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Rectum Swab necessary?
Hi and thank you for the service you provide.
I'm concerned that I have an undiagnosed STD, specifically gonorrhea or DGI. I'm a bisexual male that is sexually active and have been with multiple partners. My last sexual encounter was in early September. Any intercourse was protected but there was a lot of rubbing before a condom was put on.
I have a tingling sensation, mainly on my penis, but on occasion it's felt near my rectum/anus. The discomfort is occasionally accompanied by muscle aches (not sure if it's joint pain/arthritis), and I've been tired. The penis/anus discomfort has been consistent with the exception of when I get up in the morning and for a short period after I urinate. I've had the aforementioned symptoms since mid-Sept.
I've had a number of STD tests since September -- 30, 60 and 90 days from my last sexual encounter. All tests for chlamydia, gonorrhea, HIV, and Hep B/C were negative. Should I be concerned that the the tests were limited to blood, urine, and a culture swab (urethral only) and that a throat and/or rectum swab was never taken?
I was treated with a number of antibiotics over the last 90 days for NGU and Prostatitis (after my last sexual experience) including:
- 8 pills of 250mg of Z-Pak taken at once (late Sept)
- Metronidazole 2 g orally in a single dose PLUS Azithromycin 1 g (late Oct)
- Injection of 80mg of gentamicin in my buttock (mid-Nov)
- 7 days of bactrim every 12 hours (Mid - Nov)
- 10 days of 500mg of Cipro every 12 hours (Late - Nov)
I'm concerned that I have gonorrhea in the rectum or DGI and it hasn't been diagnosed because a rectum swab was never done.
Any reason for concern? Should I go get tested again?
I appreciate your help.
I'm concerned that I have an undiagnosed STD, specifically gonorrhea or DGI. I'm a bisexual male that is sexually active and have been with multiple partners. My last sexual encounter was in early September. Any intercourse was protected but there was a lot of rubbing before a condom was put on.
I have a tingling sensation, mainly on my penis, but on occasion it's felt near my rectum/anus. The discomfort is occasionally accompanied by muscle aches (not sure if it's joint pain/arthritis), and I've been tired. The penis/anus discomfort has been consistent with the exception of when I get up in the morning and for a short period after I urinate. I've had the aforementioned symptoms since mid-Sept.
I've had a number of STD tests since September -- 30, 60 and 90 days from my last sexual encounter. All tests for chlamydia, gonorrhea, HIV, and Hep B/C were negative. Should I be concerned that the the tests were limited to blood, urine, and a culture swab (urethral only) and that a throat and/or rectum swab was never taken?
I was treated with a number of antibiotics over the last 90 days for NGU and Prostatitis (after my last sexual experience) including:
- 8 pills of 250mg of Z-Pak taken at once (late Sept)
- Metronidazole 2 g orally in a single dose PLUS Azithromycin 1 g (late Oct)
- Injection of 80mg of gentamicin in my buttock (mid-Nov)
- 7 days of bactrim every 12 hours (Mid - Nov)
- 10 days of 500mg of Cipro every 12 hours (Late - Nov)
I'm concerned that I have gonorrhea in the rectum or DGI and it hasn't been diagnosed because a rectum swab was never done.
Any reason for concern? Should I go get tested again?
I appreciate your help.
MEDICAL PROFESSIONAL
Welcome to the forum. Congratulations on adhering to safe sex with casual partners, i.e. consistent condom use for anal sex. Assuming the condoms remained intact, you are unlikely to have caught any STD. Body-rubbing and non-penetrating genital contact is safe sex, with little if any STD transmission risk.
I have to be a little skeptical about the diagnosis of NGU, unless a condom ruptured during sex. And if the problem was prostatitis -- well, that's a coincidence, since prostatitis isn't sexually transmitted or acquired. The need for multiple antibiotics may be a hint that you didn't have either NGU or prostatitis, which usually would have responded well to the first rounds of treatment.
