microcracks, accompanied by slight itching. Sometimes there are no subjective sensations, which reduces the appealability of patients to medical institutions and makes diagnosis difficult.

The subclinical form is detected mainly in the virological examination of the sexual partners of patients with any sexually transmitted infection, or in the examination of couples with impaired fertility.

Clinical diagnosis in abortive course, atypical and subclinical forms of WGH is difficult and can only be made using virological research methods.

A feature of genital herpes is multifocal. The pathological process often involves the lower urethra, the mucous membrane of the anus and rectum.

Organs of the genitourinary system in women and men that may be affected:

• entrance to the vagina;
• vagina;
• the vaginal part of the cervix;
• cervical canal;
• urethra;
• bladder;
• anus;
• ampoule of the rectum;
• mucous membrane of the uterine cavity;
• body of uterus
• the fallopian tubes;
• ovaries;
• prostate;
• seminal vesicles;

Clinical forms

1. typical;
2. atypical;
   • with macrosymptoms;
   • with microsymptoms;
3. Asymptomatic form;

It is very difficult to establish the real frequency of damage to the internal genital organs, both in women and men, since in 25-40%, and according to some data, in 60% of patients, the disease occurs without subjective sensations. It can be assumed that this pathology occurs much more often than it is diagnosed.

With herpes of the internal genitalia, there may be no complaints. Sometimes they note periodically appearing mild mucous discharge from the urethra and from the vagina. In a laboratory study of smears of the discharge canal of the cervix, vagina and urethra, an increased number of leukocytes is periodically noted (30-40 in the field of view of the discharge of the urethra, 200-250 and higher in the field of view when examining smears from the vagina), indicating the presence of an inflammatory process.

The asymptomatic form of genital herpes of the internal genitalia (asymptomatic isolation of the virus) is characterized by the absence of any complaints about the genital area in patients, objective clinical data confirming inflammation. In a laboratory study of a detachable urogenital tract, HSV is isolated, while there are no signs of inflammation (leukocytosis) in smears. In 25-30% of men with idiopathic (when the cause of infertility is not clear) infertility, HSV is excreted from the semen.

It is known that genital herpes, in 70-80% of cases, occurs in the form of a microbial association, in combination with chlamydia, urea-, mycoplasma, strepto-, staphylococci, fungal flora. It is possible that there is a combined lesion of the genitals with HSV, gonococcus, pale treponema, viral diseases transmitted through sexual contact, which indicates the need for a thorough examination of patients to exclude STIs, HIV infection.

Treatment of genital herpes

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A pronounced therapeutic effect in more than 90% of patients during treatment is achieved due to:

• Decades of experience in the treatment of recurrent herpes;
• An integrated approach to therapy;
• Individual selection of antiviral treatment (drugs and regimens) and immunomodulators;
• Experience with anti-relapse therapy;

Herpes can and should be treated

The result of treatment largely depends on the experience and skill of the doctor, as well as on the patient's patience and careful implementation of the doctor's recommendations. The treatment methods we use can significantly reduce the duration of treatment without losing the quality and effectiveness of therapy.

CAN, because the arsenal of antiviral and immune drugs that exists today allows solving many problems that arise in people suffering from recurrent forms (genitals, face, buttocks, and other rarer localizations).
The correct methodological approach to examination and therapy will allow:

1. quickly stop acute manifestations of the disease;
2. to carry out effective immunocorrection;
3. reduce the frequency and intensity of clinical manifestations of the following relapses;
4. significantly increase the duration of interrecurrent periods and achieve many months of clinical remission;

NEED TO, because timely treatment is the prevention of the development of possible complications of a herpes infection:

1. pain syndrome that develops when involved in the infectious process nervous system;
2. the spread of infection, when almost all organ systems can be involved in the infectious process;
3. pathology of pregnancy, fetus and newborn;

Your guarantee is our positive 18-year experience of working with patients suffering from severe complicated forms. We know almost everything about modern medicines (imported and domestic) and existing methods treatment. We identify and eliminate the causes that led to the development of the disease.

Our employees (dermatovenerologists, obstetricians-gynecologists, urologists-andrologists) are the authors guidelines, teaching aids and a course of lectures, according to which Russian doctors are trained; take part in international trials on herpes problems.

Diagnosis of genital herpes

Methods of laboratory diagnostics are fundamentally divided into two groups:

1. isolation and identification of the herpes virus (in cell culture) or detection of the herpes simplex virus antigen from the infected material (in the immunofluorescence reaction, etc.);
2. detection of herpes specific antibodies (IgM, IgG) in blood serum.

When diagnosing herpes, remember that:

• To reduce the likelihood of a false-negative diagnosis, especially with genital herpes and asymptomatic forms of the virus, it is necessary to examine the maximum number of samples from one patient (vaginal discharge, cervical canal, urethra, prostate juice, semen, urine), because. the herpes virus is rarely detected simultaneously in all environments.
• If a herpes infection is suspected, it is necessary to conduct a multiple virological examination of the discharge of the genitourinary system in patients, because a negative result of a single virological test cannot completely rule out the diagnosis.
• The frequency of virus isolation in women largely depends on the phase of the menstrual cycle. More than 70% of patients with herpes, the virus is shed at the beginning of the menstrual cycle.
• The detection of specific IgM immunoglobulins in the absence of IgG or with a 4-fold increase in specific IgG titers in paired blood sera obtained from a patient with an interval of 10-12 days indicates a primary infection.
• The detection of specific IgM immunoglobulins against the background of IgG in the absence of a significant increase in IgG titers in paired sera indicates an exacerbation of chronic herpes infection.
• The detection of IgG titers above the average is an indication for an additional examination of the patient and the detection of the isolation of the herpes virus in the media.

Epidemiology

Genital herpes, being a special case of herpes infection, is one of the most common sexually transmitted diseases, and differs from other diseases of this group by the lifelong carriage of the pathogen in the human body, which determines a high percentage of the formation of recurrent forms of the disease.

Transmission routes

Transmission usually occurs through close contact with an infected or infected person. The virus penetrates through the mucous membranes of the genital organs, urethra, rectum or skin microcracks.

