Oral Sex Clarifications and more

[ovrlyprnoid??]

Hey Doc,
I've seen my PCP for testing, but he gave me a lot of the same lines I see at places like the CDD (CYA type). I'm hoping these questions, while in many threads, are a little different in that they help put some perspective around some of the valuable information here.

My situation: Married, 38-year old male. Faithful until 11 days ago when I received unprotected fellatio from a woman I had just met. She is about same age, and is allegedly also married. Oral contact lasted about 3-4 minutes.I have no symptoms of anything at this time.

-You often state that passing gonorrhea through fellatio is rare or uncommon. Can you further elaborate on what that means. I realize there is no way for you to do this on society, so maybe you can think about your clinic and how often you see women show up with gonorrhea of the throat or males who get it exclusively through that contact.

-I took a gonorrhea test 7 days from the contact. My assumption is that is sufficient time elapsed.

-You've said that Amoxicillan is not effective against gonorrhea, so the single does of 800 mg (yes, one tablet) that I took 4 days after contact and 3 days before testing would not affect accuracy of the test, would it? Yes, I thought I'd play dr. before I gained my senses.

-Can you elaborate on why oral transmission is not an effective means (vs. genital)?

-You've said gonorrhea in males w/out symptoms is rare. When you say rare (again based upon your patients), what do you mean? Is that a 1/10, 1/50, 1/100 thing you've seen?

-Finally, in terms of other stds, here's what i understand: Chlamydia/HIV - no reason to test. Syphillis usually would require an open sore on the woman's mouth and would likely show symptoms. Also, very rare in heterosexual males.

-HSV1 - Likely already infected, but if not, would also likely require an Herpes sore in the woman and would likely show symptoms on me within 2 weeks.

Let me know if I'm off on any of these.

Thanks

[H. Hunter Handsfield, M.D.]

Directly to the questions.

1) Gonorrhea and fellatio:  In general, penile exposure to a partner's mouth is low risk for STD (much lower than vaginal or anal sex), but of the STDs that are seen, gonorrhea is among the most common.  There are no data to estimate the numerical risk, but the large majority of exposures don't result in gonorrhea transmisison, even if the oral partner has gonorrhea of the throat.  And gonorrhea is uncommon in heterosexual women.  These factors translate to a very low risk for any particular exposure of the sort you describe, probably only one chance in several thousand.

2) Urethral gonorrhea without symptoms is rare.  If you weren't discharging pus from your penis by 7 days, almost certainly you weren't infected and didn't need testing.  In any case, testing at 7 days is fine.  It takes only 2-3 days for gonorrhea tests to be positive.

3) That dose of amoxicillin probably would cure 80-90% of gonorrhea cases.  About 10-20% of gonorrhea bacteria in North America are totally resistant to all drugs of the penicillin class (which includes amoxicillin).

4) Transmission efficiency: It undoubtedly has to do with the how many bacteria are present in the throat of infected people, the fact that saliva inhibits many bacteria, and that in most episodes of oral sex, the amount of oral secretions that get into the urethra is small.  But this is just common sense, not data.  No research has been done and I don't expect ever will be done on such an arcane issue.

5) If you search the medical literature, you will find that I was the investigator who first pointed out the very existance of asymptomatic urethral gonorrhea in men, 35 years ago.  At the time, it appeared that up to 10% of urethral infections stayed asymptomatc.  However, we now know that some gonorrhea strains are more likely than others to result in infection without symptoms.  For a variety of reasons, those particular strains currently are rare in almost all parts of the world.  Today, most likely at least 99% of urethral gonorrhea infections result in symptoms, although sometimes they can be mild.

You've got it right about HIV and syphilis, although testing for those still would be warranted in some settings involving oral-genital exposure, such as in men who have sex with men and in parts of the world where those infections are more common than in Europe and North America.

Regards--  HHH, MD

[ovrlyprnoid??]

Excellent information (sorry for the flattery). It certainly puts the incident in perspective of real-world risks, which is what I wanted. Well worth my $15 and hopefully someone else gets use out of the info.

My only follow up would be on the Amoxicillan. It was only one dose I took - of a perscription that said to take one dose twice per day for 10 days. Just confirming what you wrote considered that. And, if you are saying it would have cured 80+ percent, in general how quickly would i not be "contagious" to my wife after having taken the medicine? My only remaining concern (as small as it is in light of your estimates) is that I contracted gonorrhea (call it day 0), took the anti-biotic (day 4), then had sex with my wife (day 5) and could have transmitted it, but it was killed by the time I got to the dr. on day 7 (and I will test negative).

Or am I thinking way too conspiracy theory on this?

Thanks agian.

[H. Hunter Handsfield, M.D.]

I misunderstood the amount of amoxicillin.  Single dose treatment with 800 mg, probably would cure ~70% of gonorrhea.  If you were infected, and if the antibiotic worked, within a few hours you probably would not be infectious for another sex partner.  And as we already discussed, the chance you were infected was low.  I never guarantee anything, but I see no signficant risk for your wife.

[ovrlyprnoid??]

Thank you for the response. I realize I'm nearing the point of cut-offf due to paranoia, so I purposefully waited 3 weeks before deciding to pursue this. I've also seen a mental health specialist and am taking anti-anxiety medicine (I'm guessing it would have been your next suggestion).

Just one thing confuses me, which is the treatment question. I spoke further with my PCP.Originally I was concerned with his std knowledge, but my subsequent questions for him, answers have been consistent with yours, so I feel better. He even suggested that I NOT get tested for the infection unless I developed symptoms.

The one area where he responded differently is the Amoxicillin. His exact words were that he would be "extremely surprised if one dose of that size Amoxicillin would have any effect on a bacteria like Gonorrhea." He also said that this drug didn't cover it very well, so they never prescribe it anymore. He said that when it was a recommended course of treatment, they minimum single dose he saw as effective was 3g. This seems consistent with much of the research I've done on Amoxicillin. Further, most people who take it for other reasons (where it might also cure gonorrhea) are on it for 5-10 days at 1g per day, many, many times the amount I consumed. Any thoughts?

My guess is that you will defer to my PCP and I'll need to move on with life and just not being 100% certain. It has been more than a month since the incident and I guess even if I would have passed it on to my wife, then cured my case by taking amoxicillin, I probably would have re-acquired it from her (we have intercourse quite regularly) and I would have developed symptoms by now.

Your final response would be appreciated!

[H. Hunter Handsfield, M.D.]

OK, maybe amoxicillin would be only 40-50% effective in that dose; it certainly would have somewhat more likelihood of an effect than your PCP indicates.  In all other respects, I agree with your PCP, including the advicd that testing for gonorrhea isn't necessary in this situation, in the absence of symptoms.