Herpetic urethritis- a disease characterized by a vivid clinical picture, capable of becoming chronic over time. Pathology is becoming more and more common today. Therefore, it is necessary to know exactly what symptoms it manifests itself and how to treat it.
What are the causes of herpetic urethritis, patients are often interested in their doctors, and how to recognize the disease in a timely manner.
What pills to drink with this disease, and how can you protect yourself from this disease?
Herpetic urethritis: causes of pathology
The main cause of the pathology is herpes type 1 and type 2 with herpetic urethritis. virus herpes simplex infected today a large number of people, and the prevalence of infection continues to rise. But why someone develops a disease, and someone lives all his life, not even knowing that he is sick, patients are interested.
The role of immunity in the development of the disease cannot be overstated. The fact is that herpes is an infection that can be in the patient's body for a long time without showing itself.
For the first time, a pathogenic microorganism usually makes itself felt if, for some reason, the body's immune defenses are reduced. A drop in the level of immunity inevitably leads to the manifestation of clinical symptoms.
Today, doctors identify the following factors that contribute to the onset of symptoms of the disease:
- frequent, prolonged in duration and high in intensity stressful effects that adversely affect the immune system;
- the rhythm of life, leading to disruption of sleep and wakefulness, due to which the immune system cannot fully recover;
- malnutrition, abuse harmful products which negatively affect the general condition of the body;
- contact with respiratory viruses that cause a sharp drop in immunity;
- the presence of congenital or acquired immunodeficiency (for example, herpetic urethritis is diagnosed as one of the manifestations of an immunodeficiency state);
- hormonal shake-ups, which are especially characteristic of women during the period of bearing a child, menopause, and also monthly before menstruation;
- chronic diseases of the liver, lungs, heart and other organs and systems, which have a debilitating effect on the human body, can contribute to the development of symptoms of the disease.
The appearance of symptoms of herpetic urethritis in most cases indicates that the patient's immunity has suffered serious damage for some reason. At healthy people signs of the disease are not detected.
Symptoms of herpetic urethritis
Get infected with the herpes simplex virus disease-causing, can be done in different ways.
In the first place in terms of implementation is sexual contact, especially if it is not protected by barrier contraceptives.
Sex can be dangerous even if people use a condom. Since the virus can, among other things, be transmitted by touch, and not only through body fluids. In addition to the sexual way, the contact-household way is often realized. In this case, transmission occurs through shared hygiene items such as towels. It is also possible to infect a small child during childbirth.
Symptoms of herpetic urethritis are usually pronounced, especially if the clinical picture develops for the first time. The patient complains about:
- the appearance of a rash in the genital area, causing significant inconvenience;
- strong, which is accompanied by every urination;
- an increase in body temperature to subfebrile values, and sometimes even higher;
- a sharp deterioration in general well-being, complaints of fatigue, decreased performance;
- apathetic mood, lack of interest in things that previously aroused interest;
- a feeling that is episodic (often patients describe the pain as unbearable, acute);
- frequent urge to empty the bladder, which may not always end in the release of urine;
- complaints of a feeling of fullness in the bladder, even if the patient has just gone to relieve himself.
Herpetic urethritis in women and men may differ in localization.
In the fair sex, the presence of pathological formations on the external genital organs is usually not noted. All of them are located exclusively in the urethra. With men, the situation is different.
In the representatives of the stronger sex, rashes can cover not only the inner part of the urethra, invisible to the eye, but also the penis itself. As a result, rashes can be injured by rubbing against clothing while walking or making other movements. Therefore, herpetic urethritis in men may be accompanied by a small release of blood.
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.
- 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.
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.
- 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.
- 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, you can not ignore the 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.
Herpetic urethritis: approaches to diagnosis
How to take tests for herpetic urethritis, many patients are interested in their attending physicians. In most cases, smear and blood tests are performed for herpetic urethritis. If it is decided to conduct a study using a smear, then it is recommended to take it in the area of localization of the rash. A scraping may also be performed there.
With a pronounced course of infection, good results are also obtained by assessing the blood that is taken from a vein, as in a classic study. Further, the patient can undergo three diagnostic options:
- ELISA is the most common and cheapest option, during which antibodies secreted by the body to fight viral particles are detected or excreted;
- PCR is a more expensive, but also more reliable method, in which pathogen DNA is isolated even in the smallest concentrations;
- Antigen highlighting, in which blood treated with special reagents is highlighted, and pathogenic parts are highlighted in a special color.