In couples where one of the partners is infected, the probability of infection of the second partner within a year is 10%. In most cases, infection occurs when the infected partner has not had a clinically significant recurrence of genital herpes. Asymptomatic and unrecognized forms of infection play an important role in the spread of the virus. The virus can be shed in semen, cases of infection of women with artificial insemination. Speaking about the ways of transmission of the virus, it is necessary to note the important epidemiological significance of oral-genital contacts, which is associated with an increase in the frequency of isolation of type 1 herpes from the organs of the genitourinary system.

Who gets sick more often?

Among college students, antibodies to the herpes virus type II are detected in 4% of those surveyed, among university students - in 9%, among representatives of the middle strata of society - in 25%; among patients of dermatovenerological clinics with heterosexual orientation - in 26%; among homosexuals and lesbians - 46%, among prostitutes - 70-80%. Antibodies to genital herpes are more often detected in representatives negroid race than whites. Women are infected more often than men with the same number of sexual partners during their lifetime. IN developed countries The virus affects 10-20% of the adult population.

Numerous studies on the general population have shown that the incidence rate increases with age: isolated cases are detected in the group of patients aged 0-14 years; the highest incidence is registered in the age group of 20-29 years; the second peak of incidence falls on 35-40 years.

The main risk factors for developing the virus are a large number of sexual partners throughout life, early onset of sexual activity, homosexuality in men, belonging to the black race, female gender and the presence of sexually transmitted infections in the anamnesis.

Compulsory registration of genital herpes was introduced in the Russian Federation in 1993. During the period 1993-99, the incidence of this virus in Russia increased from 8.5 cases to 16.3 per 100,000 population. The incidence in Moscow has increased from 11.0 to 74.8 cases per 100,000 population and has practically reached the level of European countries.

Clinical features of herpes infection in women

Herpes of the urethra and bladder

Herpetic urethritis in women is subjectively manifested by pain and pain at the beginning of urination, frequent urge to urinate. With herpetic cystitis, hematuria, the appearance of pain at the end of urination, blood in the urine, and pain in the bladder area appear.

Herpetic cystitis

In a woman, it may be the first and only sign of HSV infection of the urogenital area. It often occurs in the first 1-3 months after the onset of sexual activity or change of sexual partner.

The lesion in the anal region is usually a recurrent fissure, which is often the reason for diagnostic errors. Such patients with an erroneous diagnosis of "anus fissure" end up with surgeons. The itchy form of herpes anus and herpetic lesion of hemorrhoids are also difficult to diagnose.

The list of diseases etiologically associated with HSV is constantly increasing. According to the literature, in 3.6% of women suffering from colpitis and leukoplakia of the cervix that are not treatable, HSV is one of the etiological factors of the disease. A new form of latent intrauterine HSV-II infection with localization of the pathological process in the glandular epithelium of the endometrium is described. It has been proven that HSV can cause the development of endometritis and salpingo-oophoritis.

The asymptomatic form of herpes of the internal genitalia is detected in 20-40% of women suffering from RG of the buttocks and thighs. This important circumstance must be taken into account when planning pregnancy in women with this form of WG due to the existing likelihood of developing complications of HSV infection during pregnancy.

The etiopathogenetic role of HSV in cervical cancer has been established. The foregoing emphasizes the growing etiological role of HSV in the structure of diseases of the pelvic organs in women.

herpes and pregnancy

The prevalence of HSV among pregnant women in the US is 22-36%, in Europe 14-19%. Viremia in women during pregnancy can cause fetal death, stillbirth, and premature birth. Herpesviruses cause up to 30% of spontaneous abortions early dates pregnancy and over 50% of late miscarriages, are second only to the rubella virus in terms of teratogenicity (development of fetal deformities).

The most severe forms of neonatal herpes develop when a newborn is infected with the herpes simplex virus during childbirth. With primary HH in the mother, from 30% to 80% of children are infected, with recurrent herpes - 3-5%. Infection of the fetus during delivery, if the mother had herpetic eruptions at the end of pregnancy, occurs in 50% of women with HH; while 60-80% of infected children develop encephalitis.

Genital herpes in men

If the study of herpes of the external genitalia and the adverse effect of herpes infection on the reproductive function of women has been given close attention for many years, then information about the herpes simplex virus as the cause of diseases of the genitourinary system (MPS) in men is very limited. It should be said that it is often very difficult to assess the true role of the herpes simplex virus in the development of the pathology of the MPS organs in men, taking into account the frequent asymptomatic or asymptomatic course of the infection.

herpes urethra

Subjectively, herpes urethra is manifested by pain in the form of burning, sensation of heat, hyperesthesia along the urethra at rest and during urination, pain at the beginning of urination.

The MPS organs in men are in close anatomical and physiological relationship, which does not allow a mechanistic approach to assessing the results of a laboratory study. Thus, the detection of herpes simplex virus in the urine or urethral discharge makes it possible to suspect the possibility of involvement in the infectious process of the prostate gland, even if the herpes simplex virus is not detected in the prostate juice, but there are clinical data on torpid prostatitis.

Bladder herpes

The leading symptoms of herpetic cystitis are the appearance of pain at the end of urination, dysuric phenomena; hematuria is its characteristic manifestation. Patients have a disorder of urination: the frequency, nature of the jet, the amount of urine change. Herpetic cystitis in men is usually secondary and develops as a complication during exacerbation of chronic herpetic urethritis or prostatitis.

Herpes of the anal area and rectum

Herpetic lesions of the anal region and ampulla of the rectum occur in both heterosexual men and homosexuals. The lesion is usually a recurrent fissure.

With damage to the sphincter and mucous membrane of the rectal ampulla (herpetic proctitis), patients are concerned about itching, burning sensation and soreness in the lesion, there are small erosions in the form of superficial cracks with a fixed localization, bleeding during defecation. The appearance of rashes may be accompanied by sharp arching pains in the sigma area, flatulence and tenesmus, which are symptoms of irritation of the pelvic plexus.

Herpes prostate (herpetic prostatitis)

In clinical practice, the diagnosis of chronic herpetic prostatitis is rarely made by urologists. The reason, apparently, is that virological diagnostic methods are not included in the standard examination of patients with chronic prostatitis. The doctor's stereotype of thinking is triggered, and patients are traditionally examined for sexual infections of a non-viral nature.

In the clinical course of prostatitis, functional changes are noted - reproductive changes, pain (with irradiation to the external genitalia, perineum, lower back) and dysuric syndromes.

