In late 2023 I had a brief extramarital mistake and allowed a friend to perform unprotected oral sex on me. It lasted less than 2 minutes before I realized how wrong it was and stopped it. 5 days later I developed some mild dysuria. After 14 days of this, I went to my PCP, he said as there was no discharge it was probably NGU and provided 1.5g azithromycin. 10 days later I started to feel a little better and assumed the antibiotics worked.  A month later I had unprotected intercourse with my wife and thought nothing of it. 2 months later she complained of pain and some bleeding from her anus. Panicking that this could have been gonorrhea, I gave her 800 mg of cefixime that evening, 800 mg 12 hours later, and 800 mg 24 hours after that. By day 7 she was fine again. I also took 2 x 800mg separated by about 20 hours. I assumed that if this was gonorrhea the fact that rectal symptoms resolved meant any vaginal infection would also be cured. We have just one protected sexual encounter since (guilt has paralyzed me). 12 months from the treatment she is having intermittent nausea and mil intermittent abdominal pain. Could this be PID from a vaginal infection that wasn't cured by the cefixime? 

Note, she had her cervix, uterus, and fallopian tubes removed 8 years ago.

My first reaction is sorrow you treated your wife for presumed gonorrhea, apparently without medical advice. Having had a total hysterectomy, there was no possibiity gonorrhea explained her symptoms, even if you had it -- which almost certainly you did not. (But maybe you're a health professional? Hints of it from the terminology you use....)

Going to your exposure a bit over a year ago, dysuria alone rarely is due to bacterial urethritis, i.e. gonorrhea, chlamydia, or nongonococcal urethritis. In fact, my forum colleague Dr. Hook was the lead investigator on the most important study done on this topic:  absence of visible discharge excluded these diagnoses. Dysuria along generally means a non-STD UTI; or sometimes a sexually acquired viral infection, sometimes acquired from oral sex (e.g. some strains of adenovirus). I can't fault your PCP prescribing azithromycin as a precaution, but it made no difference:  if you had had an azithromycin-susceptible infection, it would have cleared in a day or two. Ten days after that treatment -- apparently 3-4 weeks since the exposure -- is much more consistent with adenovirus or similar infection. But even that seems unlikely:  my strongest suspicion is that your symptoms were the result of anxiety magnifying trivial symptoms or even normal sensations that otherwise you would have ignored or perhaps not even noticed.

Accordingly, I am confident you had no STD to transmit to your wife. And not having had anal sex with your wife makes rectal infection unlikely; and two months is much too long an incubation period as well. Her rectal symptoms almost certainly had nothig to do with your other sexual experience. As for her current symptoms, she cannot have PID:  by definition, PID is inflammation of fallopian tubes + uterus. And vaginal infection alone cannot cause abdominal pain.

I would strongly advise you to completely disregard your sexual indiscretion a year ago and cease any worry or concern about your wife's symptoms having anything to do with it. Of course she should see a physician if she has ongoing symptoms that concern her. But no mention need be made of your other sexual contact.

I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD

As you guessed, I am in healthcare, which is why I treated her in the manner I did. I understand that gonorrhea has become less susceptible to cefixime, especially as a single dose, so I calculated that the 2 doses of 800 mg separated by 12 hours should ensure 28-32 hours of 1mg/l cefixime which should cure almost all strains of gonorrhea. With that treatment, would you think an infection could persist?

I am aware that urethral and cervical infections eventually clear by the immune system, I am curious about the natural history of gonococcal PID. There is very little published about it, I suspect because the signs were not recognized in the pre-antibiotic era. Would the immune system also cure these infections, or would it persist for extended periods?

The natural course of GC PID is irrelevant since she could not have had it. Surely you understand that absence of an upper genital tract makes PID impossible, right? (Probably in the pre-antibiotic era, most GC PID gradually resolved, probably usually over several months, leaving permanently scarred and obstructed tubes, i.e. permanent tubal infertility -- probably bilaterally in most cases.)

Obviously there is little hard data for this, but how long can untreated gonorrhea or chlamydia last? I know that all known infections in the pre-antibiotic era cleared up, but how long could they persist?

In regards to PID treatment, is there a reason that no studies on oral cephalosporins exist? I know that parental antibiotics have more favorable pharmacokinetics, but surely oral cefixime must have some use in this area?

Does gonorrhea ever infect the prostate anymore? I know that it was an issue in the past. When it did, did that also eventually clear, or were these people constantly infected?

With regards to oral cephalosporins and decreased susceptibility, why aren't multi-dose treatments being studied? In many settings, ceftriaxone isn't always available or easily administered, but oral ones are usually easier to obtain. I should think, if patient adherence isn't an issue, 2 or more doses of oral treatment would be extremely convenient.

Finally, is it possible that a treatment of gonorrhea could work rectally but fail vaginally? I know that oral infections are more difficult to treat, but I would think that urogenital infection would be cured if rectal infections were.

Gonorrhea rarely infects the prostate. How often it happened in the past is uncertain; as a percentage of urethral infections, maybe 1-2% if untreated in the feint few weeks. There is absolutely nothing in your situation that makes this a possibility.

Excellent question about multi-dose treatment for gonorrhea. As it happens, this is back on the table for consideration by public health and STI experts; an anticipated change in the next round of Canada's national guidelines probably will include a 3 day (6 dose) regimen of cefixime. Not sure what to expect elsewhere, but there is increasing understanding that single-dose treatment always had a somewhat pejorative rationale -- that people with gonorrhea are inherently too unreliable to be trusted with multi-dose treatment. Obviously that's not true -- at least no more true for people with gonorrhea than any other medical condition. It's an old fashioned perception based on misunderstandings about "that kind" of patient. It also was very racist; GC always has been more than tenfold more common in African Americans than whites.

In general, genital and rectal infections respond equally well to all treatments; it is correct that oral infections are more difficult to eradicate -- although this depends a lot on the particular antibiotic used.

That completes the two follow-up exchanges included with each question and so ends this thread. I hope the discussion has been helpful. Best wishes.