The immunogram and the role of the immunologist in herpetic urethritis, if it often recurs, are enormous. With the help of an immunogram, it is possible to determine whether there are any violations in the activity of immunity. And the immunologist will help decipher the data of the immunogram and will treat the patient if the immunity is somehow impaired.
Treatment methods for herpetic urethritis
Treatment is selected by the doctor in each case individually. The choice of drugs, their dosages and features of use depends on the severity of the infection, the general health of the patient and a number of other features. Most often, the following treatment regimen is possible:
As an alternative to Acyclovir, Famciclovir or Valaciclovir can be used. The first drug is drunk 5-6 times a day for the same period, and the second is used twice a day in the same course. The drugs are similar, the differences in them are explained only by different excipients.
An alternative to Acyclovir in the form of an ointment can be Zovirax, which has similar effects. It is important to remember that if a patient has concomitant infectious diseases, therapy should be aimed not only at eliminating the herpes simplex virus.
Which doctor to contact many patients ask. First of all, it is recommended to visit a urologist or dermatovenereologist. Which will be able to diagnose and choose the right therapy. Additionally, a visit to an infectious disease specialist, immunologist-allergist may be recommended.
Fundamentals of prevention of herpetic urethritis
Prevention of the disease is very simple, although non-specific. First of all, it is necessary to exclude sexual and domestic infection herpetic urethritis. For this it is recommended:
- observe safety rules when having sex, using barrier contraceptives, especially if the partner is unreliable;
- observe simple rules of personal hygiene;
- refuse to use common hygiene items such as towels, washcloths, etc.;
- lead healthy lifestyle life, normalizing sleep and wakefulness, giving preference to wholesome food;
- regularly undergo preventive examinations with a urologist or gynecologist;
- do not delay contacting a doctor if any alarming symptoms appear.
Compliance with preventive measures will help to significantly reduce the likelihood of contracting this unpleasant infection. However, unfortunately, it will not completely rule it out.
If symptoms appear that may indicate an infection with a pathology, one should not hesitate to contact a doctor. Herpetic urethritis is dangerous for both men and women. In the representatives of the stronger sex, a neglected disease leads to a decrease in sexual activity, infertility. And women, in addition to infertility, with severely neglected pathology, may encounter fusion of the labia minora.
If you suspect herpetic urethritis, contact a competent venereologist.
Herpetic urethritis is a viral disease, which is characterized by an extensive clinical picture. In recent years, the disease has been actively spreading, so you should understand how to treat it.
Why do people get herpetic urethritis?
The causative agent of ordinary herpetic urethritis is considered to be the second type of herpes virus, which is secreted mainly when the human genital organs are affected. Infection usually occurs as a result of close contact, especially intimate.
You can become infected with herpetic urethritis from a man or woman whose body is already infected and has symptoms of the disease. Also, sometimes there are no pronounced symptoms, but the virus is present in a dormant state. During the initial infection, the symptoms are usually pronounced, and then the virus switches to a latent state. The next exacerbation of urethritis from herpes occurs in four out of five infected people, so the disappearance of symptoms does not indicate recovery.
What are the symptoms of the disease?
In men, herpes urethritis with its characteristic symptoms appears several days after contact with the carrier. Erythema and vesicles form on the penis and inside the urinary canal, which eventually rupture and form ulcers with a red border in their place.
Herpetic urethritis is accompanied by rashes in the navicular fossa that do not exit the urinary canal. They look like multiple erosions, merging into large inflamed spots. In this case, the patient experiences pain, he is overcome by fever and inguinal lymphadenitis.
In women with urethritis from herpes, scanty mucous discharge is possible. In addition, there is burning and tingling. Symptoms usually disappear after a few days, but there is a high chance of recurrence after a few weeks or months.
When a bacterial infection joins the herpetic urethritis, pus is present in the discharge and they become abundant. It is much more difficult to cure such a form.
How is this pathology treated?
To begin with, a reliable diagnosis is necessary in order not to harm yourself with self-medication. It is not easy to treat herpes urethritis, since the disease often occurs in a latent state. Gives the best results A complex 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 treatment it is not possible to recover, you can continue to take the medicine.
Basically, all these methods are aimed at stopping relapses, but do not completely exclude them. Special therapy for relapses is prescribed episodically with clinical manifestations of the disease. It is prescribed for long courses to people whose herpetic urethritis worsens up to six times a year or more.