Often in patients recurrent genital herpes prostatitis proceeds subclinically: in these patients, the diagnosis of prostatitis is made on the basis of the appearance of leukocytosis in the secretion of the prostate and a decrease in the number of lecithin grains.

It must be remembered that herpetic prostatitis can exist as an isolated form of herpes infection. In this case, there are no symptoms of RGH and HSV is not detected in the discharge of the urethra. The etiological diagnosis is based on the detection of the herpes simplex virus in the secretion of the prostate gland, while the pathogenic flora is secreted and in the third portion, urine is absent.

Genital herpes during pregnancy (risk prevention, treatment)

Herpetic urethritis is an inflammation of the urethra caused by the herpes simplex virus. According to statistics, this form of the disease accounts for 0.3 to 2.9% of all cases of non-gonococcal urethritis. The disease is not always accompanied by symptoms.

The herpes virus using PCR is isolated from the urethra of 5.4-7.6% of men. A feature of the pathological process is the lack of spread to the upper parts of the genitourinary system. Herpes does not even affect the entire urethra. The area of ​​inflammation is limited only to its distal part.

In this article you will learn:

Causes of herpetic urethritis

The immediate cause is the herpes simplex virus. In most cases, this is HPV type 2. Less commonly - type 1 (approximately 30% of cases). The disease is transmitted through sexual contact. When infected, not all patients develop inflammation of the urethra. Only one in three suffers from signs of urethritis. In the rest, the affected area is the genitals and the skin near them.

With herpetic urethritis, inflammatory foci form inside the urethra. They are presented:

• small erosions;
• diffusely reddened mucosa;
• vascular spots.

Methods of transmission of genital herpes and the path of the virus in the body

The main mode of transmission of the herpes virus is direct contact. Not surprisingly, in the vast majority of cases, men become infected with this disease during sexual contact.

A feature of herpes is that the virus is able to equally successfully penetrate the body in almost any way possible for it, as a rule - through the mucous membranes, a little less often - through damage to the outer integument of the body: scratches, sores, wounds. This means that regardless of where the herpes is localized in the carrier - on the lips, genitals or other parts of the body - it will equally easily be transferred to the genitals of the infected person upon contact.

herpetic urethritis virus

Related to this is the outbreak and rapid spread of the virus over the past half century. The sexual revolution of the 60s led to the massive popularization of oral sex, which at times increased the number of genital herpes infections from those who suffered from a seemingly harmless enough cold on the lips.

• airborne, which is not typical for the genital as a whole - this is how labial herpes (cold on the lips) is usually transmitted.
• household when using common hygiene products, towels, linen There is also a risk of infection of the child when caring for him from a mother infected with herpes. However, genital herpes is rarely transmitted in this way.

The main gateway for the virus is the mucous membranes of the body. Genital herpes is most often transmitted when viral particles enter the glans penis and anus. Here, men have a slight advantage over women - even if the virus gets on the skin near the vas deferens, the possibilities of its penetration into the tracts themselves are small due to small sizes openings of the urinary canal itself and the presence of biological fluids in it.

Symptoms of herpetic urethritis

Symptoms of herpetic urethritis in men occur 3-7 days after contact: on the penis, the inner surface of the foreskin, in the urethra, local erythema, vesicles appear, which, breaking through, form ulcers framed by a red inflammatory border.

Herpetic eruptions are usually localized in the navicular fossa and do not go beyond the hanging part of the urethra. With ureteroscopy, they look like multiple small erosions, sometimes merging into a larger focus, which is accompanied by pain and fever, inguinal lymphadenitis, dysuria.

There is scanty mucous discharge from the urethra, usually in the form of a morning drop, accompanied by a slight tingling or burning sensation. As a rule, the symptoms of herpetic urethritis disappear after 1-2 weeks. but most patients experience relapses at intervals of weeks to years.

As a rule, relapses of viral urethritis are milder than the primary infection. In the case of a bacterial infection, the discharge becomes purulent, more abundant, and the duration of the disease increases to 3 weeks or more. In sexual partners of patients with herpetic urethritis, long-term endocervicitis is often found, which is also very resistant to ongoing treatment.

Classification of herpetic urethritis

The infection is divided by doctors into 4 main forms. The division into forms is based on the severity of the symptoms of the disease.

1. Light form. The first episode is easy. The patient may complain of a small number of rashes localized intimately, but there are no complaints of fever and deterioration in general well-being, indicating general intoxication. Pathology recurs no more than 4 times a year.
2. Medium form. The first episode is a bit more difficult. The rash is characterized as more widespread, very thick, conspicuous. Localization is possible not only in the genital area, but also in other places. Fever, deterioration of health and other symptoms of viral intoxication are still absent. Relapses occur 5 or more times a year.
3. Severe form. If the infection is severe, the initial episode is considered severe. A thick, numerous eruption is found in the urethra, causing the patient great discomfort, which is difficult or impossible to ignore. The rash may spread to other parts of the body. There are complaints about the symptoms of general intoxication, although mild. The patient draws the doctor's attention to an increase in temperature, a deterioration in general well-being.
4. Very severe form. A very severe form is characterized by frequent relapses that are difficult to control even with medication. The patient complains of a pronounced spread of the rash, which is easily noticed by the doctor during the examination. Also cannot be ignored high temperature and severe symptoms of intoxication. The frequency of recurrence of the disease directly depends on the form of the disease and the characteristics of the patient's immunity.

Diagnostics and therapy

A sign of the presence of infection - detection in scrapings or smears of the pathogen. The material is collected from the base of fresh herpetic lesions of the skin, mucous membranes of the urethra or from intracellular inclusions. To confirm the diagnosis, PCR diagnostics are performed, an indirect agglutination reaction (the herpes virus is fixed on sensitized erythrocytes). This is a quick study, the result can be known within a few hours.

Modern examination includes specific and sensitive methods for detecting the antigen of the virus. This is a direct immunofluorescence reaction, in which the nuclei of the affected structures are highlighted in bright green. Treatment of urethritis of herpetic nature is complex. The disease proceeds latently. Special principles have been developed that guarantee the successful treatment of genital herpes:

• treatment of the primary clinical episode of herpes;
• fight against relapses;
• long-term suppressive therapy.

Primary infection with genital herpes is treated with:

• Acyclovir (three times a day for a week);
• Famciclovir (5 times a day, 7-10 days);
• Valaciclovir (twice a day, 7-10 days).

