Oral Gonorrhea and Associated Risks

[cscott521]

Dear Doctor,

I am a man who recently had two homosexual encounters three days apart from one another. The first, which happened nine days ago, involved oral sex without ejaculation both ways with one partner. The second, which occurred three days later with a different person involved oral sex without ejaculation both ways and insertive anal sex (me "topping" the other person) with a latex (Durex) condom which remained intact. Both partners said that they have been tested within the past two months and are HIV negative.

Since I used protection for the insertive anal sex during the second encounter and checked both before and afterwards to determine whether the condom on my penis remained intact, I am not really worried about contracting HIV from that particular act. However, I recently developed a mild sore throat confined to one side of my throat. I do not have a fever, rash, or swollen lymph nodes. I am worried that I may have pharyngeal gonorrhea. If I contracted it from the first encounter (receptive oral sex), I may have had the infection without any symptoms when the second encounter occurred. My question is: how much more likely is transmission of HIV through sucking someone's penis (without ejaculation) if you already have pharyngeal gonorrhea (with or without symptoms)? I've never thought of oral sex without ejaculation as a risky activity in terms of HIV transmission but now I am not so sure because of the possibility of acquiring some other STD in my throat from the first encounter which (theoretically?) increases the risk of HIV transmission for the second encounter.

I plan to get tested for all STD's including HIV next week. My city's department of public health offers free testing but only asks for a urine sample to test for gonorrhea and chlamydia. Should I specifically request an oral swab and culture?

Your advice and wisdom would be greatly appreciated. Thank you.

[H. Hunter Handsfield, M.D.]

Gonorrhea of the pharynx (throat) conceivably could explain your symptoms, but it is very unlikely, for several reasons.  First, sore throat is uncommon in pharyngeal gonorrhea; over 90% of cases are entirely without symptoms.  Second, asymptomatic urethral gonorrhea is rare; if your oral partner had it, most likely he would have been aware of the pus dripping from his penis, and you might have seen the evidence yourself.  Third, garden variety respiratory viruses are literally hundreds of times more common than gonorrhea.

Your comment about ejaculation doesn't make much sense.  The risk of STDs or HIV with ejaculation in the mouth probably is somewhat higher without ejaculation, but probably not by very much.  And yes, having another STD when exposed to HIV (or being exposed to both simultaneously) increases the risk of catching HIV.  But when the HIV risk is extremely low (estimated at once in every 10,000 oral exposures, if the insertive partner has HIV), the effect of the STD is trivial.  Doubling a very low risk still leaves very low risk.

Because you are anxious about it, you should follow through with your plans for an STD evaluation, including a test for pharyngeal gonorrhea.  You can expect a negative result; it is far more likely that you just caught a cold or similar virus.  A urine test won't detect oral infection.  As a sexually active person outside an exclusively monogamous relationship, you should be tested for common STDs and HIV from time to time, like once a year, and urine testing -- as well as rectal testing, if other guys ever top you -- is reasonable from that perspective.  But not based on the exposure events you describe here.

I hope this helps.  Best wishes---  HHH, MD

[Dallasfan]

9 days is too early to be testing for HIV. For your oral gonorrhea question, I would recommend a culture as a urine  test or penile swab would not answer your question. Given that oral gonorrhea is uncommon, this would be the best way to test.  Take care.