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.
Most often aggravated after menstruation or before it.
In men - after intercourse.
For secondary herpes, the same symptoms are characteristic as for the primary. The same organs (urethra) are affected, a rash appears in the same places.
But the symptoms are usually less pronounced. This is due to the fact that the immune system is already “aware” of the danger and adequately responds to the pathological process.
The self-healing period for secondary herpetic urethritis is reduced to 5-7 days. The period of contagion is also reduced.
The infection often occurs without general symptoms of intoxication or with a slight increase in body temperature. The pathology proceeds much more severely and longer against the background of immunodeficiency, in aged and weakened patients.
The severity of herpetic urethritis
Manifesting herpetic urethritis, depending on the frequency of relapses and the severity of clinical symptoms, has four degrees of severity:
- mild - no more than 4 relapses per year, no fever, no pain, only single elements of the rash appear;
- medium - 5 or more relapses per year, pain is mild, single elements of the rash, no severe intoxication, a slight increase in body temperature is possible;
- severe - up to 5 relapses per year, severe pain in the urethra, thick rash, fever up to 38 degrees and above, severe intoxication;
- extremely severe - more than 5 relapses per year, proceeds in two stages (first intoxication, then rashes and pain in the urethra), accompanied by high body temperature (up to 39 degrees and above), damage to several organs of the urogenital tract at once.
Based on the dynamics of the clinical course and the frequency of exacerbations, the following forms of herpetic urethritis are distinguished:
- arrhythmic - exacerbations occur randomly;
- monotonous - relapses occur at regular intervals;
- fading - exacerbations occur at gradually increasing intervals (the duration of the remission period increases).
Diagnosis of herpetic urethritis
Laboratory tests are required to diagnose genital herpes.
Virus identification is usually done in one of two ways:
ELISA is the determination of antibodies in the blood.
Antibodies are factors of the immune system that are produced in response to the penetration of the pathogen into the body. Their presence confirms the presence of the herpes virus in the body.
The PCR method of the pathogen can be determined in the following clinical material:
- scraping from the urethra (most informative for suspected herpetic urethritis);
- blood.
The essence of the study is to determine the DNA of the herpes virus type 1 or 2.
Herpetic urethritis: treatment
So far, no treatment has been developed that would completely get rid of the herpes simplex virus. However, there are those that improve the patient's quality of life.
At one time G.B. Elion, the pharmacologist who discovered acyclovir in 1988, received Nobel Prize. This drug, as well as its analogues (famciclovir, valaciclovir) are used to date in the treatment of herpetic urethritis.
They have the same clinical efficacy. But they differ in the frequency of administration - some drugs are more convenient for the patient.
Purposes of their application:
- symptom reduction;
- prevention of the spread of infection in the population;
- reduction in the frequency of exacerbations.
Many treatment regimens for herpetic urethritis have been developed.
The choice of dosages and duration of treatment depends on a number of factors:
- form of herpetic urethritis (primary or secondary);
- its severity;
- the presence of concomitant pathology;
- the patient's condition (somatic diseases, immunodeficiency, age, pregnancy, etc.);
- previous treatment experience;
- laboratory test data;
- the prevalence of herpes (the number of organs that are affected by the pathological process).
In case of symptoms of urogenital herpes, please contact our clinic. We can take tests to confirm the infection. After receiving their results, an experienced venereologist will prescribe a quality treatment.
If you suspect herpetic urethritis, please contact the author of this article - a urologist, venereologist in Moscow with 15 years of experience.
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 these symptoms, 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 infection with an STI had occurred.
The doctor explained to J. that, although she did not have convincing data for the presence of a fresh STI, but, realizing that this issue was most of all of 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.
Surveys to identify possible causes diseases.
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 (cutting when urinating). In addition, the information reported by the patient, important for detecting a possible infection, was that the complaints appeared about a week after her husband returned from a business trip. Those. it was necessary to take into account the 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. Incubation period at UT no 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 abnormal vaginal discharge and is considered as 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 as early as 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.
.. In this regard, in the presence of 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 have bothered her in recent years, which completely fit into the natural course of HSV infection, and the “effect” of the applied J. medicines 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 herpetic infection manifests 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 a patient who has heard about his diagnosis for the first time.