Therapy of the disease is important to start at an early stage, the effectiveness and duration of treatment depends on it. With a poor result of treatment after the tenth day, it is possible to continue the course of taking the medication or replace it with an effective analogue.

The drug of choice in the treatment of the disease is Acyclovir. Can it cure herpes? Usually, this remedy is quite successful in fighting the disease. It has been proven that the drug, with its timely and proper use, reduces the prevalence of the virus, the severity of clinical symptoms. It is prescribed in tablet form, in the form of injections or topically (3-5% acyclovir ointment).

What is dangerous herpes in the bladder

The virus negatively affects the entire reproductive and reproductive system. Usually infection is not limited to one organ. Possible complications depending on the location of the lesion, and the type of disease:

1. Chronic herpes of the bladder - leads to the appearance of wounds and damage to the integrity of the structure, up to rupture of the walls.
2. Infertility and involuntary abortion - if the infection passes to the genitals, the woman cannot bear the child normally. With prolonged damage, scars appear in the genital tract, preventing natural fertilization.
3. Violation of the kidneys - a worsened outflow of urine, the likelihood of developing reflux (reverse reflux of urine) leads to severe pathologies. Patients are diagnosed with renal failure, pyelonephritis.
4. Problems with the bladder in men quickly affect the functions of the prostate gland, often becoming the cause of the development of prostatitis.

A viral illness will not go away on its own. Perhaps a temporary reduction in symptomatic manifestations. In this case, the disease will develop in a recurrent, chronic form. will continue Negative influence herpes virus on the bladder, which will lead to the appearance of ulcers, rupture of the walls and partial loss of function of damaged tissues.

Genital and simple herpes are not cured on their own. Long-term drug therapy is required. Folk remedies and alternative medicine are ineffective.

How is this pathology treated?

First, you need a reliable diagnosis from a doctor who treats urethritis, so as not to harm yourself with self-medication. It is not easy to treat herpes urethritis, since the disease often occurs in a latent state. The best results are obtained by an integrated approach, including:

• the fight against clinical manifestations of the disease;
• exclusion of relapses;
• suppressive therapy.

When the first symptoms of herpetic urethritis are detected, treatment usually includes:

• taking Acyclovir three times a day, 400 mg for 7-10 days, or five times a day, 200 mg in the same course;
• Famciclovir up to five times a day, 250 mg in the same course;
• taking 1 g of Valaciclovir twice a day for ten days.

The sooner treatment begins, the easier it will be to get rid of clinical manifestations. If after a ten-day course of taking antibiotics, urethritis cannot be cured, you can continue to take the medicine. After curing the disease, prevention may require a course lasting up to ten days, including:

• double dose of Acyclovir 400 mg;
• the use of famciclovir twice a day, 250 mg;
• a single dose of 500 mg Valaciclovir.

Also, doctors can prescribe Megasil, Bonofton, Bromuridine, Gossypol and other similar drugs. Additionally, immunomodulators are often required, including:

• Roferon;
• Cycloferon;
• Interferon and their analogues.

Until the final remission, a special vaccination against herpes infection may be required, which will help the body fight pathogenic viruses.

Preventive measures

The main rule of prevention is to reduce the risk of microflora disturbance. Experts recommend:

1. Eat properly. It is necessary to abandon the consumption of junk food, which includes products fast food and fast food.
2. Eliminate stress, neurosis and prolonged depression.
3. Timely treat infectious lesions of the genital tract.
4. Use contraceptives during intercourse.
5. Follow the rules of intimate hygiene. Having vaginal sex after anal sex is necessary only after washing. Water procedures must be performed not only by a woman, but also by a man.

In addition, it is necessary to have a regular sexual life and exclude the frequent change of sexual partners. Compliance with the rules of prevention will help reduce the risk of developing the disease.

Herpetic urethritis is a disease in which the pathological process affects the genitals. The cause of the symptoms is the herpes virus, which can penetrate the mucous membranes during unprotected intercourse. Treatment is always long, and the disappearance of symptoms does not mean complete recovery. Once in the body once, the herpes virus remains there forever. Ointments or antiviral drugs will not help to achieve complete recovery. That is why it is important to observe hygiene and preventive measures.

For citation: Gomberg M.A. Clinical analysis of a case of genital herpes in a young woman // BC. 2010. No. 12. S. 782