In any case, the symptoms you describe are not suggestive of gonorrhea, and certainly not of disseminated gonococcal infection (DGI). Further, the antibiotics you have had almost certainly would have eradicated gonorrhea of any anatomic site (urethra, rectum, throat) if you were infected infected at the time you took the drugs. By themselves, azithromycin, gentamicin, bactrim, and ciprofloxacin would probably have worked -- and together you can be sure that any gonorrhea you had was cured. One or more of these antibiotics also would have resolved any other bacterial STD for which you might have been at risk, including chlamydia, syphilis, trichomonas, and the various causes of nongonococcal urethritis (NGU).
Therefore, at this time there is no point in testing for gonorrhea of the rectum or any other site, and no need to test for any other STD either. Your symptoms are rather vague, and are exactly the sort that usually suggest a psychological origin, such as anxiety magnifying otherwise minor or normal body sensations. (They could be due to a prostate problem -- but if these are the main symptoms you have had all along, this reinforces my skepticism about the original diagnosis.) But of course if any symptoms continue, or if you otherwise remain concerned, return to your doctor or clinic for reevaluation. In the meantime, you can be very confident no STD is the problem.
Regards-- HHH, MD
I have to be a little skeptical about the diagnosis of NGU, unless a condom ruptured during sex. And if the problem was prostatitis -- well, that's a coincidence, since prostatitis isn't sexually transmitted or acquired. The need for multiple antibiotics may be a hint that you didn't have either NGU or prostatitis, which usually would have responded well to the first rounds of treatment.
In any case, the symptoms you describe are not suggestive of gonorrhea, and certainly not of disseminated gonococcal infection (DGI). Further, the antibiotics you have had almost certainly would have eradicated gonorrhea of any anatomic site (urethra, rectum, throat) if you were infected infected at the time you took the drugs. By themselves, azithromycin, gentamicin, bactrim, and ciprofloxacin would probably have worked -- and together you can be sure that any gonorrhea you had was cured. One or more of these antibiotics also would have resolved any other bacterial STD for which you might have been at risk, including chlamydia, syphilis, trichomonas, and the various causes of nongonococcal urethritis (NGU).
Therefore, at this time there is no point in testing for gonorrhea of the rectum or any other site, and no need to test for any other STD either. Your symptoms are rather vague, and are exactly the sort that usually suggest a psychological origin, such as anxiety magnifying otherwise minor or normal body sensations. (They could be due to a prostate problem -- but if these are the main symptoms you have had all along, this reinforces my skepticism about the original diagnosis.) But of course if any symptoms continue, or if you otherwise remain concerned, return to your doctor or clinic for reevaluation. In the meantime, you can be very confident no STD is the problem.
Regards-- HHH, MD
MEDICAL PROFESSIONAL
This is good question and an important one, although it has nothing to do with DGI. Thanks for asking it. This is a good opportunity to explain this important issue, so I'm writing a blog-like response that I can save in case there are similar questions in the future.
You are correct to be concerned. Many (most?) clinics and physicians providing STD services neglect non-genital sites. This needs to change. In addition to genital testing for chlamydia and gonorrhea via urine or urethral, cervical, or vaginal swabs, STD testing in men or women who are the receptive partners in anal sex ("bottom") should routinely include rectal swabs for gonorrhea and chlamydia testing.
Also, men or women who perform oral sex on men generally should have throat swabs collected for gonorrhea testing. Chlamydia testing isn't necessary, since chlamydia rarely infects the oral cavity, and when it does the infection rarely is transmitted to partners. Cunnilingus -- oral contact with female genitals -- carries very low risk for both chlamydia and gonorrhea. Not zero risk, but low enough so that throat testing generally isn't recommended or required for persons who have performed oral on their female partners.