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 treatment options;
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 wider than those that interested G. 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." Vice versa, great success a doctor can recognize a situation where, despite the diagnosis of STIs in the spouses, which unequivocally indicates the fact of infidelity, 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 such an explanation for the perfect diagnostic error that would not cause the patient to want to sue the doctors without fail - naturally, if such errors were not so gross that they led to grave 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 is also absolutely certain 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 modern ideas about herpes infection, people with positive results 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 of 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 it is 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 made 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 rare, clinically silent 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 the 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, patient Zh. could be recommended episodic therapy, 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.
At her next appointment, 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 establish 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. The joint decision in favor of Valtrex was based both on the existing recommendations for the treatment of HH, 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 acceptable in terms of cost.
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.
For citation: Semenova T.B., Stoyanov V.B. Herpetic infection of the genitourinary system in men // BC. 2001. No. 13. S. 568
Moscow city antiherpetic center
H The uncontrolled worldwide increase in the incidence of genital herpes (HH) puts the problem of herpes virus infection (HI) on a par with the most pressing socially significant health problems. The incidence of HH in Western Europe exceeds 80 cases per 100,000 population. At present, according to B. Halioua et al. (1999), there are 86 million people in the world infected with herpes simplex type 2 viruses (HSV-II), traditionally associated with HH, although it has been proven that HH can also be caused by HSV type 1.
Our analysis of official statistics showed that the incidence of HH in Russia for 1993-1999. increased from 8.5 to 16.3 cases per 100 thousand population, and in Moscow - from 11.0 to 74.8. The bulk of patients in Russia go to doctors on their own: 70-94% of registered patients. The proportion of active detection of patients with HH by first-line health care providers for all types of preventive examinations in Russia amounted to 22.7-27.8%, in Moscow - 5.4-7.2%. At the same time, obstetricians-gynecologists detect 45.1-54.8%, dermatovenereologists - 39.8-43.8% of the total number of actively diagnosed patients with HH, and urologists account for no more than 5-12%.
If close attention is paid to the study of herpes of the external genitalia and the adverse effect of GI on the reproductive function of women, then information about HSV as an etiological factor in 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 HSV in the development of the pathology of the MPS organs in men, taking into account the frequent low- or asymptomatic course of the infection.
Herpes is called "many-faced" and "insidious", referring to the variety of manifestations of the disease and accompanying symptoms due to the peculiarities of the pathogenesis of GI. The main links of pathogenesis herpes infections are:
1. Infection of the sensory ganglia of the autonomic nervous system and lifelong persistence of HSV in them.
2. Defeat of immunocompetent cells, which leads to secondary immunodeficiency, creating conditions for relapses of the disease.
3. Tropism of HSV to epithelial and nerve cells, which determines the polymorphism of the clinical manifestations of herpes infection.
Infection of the genitals occurs through close physical contact with a patient or virus carrier during genital, orogenital, genito-rectal and oral-anal contacts. Only 10% of those infected develop clinical symptoms of primary HH.
The virus begins to multiply at the site of inoculation, where typical blisters appear, and enters the bloodstream and lymphatic system. In the early stages of HI, viral particles also penetrate into the nerve endings of the skin or mucous membrane, move centripetally along the axoplasm, reach the peripheral, then segmental and regional sensory ganglia of the central nervous system, where they remain latent in nerve cells for life.
Infection of sensory ganglia is one of the important stages in the pathogenesis of HI. With herpes, the genitals are sensitive ganglia of the lumbosacral spine, which serve as a reservoir of the virus for its sexual transmission. The spread of HSV in the centrifugal direction during a relapse determines the anatomical fixation of the lesions during relapses.
HSV can affect any nerve formations, which will clinically manifest itself with various neurological symptoms, depending on the properties of the nerve formations involved in the infectious process. With the defeat of the sympathetic nodes and peripheral nerves, patients have symptoms of ganglioneuritis; combined damage to the ganglia and segmental roots of the spinal cord causes clinical manifestations of ganglioradiculoneuritis. Irritation of parasympathetic fibers causes subjective sensations in the form of a burning sensation in patients. The peculiarity of the pain syndrome in recurrent herpes (HR) is that it can periodically occur regardless of skin manifestations, which greatly complicates its interpretation. Neurological symptoms that complicate the course of the disease and worsen the prognosis occur in every 3rd patient suffering from recurrent genital herpes (RGH).
The literature describes cases of acute urinary retention caused by sacral myeloradiculitis (Elsberg's syndrome), meningitis and radiculomyelopathy caused by HSV.
