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Pharyngeal Gonorrhea After Exposure to Penis With No Discharge
Dear Dr. Hook and/or Dr. Handsfield:
I am a 28-yo old male in a long-term partnered relationship with another 28-yo male. Seventeen days ago, after a bit too much alcohol, I engaged in very brief unprotected anal sex with someone outside my relationship that lasted only about one minute (I was the insertive partner). He assured me he is STD-free and HIV- but I stopped very shortly after it began anyway.
Twelve days afterward, I felt symptoms of urethral gonorrheal infection: a tingling sensation when urinating and slight burning afterward, but no discharge. By the next day (Day 13) I noticed a small amount of white discharge only visible when "milked" from my penis. On Day 15 the symptoms progressed to readily visible, slightly yellow discharge and I went to an STD clinic that performed oral and rectal swabs and urine tests for gonorrhea and chlamydia, blood work for syphilis and a NAAT and rapid HIV test. The doctor took suspected gonorrhea and gave me a shot of Ceftriaxone and 1g of Azithromycin. Two days later my symptoms abated.
The full results aren't due for five more days. My primary concern in the interim is the health of my partner and the chance or likelihood that I could have passed this infection onto him. I have abstained entirely from any sexual contact with him since my symptoms began on Day 12, but he did briefly perform oral sex on me twice on Day 5 and Day 7 -- before I felt or showed any symptoms at all, under two minutes on both occasions, and without ejaculate.
1) What are the odds or likelihood that one can contract pharyngeal gonorrhea by performing brief oral sex on a recently infected partner with absolutely no signs or symptoms of infection whatsoever (discharge, itching, burning, etc.)?
2) Isn't 12 days an uncommonly long incubation period for gonorrhea? (I'm wondering if it could be NGU or some other problem)
3) If it is chlamydia, not gonorrhea, is there even less likelihood of passing this on through such brief oral contact?
I am a 28-yo old male in a long-term partnered relationship with another 28-yo male. Seventeen days ago, after a bit too much alcohol, I engaged in very brief unprotected anal sex with someone outside my relationship that lasted only about one minute (I was the insertive partner). He assured me he is STD-free and HIV- but I stopped very shortly after it began anyway.
Twelve days afterward, I felt symptoms of urethral gonorrheal infection: a tingling sensation when urinating and slight burning afterward, but no discharge. By the next day (Day 13) I noticed a small amount of white discharge only visible when "milked" from my penis. On Day 15 the symptoms progressed to readily visible, slightly yellow discharge and I went to an STD clinic that performed oral and rectal swabs and urine tests for gonorrhea and chlamydia, blood work for syphilis and a NAAT and rapid HIV test. The doctor took suspected gonorrhea and gave me a shot of Ceftriaxone and 1g of Azithromycin. Two days later my symptoms abated.
The full results aren't due for five more days. My primary concern in the interim is the health of my partner and the chance or likelihood that I could have passed this infection onto him. I have abstained entirely from any sexual contact with him since my symptoms began on Day 12, but he did briefly perform oral sex on me twice on Day 5 and Day 7 -- before I felt or showed any symptoms at all, under two minutes on both occasions, and without ejaculate.
1) What are the odds or likelihood that one can contract pharyngeal gonorrhea by performing brief oral sex on a recently infected partner with absolutely no signs or symptoms of infection whatsoever (discharge, itching, burning, etc.)?
2) Isn't 12 days an uncommonly long incubation period for gonorrhea? (I'm wondering if it could be NGU or some other problem)
3) If it is chlamydia, not gonorrhea, is there even less likelihood of passing this on through such brief oral contact?
MEDICAL PROFESSIONAL
OK.
That should wind up this thread. If you have follow-up testing, I don't need to know about it unless you have a positive result, which is very unlikely.
My final take-home message should be obvious: use condoms for non-monogamous sexual exposures! Statistically speaking, these events mark you as being at especially high risk of getting HIV someday, so please take it as an important milestone to assure that doesn't happen.
That should wind up this thread. If you have follow-up testing, I don't need to know about it unless you have a positive result, which is very unlikely.
My final take-home message should be obvious: use condoms for non-monogamous sexual exposures! Statistically speaking, these events mark you as being at especially high risk of getting HIV someday, so please take it as an important milestone to assure that doesn't happen.
Had the "difficult" conversation with my regular partner earlier this afternoon and he has an appointment to be treated tomorrow morning. The casual partner was tested and treated yesterday.
PS - I mistakenly referred in my comments above to my rapid HIV test as a "rapid oral." It wasn't. They drew an entire vial of blood for that test.
PS - I mistakenly referred in my comments above to my rapid HIV test as a "rapid oral." It wasn't. They drew an entire vial of blood for that test.
MEDICAL PROFESSIONAL
Most pharyngeal gonorrhea is asymptomatic. It should respond, especially to the combination of ceftriaxone and azithromycin. However, it's a little less certain than for genital or rectal gonorrhea; but apparently the clinic is planning a follow-up culture.