There are several reasons why rectal chlamydia and gonorrhea testing, and oral gonorrhea testing, are often neglected. First, until a few years ago, accurate tests weren't easily available. We now know the standard nucleic acid amplification tests (NAATs) work well for rectal specimens, and at least some NAATs probably are accurate for the throat as well. However, many labs and clinics may still be unaware, and some labs have not taken steps to certify the performance of the tests in their own hands -- a required step in some states.
Second, many clinics and doctors fail to take adequate sexual histories. Some are uncomfortable with sex in general, perhaps especially with homosexuality and with sexual practices other than vaginal intercourse. Others just don't think about it one way or the other. Whatever the reason, rectal or throat testing won't be done if the doc doesn't know these sites have been exposed. Patients can help by telling their health providers the necessary details about their sexual history, even if the doctor or nurse doesn't ask first.
Third, some providers simply don't know that sites other than the genital tract can be infected with gonorrhea or chlamydia. Here too the patient can help educate his or her doctor or clinic.
Finally, the doc may consider the testing procedures a hassle; collecting swabs from the rectum or throat may not be something they have been trained to do or to think about. However, the patient can offer to collect his or her own specimens, either in the exam room or toilet. Recent research shows that testing is equally accurate whether rectal swabs are collected by the doctor or nurse or by the patient him/herself; and a very recent study suggests the same is true for throat swabs as well.
One final word: this isn't something the patient should insist on in every case. Most of the treatments for gonorrhea or chlamydia work equally well at all anatomic sites. For example, treatment for urethral gonorrhea would also cure a rectal infection, if present. So if someone is going to be treated anyway, it's less improtant to test all sites. In your case, your very first treatment with azithromycin was adequate for chlamydia whether or not the rectum were infected -- so it wasn't all that important to know. However, when someone is being screened for common STDs and treatment won't be given unless the test is positive, it is important that all exposed sites be checked for the right STDs.
As far as your health is concerned, all these points are moot given the symptoms you describe and the treatments you have had. So that should wind up this thread. Take care.
You are correct to be concerned. Many (most?) clinics and physicians providing STD services neglect non-genital sites. This needs to change. In addition to genital testing for chlamydia and gonorrhea via urine or urethral, cervical, or vaginal swabs, STD testing in men or women who are the receptive partners in anal sex ("bottom") should routinely include rectal swabs for gonorrhea and chlamydia testing.
Also, men or women who perform oral sex on men generally should have throat swabs collected for gonorrhea testing. Chlamydia testing isn't necessary, since chlamydia rarely infects the oral cavity, and when it does the infection rarely is transmitted to partners. Cunnilingus -- oral contact with female genitals -- carries very low risk for both chlamydia and gonorrhea. Not zero risk, but low enough so that throat testing generally isn't recommended or required for persons who have performed oral on their female partners.
There are several reasons why rectal chlamydia and gonorrhea testing, and oral gonorrhea testing, are often neglected. First, until a few years ago, accurate tests weren't easily available. We now know the standard nucleic acid amplification tests (NAATs) work well for rectal specimens, and at least some NAATs probably are accurate for the throat as well. However, many labs and clinics may still be unaware, and some labs have not taken steps to certify the performance of the tests in their own hands -- a required step in some states.
Second, many clinics and doctors fail to take adequate sexual histories. Some are uncomfortable with sex in general, perhaps especially with homosexuality and with sexual practices other than vaginal intercourse. Others just don't think about it one way or the other. Whatever the reason, rectal or throat testing won't be done if the doc doesn't know these sites have been exposed. Patients can help by telling their health providers the necessary details about their sexual history, even if the doctor or nurse doesn't ask first.
Third, some providers simply don't know that sites other than the genital tract can be infected with gonorrhea or chlamydia. Here too the patient can help educate his or her doctor or clinic.
Finally, the doc may consider the testing procedures a hassle; collecting swabs from the rectum or throat may not be something they have been trained to do or to think about. However, the patient can offer to collect his or her own specimens, either in the exam room or toilet. Recent research shows that testing is equally accurate whether rectal swabs are collected by the doctor or nurse or by the patient him/herself; and a very recent study suggests the same is true for throat swabs as well.