In 25% of patients with RGH, increased traumatism, dryness and the formation of small painful bleeding cracks on the mucous membranes of the external genital organs appear during mechanical irritation.
Clinical manifestations of HH in men Herpes of the external genitalia In most cases, the primary infection of the genitals is asymptomatic, with the subsequent formation of a latent carriage of HSV or a recurrent form of genital herpes. In clinically pronounced cases, primary genital herpes usually manifests itself after 1-10 days of the incubation period and differs from subsequent relapses in a more severe and prolonged (up to 3 weeks) course (Fig. 1).
The probability of forming a recurrent form of HH depends on the serological type of HSV: when genitals are infected with HSV type 1, recurrence occurs within a year in 25% of persons who had a primary episode of HH, with HH caused by type 2 HSV, relapses occur in 89%.
Clinically, herpes of the vulva can occur in typical, atypical and subclinical (malosymptomatic) forms.
In men, rashes are usually located in the area of \u200b\u200bthe outer and inner sheets. foreskin, coronal sulcus, navicular fossa. The head and body of the penis, the skin of the scrotum is less commonly affected.
Typical form of RGG characterized by the classic dynamics of lesions (erythema - vesicles - erosive and ulcerative elements - crusting) and local subjective sensations in the form of itching, burning, pain. Lesions are usually limited, rarely widespread and localized in the same area of the skin or mucous membrane. Frequent exacerbations of RGH are often accompanied by a deterioration in the general condition of patients, symptoms of intoxication appear due to viremia ( headache, chills, malaise, subfebrile temperature), inguinal lymph nodes may increase and become painful.
Atypical forms of RGG , which greatly complicate the diagnosis, may be due to: 1) a change in the development cycle of herpetic elements in the lesion; 2) unusual localization of the focus and anatomical features of the underlying tissues.
In atypical forms of RGH, one of the stages of development predominates inflammatory process in the focus (erythema, blistering) or one of the components of inflammation (edema, hemorrhage, necrosis). According to the intensity of clinical manifestations, atypical forms can proceed rapidly with manifestation (bullous, ulcerative necrotic) or subclinically (microcracks), see Fig. 2-4.
Subclinical form of RGG It is detected mainly during virological examination of the sexual partners of patients with any sexually transmitted disease, or during the examination of couples with impaired fertility.
Herpetic infection of the pelvic organs
A feature of the GG is multifocal. The pathological process often involves the lower part of the urethra, the mucous membrane of the anus and rectum, which can occur secondarily, following the onset of herpes of the external genitalia, and can proceed as an isolated lesion.
According to the characteristics of clinical manifestations, herpetic lesions of the pelvic organs in men should be divided into:
Herpes of the lower part of the urogenital tract, anal area and rectal ampulla;
Herpes of the upper genital tract (Table 1).
Herpes of the lower urogenital tract, anal area and rectal ampulla manifests itself in two clinical forms: focal , characterized by the appearance of vesicular-erosive elements typical of herpes simplex mucous membranes, and diffuse , in which the pathological process proceeds according to the type of nonspecific inflammation.herpes urethra
The generally accepted classification of urethritis distinguishes between viral urethritis caused by HSV and human papillomavirus (HPV). HSV is more often the cause of prolonged torpid urethritis and recurrent cystitis, as well as exacerbation chronic prostatitis. The frequency of herpetic urethritis (HU) ranges from 0.3 to 2.9% of all registered non-gonococcal urethritis (Ilyin I.I., 1977; Nahmias A. et al., 1976), which allowed researchers in the 70s to classify HU as rare forms of urethritis. Works recent years showed that HU is detected in 42.4-46.6% of cases in men suffering from RGH (Baluyants E.R., 1991; Semenova T.B., 2000).
Subjectively, HU 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 incubation period in the development of HU remains unclear, but is likely to be several months, rarely weeks or days. During a clinical examination, hyperemia and swelling of the urethral sponges are determined, periodically there is a scanty mucous discharge from the external opening of the urethra. The course of HU is subacute or sluggish with periodic remissions and relapses. In the discharge of the urethra, epithelial cells and mucus usually predominate, leukocytosis periodically appears. With a mixed infection, the discharge of the urethra becomes more abundant, opaque. With a two-glass sample, the urine in the first portion is transparent, but contains inflammatory products in the form of floating threads and flakes.
The diagnosis of HU is based on the isolation of HSV from a material taken from the discharge of the urethra in cell culture or the detection of an antigen. HSV method PCR.