One last thing and I will close comment on this thread: I was also found to have pharyngeal gonorrhea, for which I have/had no symptoms. I gather the course of treatment I received is what you'd recommend for that as well?
Regardless, I am due back in a week to be retested for surety.
Regardless, I am due back in a week to be retested for surety.
MEDICAL PROFESSIONAL
I also didn't expect gonorrhea. But note my guesstimate of a 20% chance, so it's not all that surprising.
Your clinic is correct that resolution of symptoms is highly reliable in predicting cure for urethral gonorrhea. In any case, the gonorrhea antibiotic resistance problem is for antibiotics other than ceftriaxone; only 4-5 strains have ever been found to be resistant to it and those were all in Japan or Korea. And anyway, I doubt you clinic will ever know; there are no routine tests for antibiotic resistance of gonorrhea to ceftriaxone.
At least this clears the air about the "difficult conversation". Any doubt about the need doesn't apply to gonorrhea. Good luck with it.
Your clinic is correct that resolution of symptoms is highly reliable in predicting cure for urethral gonorrhea. In any case, the gonorrhea antibiotic resistance problem is for antibiotics other than ceftriaxone; only 4-5 strains have ever been found to be resistant to it and those were all in Japan or Korea. And anyway, I doubt you clinic will ever know; there are no routine tests for antibiotic resistance of gonorrhea to ceftriaxone.
At least this clears the air about the "difficult conversation". Any doubt about the need doesn't apply to gonorrhea. Good luck with it.
The tests came back positive for gonorrhea, much to my surprise. The cultures aren't yet in to determine whether or not it this is an antibiotic-resistant strain; but the clinician assured me if I am responding to treatment (it's been 72 hours exactly and the symptoms are 98% gone) then I'm probably fine. I hope you concur with that assessment.
I contacted the casual partner yesterday and he immediately sought testing and treatment. Now on to that other "difficult conversation."
I contacted the casual partner yesterday and he immediately sought testing and treatment. Now on to that other "difficult conversation."
MEDICAL PROFESSIONAL
Correct about the NAAT for HIV; a negative result at 15 days will be highly reliable. Still, most experts would also recommend another antibody test at 4-6 weeks. The combination of that result with the NAAT will be definitive.
Feel free to post your test results when they are available.
Feel free to post your test results when they are available.
I absolutely agree with you and I thank you for your candor. I'm really just trying to assess all the risks and possibilities involved so I can clearly communicate them during that "difficult conversation."
As part of my full panel of tests on Monday I did do a NAAT HIV test in addition to the rapid oral. The rapid oral, of course, was negative and I was told the NAAT could reliably detect an infection from 1-2 weeks after exposure. I had the test 15 days after contact and will learn the results next week.
Thank you again. I'll keep you posted, if you like.
As part of my full panel of tests on Monday I did do a NAAT HIV test in addition to the rapid oral. The rapid oral, of course, was negative and I was told the NAAT could reliably detect an infection from 1-2 weeks after exposure. I had the test 15 days after contact and will learn the results next week.
Thank you again. I'll keep you posted, if you like.
MEDICAL PROFESSIONAL
Thanks for the clarifications. NGU or chlamydia remain more likely (80% chance, I would say) than gonorrhea (20%). In addition to timing and scant discharge favoring NGU/chlamydia, gonorrhea usually causes substantial pain on urination, which you didn't mention. (Did you see the mini-series Band of Brothers? "I'm pissing razor blades" says a soldier with gonorrhea.)
I'm still a bit surprised the clinic didn't give you a preliminary diagnosis based on examining urethral discharge under a microscope. That's normal practice in almost all STD clinics, and quite reliably distinguishes gonorrhea from NGU or chlamydia. In any case, your treatment was exactly as recommended to cover all three possibilities.
Is it "absolutely imperative" your partner be treated? If you have gonorrhea, yes, and probably for the others as well. Most likely no harm would come if you have NGU or chlamydia and your partner were not treated. However, there are no guarantees, and perhaps you will agree it wouldn't be fair to take even a small risk of harm without his knowledge. Also, having had unprotected anal sex with a casual partner, and acquiring an STD to boot, makes HIV a realistic concern. (You should be retested for it in a few weeks.) Do you think it is appropriate to withhold any or all this information, and the potential benefit of treatment (even if that benefit is small), from your partner? How would you feel if your situation were reversed?
So you won't get support from me, and not likely from any STD specialist, to not follow standard practice, or to avoid a difficult conversation with your partner. I don't mean to lecture you, but want you to have full information on which to base a final decision.
I'm still a bit surprised the clinic didn't give you a preliminary diagnosis based on examining urethral discharge under a microscope. That's normal practice in almost all STD clinics, and quite reliably distinguishes gonorrhea from NGU or chlamydia. In any case, your treatment was exactly as recommended to cover all three possibilities.