One final word: this isn't something the patient should insist on in every case. Most of the treatments for gonorrhea or chlamydia work equally well at all anatomic sites. For example, treatment for urethral gonorrhea would also cure a rectal infection, if present. So if someone is going to be treated anyway, it's less improtant to test all sites. In your case, your very first treatment with azithromycin was adequate for chlamydia whether or not the rectum were infected -- so it wasn't all that important to know. However, when someone is being screened for common STDs and treatment won't be given unless the test is positive, it is important that all exposed sites be checked for the right STDs.
As far as your health is concerned, all these points are moot given the symptoms you describe and the treatments you have had. So that should wind up this thread. Take care.
RE: DGI
Emphasis on "*any* of the usual sites of infection" or would the clinician need to test *all* the usual sites of infection?
I guess my concern can really be boiled down to this one point. Most STD locations do a urine test for gonorrhea and chlamydia. Wouldn't this yield a false negative if the rectum or throat were infected? If the aforementioned point is true, shouldn't there be more done to educate people that the urine test is only significant for vaginal intercourse?
Emphasis on "*any* of the usual sites of infection" or would the clinician need to test *all* the usual sites of infection?
I guess my concern can really be boiled down to this one point. Most STD locations do a urine test for gonorrhea and chlamydia. Wouldn't this yield a false negative if the rectum or throat were infected? If the aforementioned point is true, shouldn't there be more done to educate people that the urine test is only significant for vaginal intercourse?
MEDICAL PROFESSIONAL
There is no single diagnostic test for DGI. If gonorrhea bacteria are identifed in the blood or in fluid from an inflamed joint, that proves the diagnosis, but such testing is usually negative; and it's never attempted unless typical symptoms are present. Otherwise, the diagnosis is made by typical symptoms plus identification of gonorrhea at any of the usual sites of infection, i.e. urethra, cervix (in women), rectum or throat.
Both gonococcal arthritis and localized gonorrhea generally resolve spontaneously over time.
Both gonococcal arthritis and localized gonorrhea generally resolve spontaneously over time.
Dr. Handsfield,
Your timely response to my inquiry is much appreciated. A comment and a few follow-up questions on the same topic if I may...
First, I believe the treatment for NGU was preventative since the antibiotics were given before the culture for gonorrhea and chlamydia came back.
I understand that my symptoms are not indicative of DGI and that any other bacterial STD is no longer an issue due to the antibiotics already taken. Case closed.
I'm curious however, if one of the tests for DGI is the swab or urine NAAT test for gonorrhea? In other words, if you have DGI you would also test positive/reactive for gonorrhea and the "location" tested is no longer relevant?
Would the course of antibiotics referenced earlier also cure DGI?
I read a few of your earlier posts on DGI where you wrote that DGI usually resolves itself after a few months. Were you referring to the arthritis or the gonorrhea itself?
Thanks again for all you do. I'd venture to guess that your work helps hundreds of thousands of people.
Your timely response to my inquiry is much appreciated. A comment and a few follow-up questions on the same topic if I may...
First, I believe the treatment for NGU was preventative since the antibiotics were given before the culture for gonorrhea and chlamydia came back.
I understand that my symptoms are not indicative of DGI and that any other bacterial STD is no longer an issue due to the antibiotics already taken. Case closed.
I'm curious however, if one of the tests for DGI is the swab or urine NAAT test for gonorrhea? In other words, if you have DGI you would also test positive/reactive for gonorrhea and the "location" tested is no longer relevant?
Would the course of antibiotics referenced earlier also cure DGI?
I read a few of your earlier posts on DGI where you wrote that DGI usually resolves itself after a few months. Were you referring to the arthritis or the gonorrhea itself?
Thanks again for all you do. I'd venture to guess that your work helps hundreds of thousands of people.
You are reading content posted in the STDs Forum
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