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 HSV 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 HSV is not detected in the prostate juice, but there are clinical data on torpid prostatitis.
With dry ureteroscopy on the mucous membrane of the urethra, a mild infiltrate (rarely transitional) with fragments of the red mucosa, with pronounced large folds and disappearing small ones, is usually found. Herpetic foci are represented by small single or merging erosions with polycyclic edges against the background of local vasodilation (focal form of HI), or severe focal hyperemia of the mucosa (diffuse form of HI). More often, the anterior and middle third of the urethra is involved in the process. Contraindications to ureteroscopy are exacerbation of urethritis and the presence of herpetic eruptions in the region of the head, scaphoid fossa and the inner layer of the foreskin of the penis. Urethroscopy is recommended when the external manifestations of herpes subside, while maintaining complaints from the urethra, the patient has chronic recurrent urethritis of unclear etiology, with the preliminary exclusion of other urogenital infections.
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. When cystoscopy observed catarrhal inflammation, single erosion.
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 anal area can be affected primarily or secondarily (with the spread of infection in a patient with GI of the external genitalia). The lesion is usually a recurrent fissure, which is often the reason for diagnostic errors. Such patients with an erroneous diagnosis of "fissure anus» get to surgeons.
With damage to the sphincter and mucous membrane of the ampulla of the rectum (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. When rectoscopy is determined by catarrhal inflammation, sometimes erosion. It is possible to make a diagnosis of herpetic proctitis only on the basis of the results of a virological examination of the patient.
Herpes of the upper genital tract manifested by symptoms of non-specific inflammation.
Typical The clinical picture of herpetic lesions of the organs of the upper genitourinary tract is manifested by symptoms of nonspecific inflammation. It is very difficult to establish the real frequency of damage to the internal genital organs in men, since in 40-60% of cases the disease occurs without subjective sensations.
With subclinical form herpes of the internal genitalia, the patient has no complaints; clinical examination does not reveal symptoms of inflammation. In a dynamic laboratory study of smears of the discharge of the urethra in the secret of the prostate, an increased number of leukocytes (up to 30-40 and higher in the field of view) is periodically detected, indicating the presence of an inflammatory process.
Asymptomatic form herpes of the internal genitalia (asymptomatic viral shedding) is characterized by the absence of any complaints and objective clinical symptoms of inflammation in patients. In a laboratory study of a detachable urogenital tract, HSV is isolated, while there are no signs of inflammation (leukocytosis) in smears.
Herpes prostate
In the modern etiopathogenetic classification of prostatitis, viral prostatitis is regarded as an infectious canalicular complication of viral urethritis. According to the classification of Mears (1992), this type of prostatitis is classified as a dubious or unproven type, according to Blumensaat (1961) - to a specific one, according to O.L. Tiktinsky and V.V. Mikhailechenko (1999) - to infectious.
In the development of viral prostatitis, the urethrogenic route of transmission is more often observed, and the descending (urogenic) route is rare - with the penetration of viruses from infected urine with cystitis through the excretory ducts of the prostate gland (PJ).
According to various authors, prostatitis is caused or maintained by HSV in 2.9 - 21.8% of cases (Weidner et al., 1981). Most often, chronic prostatitis with herpetic urethritis and RGH manifests itself in a catarrhal form, while the course of the disease is characterized by a frequent and persistently recurrent character (O.B. Kapralov, 1988; Bennett et al., 1993).
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 STDs of a non-viral nature. Meanwhile, with obliterated abacterial prostatitis, it can be assumed that the pathogenic agent is a virus.
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. In most cases, exacerbation of chronic prostatitis is preceded by the appearance of herpetic eruptions in the genital area. The appearance of vesicular-erosive elements may coincide with the appearance of complaints from the pancreas. Often, in patients with RGH, 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 GI. 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 HSV in the secret of the pancreas, while the pathogenic flora in the secret and in the third portion of urine is absent.
Ultrasound examination of the prostate gland in the region of the paraurethral zones of the prostate reveals hyperechoic fibrous foci 3-9 mm in size. In patients with herpetic prostatitis, compared with abacterial prostatitis of unclear etiology, there is a greater severity of fibrous sections in the peripheral zones. Along with this, there is an expansion of the seminal vesicles, indicating a violation of their drainage into the posterior urethra, which suggests damage to the prostatic uterus.
The variety of clinical manifestations of herpes simplex, the presence of atypical, subclinical and asymptomatic forms of the disease, the involvement of many body systems in the infectious process often make it difficult to diagnose this disease.