Patient Zh., 24 years old, turned to a dermatovenereologist.
Complaints. At the time of the examination, she had no complaints, but a week before the visit, the patient had vaginal discharge, frequent urination and a burning sensation at the end of urination, pain in the sacrum.
Disease history. Similar symptoms have been bothering me for the last 3 years. Repeatedly addressed to gynecologists and urologists. Urinalysis showed leukocytosis, while bacteriological examination of urine did not reveal flora growth. Based on the clinical picture of Zh., a diagnosis of cystitis was made and various antibiotics were prescribed, most often ciprofloxacin. After a course of antibiotic therapy, each time there was relief, but 3-4 times a year the symptoms returned again. The appearance of this symptomatology, as a rule, was preceded by the following factors: hypothermia, climate change during the holidays, or active and prolonged sexual intercourse. In addition, over the past 4 years, the patient had three times vaginal discharge, also accompanied by a burning sensation. She did not go to gynecologists, but on the advice of a friend who, according to her, had similar symptoms, she used clotrimazole suppositories. Within 5-6 days, the discharge and discomfort stopped. The last exacerbation was much more severe than before, and coincided with the return of her husband from a business trip (a week before the onset of symptoms). Without going to the doctors, the patient again used the usual tactics that helped her earlier in similar situations (suppositories with clotrimazole 1 at night in the vagina for 6 days). If this tactic did not help, the patient took the antibiotic ciprofloxacin 250 mg 2 times a day. 5 days. There were no cases when one or another treatment applied did not lead to the disappearance of symptoms at the end of the course. This time, only clotrimazole was sufficient. By the 6th day of its use, all clinical manifestations subsided. Nevertheless, frightened by the latest aggravation that arose after the return of her husband, the patient decided to undergo an examination.
The patient took the last aggravation very seriously, because she began to suspect her husband of infidelity. I became irritable and thought about divorce. The sexual life has gone wrong. I consulted with my friends, began to look for an explanation of my symptoms on the Internet. Because of the suspicions that arose, this time I decided not to go to a gynecologist or urologist, which I did earlier when similar symptoms appeared, but to a dermatovenereologist in order to be carefully examined for sexually transmitted infections (STIs).
Life history and gynecological history. Menstruation from the age of 14, established immediately. Married 4 years. The husband is 5 years older than Zh., and is the patient's first and only sexual partner. Zh. did not have any pregnancies. Until now, spouses have been protected during sexual intercourse with a condom in order to prevent unwanted pregnancies. Sometimes the husband noted the presence of small abrasions on the head of the penis, then the spouses did not use a condom, and in order to prevent unwanted pregnancy, they practiced coitus interruptus.
inspection data. Physical examination of the patient revealed no anogenital warts, molluscum contagiosum, scabies, and pubic lice.
When examining the vulva, a slight hyperemia was revealed in the area of ​​the vestibule of the vagina and sponges of the urethra. Milky discharge from the vagina was noted, somewhat more abundant than normal, without an unusual smell. The cervix on examination without features. Slight hyperemia around the opening of the cervical canal. The pH value of the vaginal discharge was 4.5. Aminotest of vaginal contents with 10% KOH gave a negative result. Bimanual examination revealed no pathology.
The tasks facing the doctor could be divided into 2 groups.
1. Directly related to the disease, for which it was necessary to establish the cause of the patient's symptoms.
2. Prevent possible wrong conclusions about her husband's infidelity and try to find reasons to get the patient out of a depressive state.
Obviously, both these tasks had to be solved in parallel, since the patient's psychological state could be reflected in her desire to cooperate with the doctor and trust him.
Consider the actions of the doctor, taking into account the tasks.
Since it became clear from the conversation with the patient that her main concern was related to the suspicion of infection with a sexually transmitted infection, for which there were reasons, it was necessary to establish the possible cause of the symptoms as soon as possible and to establish whether a recent STI infection had actually occurred.
The doctor explained to Zh. that, although she did not have convincing data for the presence of a recent STI, but, realizing that this issue was of most concern to the patient, he suggested, in the process of searching for the causes of her recurrent symptoms, to conduct an examination for all major STIs.
This decision reassured Zh. solved both of her concerns and also strengthened her confidence in the doctor.
Examinations to identify possible causes of the disease.
The main question was the following: for which infections should the patient be examined, given her history and suspicions of the possibility of a recent STI infection?
The patient's complaints suggested the presence of an infection in the vagina (discharge) and in the urinary tract (crimping during urination). In addition, the information reported by the patient, important for the detection of a possible infection, was that the complaints appeared about a week after her husband's return from a business trip. Those. should have taken into account incubation period, which for various STIs varies from 2 days to six months.
As shown in the chart below (Figure 1), there are three main infectious causes of vaginal discharge: bacterial vaginosis (BV), urogenital trichomoniasis (UT), and urogenital candidiasis (UC). That. the differential diagnosis in the case of pathological vaginal discharge is mainly between these three nosologies. In addition, vaginal discharge can also be associated with inflammatory processes in the cervical canal, which can be caused by C. trachomatis, N. gonorrhoeae, or M. genitalium.
UT is considered the most common sexually transmitted infection. The incubation period for UT is not more than a week. The detection of this infection could indicate an STI infection from the husband. Local application of clotrimazole in trichomoniasis would not lead to the complete disappearance of symptoms.
BV, although not an STI, is considered the most common cause of abnormal vaginal discharge and is considered a vaginal dysbiosis. Its occurrence could have nothing to do with getting the infection from the husband.
UC is also widespread, accounting for about 1/3 of cases in the structure of infectious lesions of the vagina, but it does not apply to STIs, as well as BV. Clotrimazole could indeed lead to the disappearance of symptoms if candidiasis was its cause.
Thus, of the three main causes of vaginal discharge, only UT could indicate the infection of our patient with an STI.
With regard to C. trachomatis, N. gonorrhoeae, or M. genitalium, it is impossible to exclude their presence in a patient without special examination, but the likelihood of vaginal discharge just a week after potential infection with these infections seemed unlikely. The fact is that only a very pronounced inflammation in the cervical canal can manifest itself as discharge from the vagina, and even so soon - just a week after a possible infection. The incubation period for chlamydial infection is 10-14 days. The role of M. genitalium in cervicitis has not yet been proven, although there are reports of a possible role of this infection in this nosology. But with gonorrhea, the incubation period is quite short (3-5 days). With none of these infections, the effect of the use of clotrimazole should not be expected. In any case, it was necessary to examine the patient for all these infections.
Causes of urinary tract symptoms
Frequent urination and a burning sensation are the main signs of urethritis or cystitis. What can be the cause of these diseases? The most common cause of urethritis and cystitis are bacteria, in particular E. coli. In addition, pathogens that cause diseases related to STIs that cause cervicitis in women, namely C. trachomatis, N. gonorrhoeae or M. genitalium, can also enter the urethra. However, in the case of our patient, it would be unlikely that the intravaginal application of clotrimazole in this case would have had an effect. The cause of cystitis and urethritis can also be yeast-like fungi of the genus Candida, but again, in these cases, the symptoms would not go away after the intravaginal use of clotrimazole suppositories.
But what about viruses? In particular, the herpes simplex virus (HSV)? Could HSV be the cause of the urinary tract symptoms that our patient described?
The fact that HSV can cause urethritis has long been known. According to foreign studies, the frequency of detection of HSV-1, 2 in urethritis ranges from 6 to 25%.
It is generally accepted that the clinical picture of classic herpetic urethritis, in addition to discharge and symptoms of dysuria, includes the presence of vesicular or erosive elements in the genital area. Meanwhile, it is known that the clinical course of herpetic urethritis is often not accompanied by classic symptoms of genital herpes.
Are there any grounds for assuming the viral nature of the problems troubling our patient?
Let's compare the characteristics of urethritis of bacterial or fungal etiology with viral ones caused by HSV.
How to distinguish urethritis of bacterial origin from herpetic urethritis?
.. With a bacterial genitourinary infection, it is always possible to obtain growth of bacteria in culture, but not with herpetic urethritis.
.. With herpetic urethritis, as a rule, there is no frequent and imperative urge to urinate, because, unlike cystitis, there are no spastic contractions of the bladder.
.. When examining scrapings from the urethra, HSV can be detected, although the result is often false negative.
And how to distinguish candidal lesions of the genitals from HSV infection?
What common?
.. Itching in the genital area is one of the leading symptoms of HSV and genital candidiasis in women.
.. Therefore, subject to availability periodic itching in the genital area, a diagnosis of candidiasis is made, while in fact it may be a manifestation of a herpes infection.
What are the differences?
