[Question #2021] HSV2 possibility and balanitis

47 months ago

Uncircumcised male. 3 month ago, I met a woman in a bar during a business trip and we had a one night stand.

After 7 + mins of protected vaginal sex we switched positions, less than a min later she complained about sharp pain; we stopped intercourse; she took my condom off, manually stimulated me for about 5 mins, it was kind of rough. She offered oral, I actually put a new condom before she performed oral sex.

The morning after I asked if she was OK; she told me that she has HSV2; diagnosed 2 years ago; and maybe was having the beginning of an outbreak. I did not ask a lot more.

Day 3 a saw a bright red flat itchy rash on one side of the prepuce, 3/4 x 1/2 inch.

Day 7 the rash was worse. It was painful and itchy. Extended to the glan and scrotum.

Day 14 I saw my PCP, he said that it looked like fungus, balanitis. No blisters, vesicles, or sores. Tried OTC clotrimazole cream. During the next weeks I had paresthesia.

Week 3 I visited a urologist, prescribed me itraconazole, 100mg 14 days. Said it did not look like herpes, prescribed me Valtrex as precaution (500mg/twice/ 7 days)

Week 4 Switched to clotrimazole/beta/gentamicin.

Week 8 I didn’t improve significantly. PCP said the cream maybe was hurting (I stopped it)

Week 8.5 Full panel STD, all negative except igg HSV-1. I never have had unprotected sex, including oral.

Week 13 I’m about 80 % OK, still mild itchy rash left.

Assuming she was having an outbreak, what are the chances of being infected with HSV2 wearing a condom?  Could you comment about my symptoms?

Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
47 months ago
I think the chances of your acquiring herpes in the situation you described is really very low.  You get a gold star for using condoms the whole time and that likely protected you from getting a new infection, especially if she was just starting to get an outbreak. Herpes lesions truly are blistery and tender - they are not a diffuse red rash.  The clinician that saw you apparently agreed and felt it looked fungal.  And that fits with the way a fungal rash might appear.  But the puzzling thing here is that it was on the head of your penis first, which was covered by a condom, so I'm wondering if you might have had sensitivity to the condom or something else. 

The good news is that the puzzling part probably doesn't apply to herpes - it just does not sound herpetic to me - single encounter, fully protected (both oral and genital), flat rash with no blisters, two docs saying not herpes, negative test at 8 weeks.  I think you are good here in terms of herpes.

Terri
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47 months ago

Dear Terri,

Thank you for your service in this website. I am sure everyone here appreciates it.

Just to help me to clarify some of the myths around about HSV, I have few follow up questions.

(1) In your 33+ years of clinical experience how often did you see posthitis or balanitis, without lesions as a symptom for HSV-2?

(2) In the cases when lesions are present, is the irritation/inflammation on the skin  limited around the lesions?

(3) The only possible explanation I got about why the irritation appeared first in the prepuce (protected by the condom) was the rough HJ. Do you think make sense? Can an initial irritation due to friction trigger a fungal infection?

I have been worried because unfortunately my case of balanoposthitis was severe and very painful. It took a long time to get better.  I am a middle age man and never had any issue in my genitals before. I have had very few sex partners and before this single encounter they represented no risk. Even in past long-term committed relationships everything was protected, but with this virus I only need to be unlucky once.

I hope this experience is an opportunity to learn.

Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
47 months ago
1.  Balanitis, by definition, has symptoms, so I don't understand the question
2.  Yes
3.  I don't think that irritation due to friction would cause a fungal infection, no, not by itself
How long ago was this contact?  Have you had herpes antibody testing done yet?

Terri
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47 months ago

Hi Terri,

Thank for your reply.

I am going to try to clarify my question.

There are some claims that irritation and inflammation (discrete or diffused) of the foreskin and/or glan can be indications or a HSV infection, even if lesion such as vesicles, blisters, ulcers, or cuts are not present.

(1) Can herpes really manifest as just irritation and inflammation of the skin on the genitals without the present of lesions like blisters or vesicles?  In other words, just an itchy painful rash with no lesions?, if so how commonly happens in this way?

I think you already answer my second question, but just for my reassurance.

(2) In the case of an HSV infection, the skin irritation and inflammation is discrete and only around the lesions (blisters, vesicles, etc)? correct?

It has been 14 weeks since the encounter and I am mostly recovered around 80-85% better .

I had negative igg HSV-2 at 8.5 and 13 weeks (labcorp). I took Valtrex for about 10 days (some days 500mg twice a day and some only 500mg once a day). That happened around weeks 3 and 4.

I got the prescription for Valtrex because at that point I was in a lot pain and discomfort. The irritation covered the entire prepuce and glan and most of the scrotum. I never had the typical lesions such as blisters, vesicles or ulcers. But the most important thing for me was just to get better, and the ideal was that even if valtrex may not help at least it would not hurt.

I never had anything remotely like this before in my like, I practice perfect hygiene and take very good care of myself in any way, that why I am not completely convince about the fungal diagnosis. My risk of STDs was also basically no exiting before this encounter.

As you have shown in your research, fully reliable HSV testing is still a challenge (excluding WB, which is a hassle). Two decades ago was even worse and more misinformation and even then, together with first gf we assumed that we could have oral HSV-1 (asymptomatic) and then avoided as much as we could the risk of genital HSV-1 (HSV-2 was not a possibility for either of us). Later partners were negatives of HSV-2 and they were also very careful about STDs. I have kept the same attitude about STD's, specially about HSV-2 until this encounter, which still was fully protected vaginal and oral, but she was probably having the beginning of an outbreak; which obviously, I did not know.

Once again, I am very thankful for you help in this forum.

Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
47 months ago

(1) Can herpes really manifest as just irritation and inflammation of the skin on the genitals without the present of lesions like blisters or vesicles?  In other words, just an itchy painful rash with no lesions?, if so how commonly happens in this way?. 

In my experience, herpes does not present as a diffuse rash - it presents as specific sores, either in a group or individually.  A diffuse irritation or rash is a very different thing.

I think you already answer my second question, but just for my reassurance.

(2) In the case of an HSV infection, the skin irritation and inflammation is discrete and only around the lesions (blisters, vesicles, etc)? correct?

Yes, correct.  Discrete lesions is a good way to describe how herpes lesions would appear. 
Yes, western blot can be a hassle - either a big or a small hassle, depending upon where you live, but it does give people some big relief if they are wondering about the accuracy of the western blot. 
I think your consistent condom use in this situation provided you good protection against the acquisition of herpes.

Terri
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