Diagnosis of herpes The diagnosis of recurrent genital herpes with typical clinical manifestations of the disease is not difficult and can be made visually when examining the patient. Significant difficulties arise with atypical forms of HH or with herpetic lesions of the OMT. In these cases, a carefully collected anamnesis is important. Complaints of itching, burning, scanty mucous discharge from the urethra, bloody discharge from the rectum, indications of pain syndrome, recurrent nature of the OMT disease, as well as resistance of the disease to previous antibiotic therapy. In addition, patients often note a tendency to colds, fear of drafts, recurrent general weakness, malaise, subfebrile temperature, depressive states. Patients with HH often experience pain, which patients do not always associate with exacerbations of herpes. For recurrent herpes, regardless of the place of manifestation of the pathological process, a wavy course is characteristic, when painful conditions are replaced by periods of well-being, even without specific therapy.
The diagnosis of HSV infection is also complicated by the fact that HSV is often found in association with other microorganisms: chlamydia, strepto- and staphylococci, fungal flora, etc. Mixed HSV infection with gonococcus, treponema pallidum, HIV is not excluded, which indicates the need for careful examinations of patients.
Existing Methods laboratory diagnostics Herpes simplex is fundamentally divided into two groups:
1) isolation and identification of HSV in cell culture or detection of the pathogen antigen from infected material during cytological, immunofluorescent studies, enzyme immunoassay (ELISA), PCR;
2) detection of virus-specific antibodies in blood serum.
The frequency of HSV isolation from various biological media varies. When examining more than 200 patients with an established diagnosis of WGH suffering from chronic diseases of OMT, HSV was isolated from the discharge of the urethra in 22% of cases, prostate juice - 23%, semen - 15%, urine - 26%. HSV can be detected not in everyone, but in 1-2 out of 3-4 biological materials obtained from the patient. Therefore, to reduce the likelihood of a false negative diagnosis, it is necessary to examine the maximum number of samples from one patient. A negative result of a single virological test cannot completely exclude the diagnosis of genital herpes. If HSV infection is suspected, it is necessary to conduct a repeated virological examination of the discharge of the genitourinary system (1 time in 7 days, 2-4 times a month), and in some cases, use several examination methods.
Diagnostic value in primary GI is the detection of IgM and / or a fourfold increase in the titers of specific immunoglobulins G (IgG) in paired blood sera obtained from a patient with an interval of 10-12 days. Recurrent herpes usually occurs against the background of high IgG levels, indicating constant antigenic stimulation of the patient's body. The appearance of IgM in a patient suffering from RGH indicates an exacerbation of the disease.
Treatment of genital herpes General principles for the treatment of herpes simplex Modern medicine does not have methods of treatment to eliminate HSV from the body. Therefore, the goal of treatment is to suppress the reproduction of HSV during an exacerbation, the formation of an adequate immune response and its long-term preservation in order to block the reactivation of HSV in persistence foci.
Currently, there are two main directions in the treatment of herpes simplex:
1.Antiviral therapy, the main place in which is given to acyclovir (ACV) drugs, which are used to stop the recurrence of herpes, prevent and treat complications of HSV infection.
2. Complex treatment method, the purpose of which is to increase interrelapse periods, includes immunotherapy (specific and non-specific) in combination with antiviral treatment.
Correction of violations of nonspecific and specific immunity is one of the main directions in the complex therapy of herpes simplex.
Synthetic interferon inducers (IFN) have a pronounced immunomodulatory effect in the treatment and prevention of complications of herpes simplex. Among them is a domestic drug Poludan .
To date, convincing clinical data have been obtained on the high efficacy of Poludan for the treatment of various clinical forms of recurrent herpes. Poludan has a general immunostimulating effect, which allows it to be used in secondary immunodeficiency conditions caused not only by herpesvirus infections. In these cases, poludan is administered subcutaneously in the forearm: 200 mcg (1 bottle) is dissolved ex tempore in 1 ml of distilled water, administered daily, for a course of 10 injections.
One of the advantages of the IFN inducer tilorone (Amiksina) is an oral route of administration, which allows patients to independently carry out preventive courses of anti-relapse therapy recommended by the doctor. The mechanism of action of Amiksin includes: induction of interferons of types a, b, g, immunocorrection and direct antiviral action. Amiksin has a mild immunomodulatory effect, stimulates bone marrow stem cells, enhances antibody formation, and reduces the degree of immunosuppression.