Differences - microbiological: in the presence of recurrent itching of the genitals and a negative result of the native test for the presence of a yeast infection, an examination for HSV should be performed.
Table 1 presents the differential diagnosis, based on our own clinical experience, of various pathological conditions that in women may be accompanied by a burning sensation in the urogenital region.
Based on the data in the presented table, HSV is the most likely cause of such a variety of symptoms that the patient described. Such an assumption, of course, requires confirmation and does not cancel a thorough examination in order to determine other possible causes.
So, let's return to one of the main tasks formulated at the very beginning of work with the patient: what infections should she be examined for in order to establish the cause of her symptoms, and also to determine the possibility of her having an STI.
Examination plan for G. for STIs
.. Microscopy of smears from the vagina and urethra with Gram stain.
.. Native preparations for testing for bacterial vaginosis, candidal infection and trichomoniasis.
.. PCR to detect N. gonorrhoeae, C. trachomatis, M. genitalium.
.. Culture for T. vaginalis.
Serological diagnosis to rule out STIs:
. diagnosis of HIV infection;
. RPR test to detect syphilis;
. determination of HBsAg and antibodies to VG-C;
. determination of type-specific IgG to HSV-1 and HSV-2.
Why HSV-1 and 2 IgM testing should not be performed during routine STI screening
. The current IgM tests have serious drawbacks:
. Cross-activity between IgM to HSV-1 and 2 is possible.
. Positive HSV-2 tests for HSV-1 lip infection ⇒ False diagnosis of genital herpes infection ⇒ Inadequate treatment and unwanted emotional problems when it comes to starting a family or long-term relationships.
. A cross-reaction with other herpes viruses is possible: CMV, Epstein-Barr and others.
.. 35% of people with HSV-2 reactivation may have IgM ⇒ the test does not distinguish between a new infection and an existing one.
. Such a test may be warranted in neonates because IgM does not cross the placenta.
. ⇒ Detection of IgM in newborns may mean that these immunoglobulins appeared in response to their own infection, and were not transplacental from the mother.
The results of the survey J.
In patient Zh., all tests for STIs were negative, except for a positive type-specific test for HSV-1 and HSV-2.
Counseling J.
After analyzing the results, the doctor explained to the patient that she is a carrier of HSV infection, which, obviously, periodically causes all the symptoms that bother her in last years, which completely fit into the natural course of HSV infection, and the “effect” of the drugs used by Zh. actually coincided in time with the end of the next exacerbation of herpes infection.
The patient was very surprised, because, in her opinion, neither she nor her husband had ever had symptoms of this disease. She imagined that a herpes infection manifested itself in the form of a blistering rash, for example, on the lips. This is always a very crucial moment for a doctor, because during the initial diagnosis of HSV infection, it is very important to conduct competent counseling, answering all possible questions of the patient who first heard about his diagnosis.
The main questions that interested J. were the following:
.. How long has she been infected and where did the infection come from?
.. Why did the doctors she went to earlier never examine her for herpes?
.. Can a herpes infection be classified as an STI if it is localized in the genital area?
The European Guidelines for the Management of Patients with Genital Herpes provide a list of questions to discuss with a patient during a primary episode of genital herpes:
1) a possible source of infection;
2) the course of the disease - the risk of developing a subclinical infection;
3) various options treatment;
4) the risk of transmission of infection through sexual or other means;
5) the risk of transmission of infection from mother to fetus during pregnancy;
6) the need to notify the obstetrician-gynecologist about the presence of the disease;
7) the consequences of infection by an infected man of an uninfected partner during pregnancy;
8) the possibility of notifying partners.
As can be seen from this list of recommended questions for discussion, this list is even broader than those that interested J. Of all the points presented here, only the consequences of infection by an infected man of an uninfected partner during pregnancy were not relevant to our case, since J. was already infected.
In the process of counseling our patient, it finally became possible to reasonably begin to consider the second important topic in order to prevent possible wrong conclusions regarding her husband's adultery and try to find arguments to improve the patient's state of mind.
In principle, it is not the task of medical counseling to conduct an "investigation to convict one of the partners of adultery." On the contrary, a great success of a doctor can be recognized as a situation when, despite the diagnosis of STIs in the spouses, which unequivocally indicates the fact of infidelity, they conduct counseling so that the fact of infection, in any case, is not used as a negative argument when the spouses decide on the issue of preserving the family .
Let us consider from this point of view the situation of patient Zh., in whom it was possible to establish the presence of HSV infection.
Here is how the doctor answered the questions posed by the patient.
. How long has she been infected and where did the infection come from?
Based on the history data, it can be assumed that the infection occurred after marriage and the source of infection, apparently, was the spouse. But at the same time, it cannot be ruled out that the spouse could have had HSV even before marriage, and the infection persists in a latent or, possibly, asymptomatic state. To clarify this issue, it was necessary to talk to Zh.'s husband and examine him.
. Why had neither gynecologists nor urologists ever examined her for herpes before?
The rules of deontology suggest that colleagues should not be accused of mismanaging a patient. We must try to find an explanation for the perfect diagnostic error that would not make the patient want to sue the doctors without fail - naturally, if such errors were not so gross that they led to serious consequences for the patient. In our case, insufficient examination of the patient did not lead to such consequences. The explanation, which suited the patient quite well, was this: most likely, the doctors previously relied too much on clinical manifestations that are quite typical for both candidiasis and bacterial cystitis, and therefore did not consider it necessary to conduct additional studies. Perhaps doctors were misled by the fact that the prescribed therapy was always accompanied by the disappearance of symptoms.
. Can a herpes infection be classified as an STI if it is localized in the genital area?
Can. But once again it should be emphasized that from this fact alone it does not follow at all that the husband contracted this infection while in marriage. It is possible that he acquired it before marriage. It can also be said for sure that the coincidence of Zh.'s last exacerbation has nothing to do with her husband's return from a business trip, where, according to Zh., he could have contracted an STI. Rather, the cause of the last exacerbation could be prolonged active sex, after which Zh. had exacerbations before. By the way, relapses after traumatization, even minor, which is quite likely with active sex, are just very typical for herpes infection.
After discussing the situation, it was decided to invite Zh.
The results of the examination of the patient's spouse Zh.
K., husband Zh., came for examination. In a conversation with a doctor, he stated that before marriage he had had sexual intercourse and among his partners there may have been those who had a herpes infection. He never had manifestations of a herpetic infection, and he believed that he did not have this disease.
However, based on the data obtained, it could be assumed that K. could also be a carrier of HSV.
A type-specific serological diagnosis was carried out, the results of which confirmed this assumption: husband Zh. was seropositive for HSV-1 and 2.
This greatly surprised the husband of our patient, because, as he claimed, he never had symptoms of the disease. The doctor had to consult his wife as well.
First of all, the doctor explained to him that, according to the current understanding of herpes infection, people who test positive for type-specific serological tests for HSV-2 are almost always infected with this virus and can transmit it to other people even in cases where they have never had symptoms. this infection.
The doctor referred to American data, according to which 22% of people over the age of 14 in the United States are carriers of HSV-2 infection, and only 10% of these people knew that they were infected.
The fact that herpes infection never manifested itself in husband Zh. meant that it was subclinical in him. Moreover, it is with this course of infection that the partner is most often infected. So there is nothing surprising that, despite the absence of clinical manifestations of a herpes infection, husband Zh. transmitted HSV to his wife.
Now it's time to discuss the situation with both spouses and outline a plan of action to control the herpes infection, especially since before the last visit to the doctor they planned the birth of a child.
Couples counseling
This is a necessary part of counseling when it comes to permanent sexual partners, since we are talking about an infection that they will have to live with for the rest of their lives, and only professionally competent counseling and therapy will allow this couple to properly control it and not become depressed due to persistence in the body of an infection caused by HSV, tk. elimination of the latter is impossible. So, the doctor invited both spouses for the final conversation.
This is how this final conversation was structured.
1. First of all, the doctor summed up the results of the examination of the spouses and informed them that the only infection that they could detect was HSV, both HSV-1 and HSV-2.
2. Symptoms that periodically bothered Zh. can be explained by the presence of this particular infection.
3. The source of infection is husband Zh., whose HSV infection proceeded subclinically.
4. Based on the anamnesis and data obtained during the examination of Zh.'s spouse, it can be concluded that he acquired HSV infection before marriage with Zh.
5. Finally, the doctor discussed the issue of existing therapeutic options.