Is it "absolutely imperative" your partner be treated? If you have gonorrhea, yes, and probably for the others as well. Most likely no harm would come if you have NGU or chlamydia and your partner were not treated. However, there are no guarantees, and perhaps you will agree it wouldn't be fair to take even a small risk of harm without his knowledge. Also, having had unprotected anal sex with a casual partner, and acquiring an STD to boot, makes HIV a realistic concern. (You should be retested for it in a few weeks.) Do you think it is appropriate to withhold any or all this information, and the potential benefit of treatment (even if that benefit is small), from your partner? How would you feel if your situation were reversed?
So you won't get support from me, and not likely from any STD specialist, to not follow standard practice, or to avoid a difficult conversation with your partner. I don't mean to lecture you, but want you to have full information on which to base a final decision.
Thank you very much for your prompt answer, Dr. Handsfield.
The results of the full panel of tests are not available for 3-7 days after I did them, so I'll have answers tomorrow at the earliest and possibly as late as Monday.
To be clear, my discharge did eventually have a slightly yellow hue to it after two days of it appearing only to be white or milky. I wouldn't say it was "large in amount," but then I've never had an STD before so I have no basis for comparison.
Assuming your guess turns out to be correct and it is chlamydial or NGU, would the initial treatment I received of Ceftriaxone 125mg and Azithromycin 1G be the proper course of treatment to eradicate it? As I said, my symptoms have disappeared altogether after only two days of that course of treatment.
Likewise, since chlamydia rarely takes hold in the throat and NGU is not known to do so either, is it merely conservative or absolutely imperative that my regular partner undergo treatment as a precaution?
Many thanks to you and Dr. Hook for your work and guidance here and elsewhere.
The results of the full panel of tests are not available for 3-7 days after I did them, so I'll have answers tomorrow at the earliest and possibly as late as Monday.
To be clear, my discharge did eventually have a slightly yellow hue to it after two days of it appearing only to be white or milky. I wouldn't say it was "large in amount," but then I've never had an STD before so I have no basis for comparison.
Assuming your guess turns out to be correct and it is chlamydial or NGU, would the initial treatment I received of Ceftriaxone 125mg and Azithromycin 1G be the proper course of treatment to eradicate it? As I said, my symptoms have disappeared altogether after only two days of that course of treatment.
Likewise, since chlamydia rarely takes hold in the throat and NGU is not known to do so either, is it merely conservative or absolutely imperative that my regular partner undergo treatment as a precaution?
Many thanks to you and Dr. Hook for your work and guidance here and elsewhere.
MEDICAL PROFESSIONAL
And whatever the diagnosis, your casual partner (the source of your infection) also should be tested and treated appropriately. If you are in contact or can find him, let him know what's going on.
MEDICAL PROFESSIONAL
Welcome to the forum. Thanks for your question.
Most likely the STD clinic examined material from your urethral swab microscopically, which is highly reliable to diagnose gonorrhea and NGU. Did they say anything about the result? My guess is that it didn't show gonorrhea, and in any case gonorrhea is unlikely based on your symptoms. Typically urethral gonorrhea symptoms start within 5 days, and the discharge is large in amount and has a yellow or creamy color (it's pus, after all). The timing and the relatively mild symptoms are typical for chlamydia or NGU, and I'm betting on one of these, and that your gonorrhea lab test will be negative.
Any of these (gonorrhea, chlamydia, NGU) can be transmitted any time after catching them, before symptoms start. To that extent, your regular partner is at risk. However, chlamydia rarely takes hold in the throat, and nonchlamydial NGU is not known to cause any oral infection either. On the other hand, we don't know for sure that NGU or chlamydia are harmless, and standard practice is to treat partners known to have been exposed to any of these infections. In other words, gonorrhea is the only one likely to be of serious concern -- but regardless of the eventual diagnosis, your partner should be treated appropriately. He and you should follow the STD clinic's advice about specific drugs and/or testing they may recommend.
I think those comments address all three of your specific questions. Let me know if anything isn't clear.
Regards-- HHH, MD
Most likely the STD clinic examined material from your urethral swab microscopically, which is highly reliable to diagnose gonorrhea and NGU. Did they say anything about the result? My guess is that it didn't show gonorrhea, and in any case gonorrhea is unlikely based on your symptoms. Typically urethral gonorrhea symptoms start within 5 days, and the discharge is large in amount and has a yellow or creamy color (it's pus, after all). The timing and the relatively mild symptoms are typical for chlamydia or NGU, and I'm betting on one of these, and that your gonorrhea lab test will be negative.
Any of these (gonorrhea, chlamydia, NGU) can be transmitted any time after catching them, before symptoms start. To that extent, your regular partner is at risk. However, chlamydia rarely takes hold in the throat, and nonchlamydial NGU is not known to cause any oral infection either. On the other hand, we don't know for sure that NGU or chlamydia are harmless, and standard practice is to treat partners known to have been exposed to any of these infections. In other words, gonorrhea is the only one likely to be of serious concern -- but regardless of the eventual diagnosis, your partner should be treated appropriately. He and you should follow the STD clinic's advice about specific drugs and/or testing they may recommend.
I think those comments address all three of your specific questions. Let me know if anything isn't clear.
Regards-- HHH, MD
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