Amiksin include in complex treatment RGG according to the scheme: 250 mg 1 time per day - 2 days, then 125 mg every other day for 3-4 weeks. According to the same scheme, Amiksin can be recommended to patients between courses of vaccine therapy to prolong the effect achieved.
Antiviral activity of the IFN inducer - Arbidola due to its immunomodulatory and antioxidant properties. Arbidol can be included in the complex treatment of WGH (0.2 g 2 times a day with meals for 10-14 days) and used between vaccine therapy courses to prevent herpes recurrence (0.2 g 1 time per day with meals for 2-3 weeks).
To stimulate the T- and B-links of cellular immunity in patients with recurrent herpes, Taktivin, Timalin, Timogen, Myelopid and other immunomodulators can be used.
Specific immunotherapy consists in the use of domestic herpes vaccine (polyvalent, fabric, killed). The therapeutic effect of the vaccine is associated with the stimulation of specific reactions of antiviral immunity, the restoration of the functional activity of immunocompetent cells and the specific desensitization of the body.
Given the peculiarities of the pathogenesis of herpes simplex, the most appropriate to achieve a therapeutic effect is the combined use of drugs with different mechanisms of antiviral action, which prevents the emergence of resistant strains of HSV. The use of interferons and their inducers in combination with a herpes vaccine and immunomodulators makes it possible to comprehensively address the issues of herpes simplex therapy.
Local treatment of GI of MPS organs in men
Achieving a therapeutic effect in the treatment of herpetic lesions of the MPS organs in men is impossible without local treatment .
In the presence of rashes on the skin and mucous membranes with RGH, patients are locally prescribed antiviral drugs for external use: Zovirax (cream), Acyclovir-acry (ointment), Gevizosh (ointment), Viru-merz (gel), Epigen (aerosol), etc. P.
Local immunostimulating therapy is of great importance in the treatment of HH. For this purpose, you can use Poludan . Poludan in RGH is used in the form of applications on the lesion, for which 200 μg of the drug (1 vial) is dissolved in 4 ml of water, a cotton swab is moistened and applied to the lesion for 5-7 minutes. The procedure is repeated 2-3 times a day for 2-4 days.
In the treatment of herpetic urethritis, Poludan is used in the form of instillations into the urethra (400 mcg diluted in 10 ml of water). The procedure is repeated 1 time per day daily for 5-7 days. You can use cycloferon liniment (according to the same scheme).
In herpetic proctitis, a pronounced therapeutic effect is observed when the patient is given a solution of Poludan in the form of microclysters (400 μg is diluted in 10 ml of water, 10 microclysters per course of treatment).
Along with local drug treatment, patients with chronic herpetic diseases of OMT undergo traditional local manipulations: bougienage of the urethra, prostate massage, followed by total instillation of Poludan solution or cycloferon liniment. To achieve a more pronounced anti-inflammatory, absorbable and analgesic effect in such patients, it is advisable to include low-frequency laser therapy in the course of treatment. In this case, it is desirable to combine the intracavitary introduction of a fiber light guide into the urethra or rectum in the pancreas projection area with laser reflex therapy.
Comprehensive treatment of men suffering from MPS herpes, including general antiviral and immunostimulating therapy in combination with local treatment, leads to a regression of clinical signs of chronic urethritis and prostatitis (reduction or resolution of pain and dysuric syndromes), normalization of laboratory parameters, stable positive dynamics of the course of RGH in 85 -90% of cases.
Conclusion Among viral diseases, herpes infection occupies one of the leading places, which is determined by the ubiquitous spread of HSV, 90% infection of the human population with it, lifelong persistence of the virus in the body, polymorphism of the clinical manifestations of herpes, and torpidity to existing methods of treatment.
Currently, the pathogenic effect of HSV on the development of chronic diseases of the urogenital area in women, the course of pregnancy and childbirth, the health of the fetus and newborn is not in doubt. The role of HSV in the development of pathological processes in the male body is clearly underestimated. However, according to domestic and foreign researchers, in men suffering from chronic inflammatory diseases of the pelvic organs, it is possible to detect HSV in the discharge of the genitourinary system in 50-60% of cases. It has been proven that HSV is an agent that disrupts spermatogenesis and has the ability to infect spermatozoa. It has special meaning in men of reproductive age and opens up new aspects in interpreting and solving the problem of infertile marriages.
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