Choice of strategy in the fight against HSV infection
1. Treatment of each episode of manifestation of infection;
2. Prevention of its relapses.

The doctor explained to the couple that, according to modern ideas, the final decision on how to control HSV infection should be taken jointly by the patient and the doctor after explaining to the patient the meaning of each of these approaches.

1. The treatment of each episode of manifestation of genital herpes (HH) infection is called episodic therapy.
It is understood as the ingestion of antiviral drugs at the time of exacerbation of the infection. This strategy is recommended for patients with infrequent, clinically unexpressed exacerbations and in the presence of a well-defined prodromal syndrome, during which the drug should be started. As a rule, such therapy is recommended for people who have no more than 6 exacerbations of HH per year.
According to the European guidelines for the management of immunocompetent adult (with normal immune status) patients with genital herpes, the recommendations of the International Forum for the Treatment of Herpes, as well as clinical guidelines for the treatment of genital herpes RADV, which is also reflected in the instructions for the use of antiherpetic drugs in the Russian Federation, with primary infection or recurrence of a previously untreated herpes infection, the following treatment regimens with etiotropic (antiherpetic) drugs should be prescribed: on average
. Acyclovir 200 mg x 5 times / day. 5 days
400 mg x 3 times / day. 5 days
. Valaciclovir 500 mg x 2 times / day. 5 days
. Famciclovir 250 mg x 3 times / day. 5 days
For all subsequent relapses of chronic herpes infection in immunocompetent adult patients, it is recommended to prescribe acyclovir and valaciclovir in the same dosages, and famciclovir - 125 mg x 2 times / day. Treatment should begin already in the prodromal period or immediately after the onset of symptoms of the disease. The duration of treatment for relapse is 3-5 days.
2. Prevention of recurrence of HSV infection or suppressive (preventive) therapy of HH.
This approach implies daily intake of etiotropic antiviral drugs continuously for a long time (4-12 months).
Indications for suppressive therapy are:
1. severe course with frequent exacerbations;
2. absence of a prodrome;
3. special circumstances (vacation, wedding, etc.);
4. while taking immunosuppressive therapy;
5. with psychosexual disorders;
6. to avoid the risk of transmission of infection.
According to the above international and Russian clinical guidelines, which is also reflected in the instructions for the use of antiherpetic drugs in the Russian Federation, the following schemes are prescribed for the suppressive therapy of HH for a long time (4-12 months) with a periodic assessment of the course of the disease:
. Acyclovir 400 mg x 2 times / day.
. Valaciclovir 500 mg x 1 time / day.
. Famciclovir 250 mg x 2 times / day.
As follows from the description of the indications and principles of episodic and suppressive therapy, episodic therapy could be recommended to patient Zh., because the number of relapses of the disease, according to the anamnesis, did not exceed 6 per year. Nevertheless, among the indications for suppressive therapy were those that were related to it. Thus, relapses in Zh. always occurred in the absence of a prodrome, often occurred during a change in climate during a vacation, and were accompanied by psycho-sexual disorders.
The doctor explained that the choice of antiherpetic therapy tactics may vary depending on the circumstances, and suggested that J. decide for herself which treatment option she prefers at the present time.
Having received so much new information, J. decided to think it over in a calm atmosphere and visit the doctor again to make a final decision regarding the choice of one or another approach to the control of herpes infection.
Appearing on next move, the patient reported that, after weighing various circumstances, she was inclined to believe that suppressive therapy was preferable in her situation, since it would help her not only cope with the occurrence of exacerbations, but also find peace after the stress and improve marital relations.
After discussing the available therapeutic options with the doctor, it was decided to suppressive therapy with valaciclovir (Valtrex) daily, 1 tablet of 500 mg. jointly decision in favor of Valtrex was based both on existing recommendations for HH therapy, and on the fact that since the patient would have to take the drug for a long time, it was preferable for her to take the drug no more than 1 time per day, and Valtrex seemed to her the most affordable.
Zh. was prescribed Valtrex and asked to come for a consultation with a doctor 3 months after its use according to the scheme of suppressive therapy: 1 tablet (500 mg) 1 time per day, regardless of food and liquid intake.
Final consultation. Pregnancy planning
Zh. came to the appointment after 3 months. During this time, while taking Valtrex, 1 tablet (500 mg) 1 time / day. She didn't have a single relapse. The patient's mood was good. Relationship with her husband improved. They vacationed together in the Italian Alps, skiing. Despite hypothermia, there were no exacerbations of herpes infection during suppressive therapy with Valtrex. The patient decided to continue therapy and asked if she could plan a pregnancy.
The doctor explained to Zh. that, according to the European guidelines for the management of patients with genital herpes, when pregnancy occurs, the obstetrician-gynecologist should be informed about the presence of HSV infection.
With regard to the continuation of suppressive therapy, when planning a pregnancy, it should be discontinued. If an exacerbation of a herpes infection occurs during pregnancy, you should visit a doctor to decide on the need for treatment.
Although there is a risk of transmission of HSV infection from mother to fetus during pregnancy, in the case of G. this risk is minimal, because she already has antibodies to this virus and a serious danger to the fetus can only be with an exacerbation of HSV infection by the time of delivery. At this point, treatment should be prescribed. Taking into account the presence of HSV in her husband, the situation during the pregnancy of J. would be much more difficult, since there would be a serious threat to the fetus if the seronegative mother were infected during pregnancy.
J. was quite satisfied with the consultation and grateful that, with the help of the doctor, she finally learned to fully control her illness and found peace of mind.

Literature
1. Reis A.J. Treatment of vaginal infections. Candidiasis, bacterial vaginosis and trichomoniasis. J Am Pharm Assos. 1997: NS37:563-569.
2. Oni AA, Adu FD, Ekweozor CC et al. Herpetic urethritis in male patients in Ibadan. West Afr J Med 1997 Jan-Mar;16(1):27-29.
3. Sturm PD, Moodley P, Khan N. et al. Aetiology of male urethritis in patients recruited from a population with a high HIV prevalence. Int J Antimicrob Agents 2004 Sep;24 Suppl 1:8-14.
4. Srugo I, Steinberg J, Madeb R et al. Agents of non-gonococcal urethritis in males attending an Israeli clinic for sexually transmitted diseases. Isr Med Assoc J 2003 Jan;5(1):24-27.
5. European guideline for the management of genital herpes. International Journal of STD & AIDS, 2001; 12 (Suppl. 3):34-39.
6. Sacks SL. The Truth about Herpes. 4th ed. Vancouver, BC: Gordon Soules Book Publishers: 1997.
7. CDC Website. Tracking the hidden epidemics: trends in STDs in the United States 2000.
8 UNAIDS/WHO. USA: Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infection 2002 Update.
9. Armstrong GL et al. Am J Epidemiol. 2001;153:912-920.
10. International Herpes Management Forum. www.IHMF.org
11. Clinical recommendations of the Russian Society of Dermatovenerologists (RODV). Ed. A.A. Kubanova, Moscow, Dex-Press, 2008.

Treatment of herpetic urethritis is an extremely difficult task, since the disease can be latent. Principles of treatment of genital herpes:

• treatment of the first clinical episode of herpes;
• relapse treatment;
• long-term suppressive therapy.

• acyclovir 400 mg orally 3 times a day for 7-10 days or 200 mg orally 5 times a day for 7-10 days;
• or famciclovir 250 mg orally 5 times a day for 7-10 days;
• or valaciclovir 1 g orally 2 times a day for 7-10 days.

Treatment of herpetic urethritis should be started as early as possible, immediately after the first symptoms of the disease appear.

With insufficient effectiveness of treatment after a 10-day course, further administration of the drug is possible.

Aciclovir is the drug of choice and usually provides a fairly successful treatment. Clinical observations have confirmed the effectiveness of this drug: when it is used in patients with a primary lesion of the genital tract, both the spread of the virus and the severity of clinical symptoms decrease. The drug is used orally, intravenously, topically (3-5% acyclovir ointment).

Existing methods of treatment of herpetic urethritis can only stop the recurrence of the disease, but not eliminate the recurrence of the disease. Most patients with a first clinical episode of herpes simplex type 2 infection then experience a relapse of the disease. This is less common in patients initially infected with herpes simplex type 1. Antiherpetic therapy for relapses is given episodically during the clinical manifestations of genital herpes to improve the condition of patients and reduce the duration of relapse. It is prescribed for a long time as a suppressive therapy, which reduces the number of relapses in patients with frequent exacerbations of the disease (more than 6 times a year) by 70-80%. With this treatment, many patients note the absence of clinical episodes. There is evidence of the efficacy and safety of taking acyclovir for more than 6 years and valaciclovir and famciclovir for more than a year.

Episodic treatment of recurrence of genital herpes should be started on the first day of clinical manifestations or during the prodromal period.

• acyclovir 400 mg 3 times a day for 5 days, or 800 mg 2 times a day for 5 days, or 800 mg 3 times a day for 2 days; .
• or famciclovir 125 mg 3 times a day for 5 days or 100" m 2 times a day for 1 day;
• or valacyclovir 1 g 2 times a day for 5 days or 500 mg 2 times a day for 3 days.

In order to prevent recurrence of herpes infection, suppressive therapy regimens have been developed:

• acyclovir 400 mg 2 times a day;
• or famciclovir 250 mg twice a day;
• or valacyclovir 500 mg 1 time per day or 1 g 1 time per day.

Valaciclovir 500 mg once daily may be less effective than other dosing regimens, as is aciclovir in patients with very frequent disease relapses (more than 10 times per year). This dictates the need to search for more effective methods chemotherapy and specific prevention of this infection.

Etiotropic treatment of herpetic urethritis may also include bromuridin, ribovirin, bonofton, epigen, gossypol, megasil.

In recurrent forms of herpetic infection, antiviral therapy is supplemented with the appointment of immunomodulators (interleukins, cycloferon, roferon, interferon inducers).

For complete remission, vaccination with a herpes vaccine and antioxidant protection are required.

It should be noted that in the treatment of children, elderly and senile people suffering from herpetic urethritis, patients with chronic renal and hepatic insufficiency, including those on hemodialysis, an appropriate dose adjustment of the drugs is necessary.