Hello Doctors, 

About 2.5 weeks ago I had a sexual encounter with another man. I am also a man. I recieved oral sex from him. No other sexual contact was made. When I asked about his status, he said he was tested about 3 months ago. About a week after the encounter, he stated he got tested again and all was negative (he said felt bad for me that I was anxious about STDs). This man is a stranger so I do not know if he is being truthful. 4 days ago I noticed a small blueish-red dot (about 1mm in diameter) on my scrotum. It was not raised or hard, and felt flush against the skin. I suspect it is a cherry angioma as I have a few of those on my stomach and back, though they are much larger. While inspecting, I accidentally scratched it. It bled pretty significantly, but stopped after about 5 min of applying pressure. The next day, the skin was raised and inflamed around the area (total diameter of the inflamed skin was about 1cm). The dot has not increased in size. Today is day 4 since i scratched it, and it appears to be healing, as the skin is no longer raised and it appears less red and inflamed. The 'dot' is still only about 1mm and now has a blueish color to.it. It does not appear similar to syphilis chancre pictures I've seen online, but I've read sometimes chancers can present atypically. My questions are: 

How likely did I acquire syphilis from this encounter?

Can you describe what an atypical chancre would look like? 

Is it typical for a chancre to show signs of healing after only a few days?

 

What does the syphilis chancre healing process look like (from appearance to healing)? 

Does this sound like a typical or atypical syphilis chancre?

Sorry, I should also add I took 200mg of doxy-pep approximately 2.5 days after the encounter. I understand it is not ideal, but it was taken before the 72 hour mark.

Thank Doctor.

You were at little risk for syphilis and do not have it. First, you describe a partner who almost certainly does not have syphilis. Second, although syphilis can be transmitted by oral sex, it is uncommon. Third, having taken 200 mg doxy-PEP, you prevented any chance of syphilis. (Doxy-PEP is not recommended after exposures like yours -- only after unprotected anal sex. But it still would have been effective.) Finally, the skin problem you found on your scrotum doesn't sound at all like a chancre. Also, the location is wrong:  chancres occur only at the exact site of inoculation, typically at sites of sexual friction; if you had acquired a chancre, it would have been on your penis.

1. "How likely...?" Near zero.

2. "describe an atypical chancre":  Basically it would still be an open sore, but without standard features of chancres (especially firm painless swelling around the ulcer; you can easily find images online). 

3. A chancre never would heal within 4 days.

4. There is no characteristic appearance of a healing chancre.

5. This doesn't sound at all like a chancre.

Glad to hear your STI tests were negative. Having taken doxy-PEP there is no point in being tested again at 6 weeks or any other time.

So sit back and relax. I have the feeling you are overreacting to a sexual decision you regret, perhaps an unusual event for you. But there is no possibility you have syphilis or any other STI as a result.

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

HHH, MD

Hi Doctor Handsfield, You are correct that this is atypical behavior, and my regular partner is unaware, so I am feeling some anxiety and guilt about the encounter. I do understand DoxyPEP may have been overkill , but I do not want to spread anything to my regular partner, nor do I want them to find out as my life will be ruined. A few follow ups and some clarification:

The oral sex I received from this man was unprotected (no condom). I also live in an area with high syphilis rates. Does that change your evaluation? 

Are you able to tell me how uncommon oral transmission of syphilis is? Dr. Google seems to say everyone and their mother is getting syphilis via oral, though I do understand the internet can be full of misinformation, and boring stories don't get the same attention as the 1%/'lottery winners'.

To confirm, a small spot that bled and exhibits signs of healing is not a syphilis chancre, even if it was 'scratched open'  which may cause an atypical appearance? I assume the description 'hard, well defined edges' means if I squeeze or press it I would feel an almost wart like texture/hard spot between my fingers? (I have had planters warts so that's what I'm familiar with)? Assuming it heals in the next few days, can I safely assume it is NOT a syphilis chancre? What should I look for if it is a chancre?  My apologies if this is a repetitive question...dr. google and anxiety are a heck of a combo.

Regarding the location of this small lesion, the man in question did lick my scrotum briefly. Does this change your evaluation? For my own curiosity, have you ever seen a chancre on the scrotum?

Can I assume the gonorrhea and chlamydia tests are conclusive? If so, why does my local clinic state two weeks is conclusive?

If you were in my position, would you resume unprotected sex with your partner?

Hi Dr. Handsfield,

I would also like to know if taking DoxyPEP over 24 hours, but under 72 hours decreases the efficacy, and if so, would that change your evaluation? Again, some sites indicate it's only useful if taken within 24 hours, and others state anytime before 72 hours is sufficient.

Many thanks!

There are no data to suggest 200 mg doxycycline is any less effective against syphilis near 72 hours compared with 24 hours.

That said, I agree with your evolving understanding about "Dr. Google". I suggest you entirely stop searching the internet about any of this; or at least avoid sites that are not run or at least moderated by professionals. Anyone can say anything they want and so much information is just BS. (Reddit is particularly risky.)

Trust me: there is no possibility you have syphilis. Give it up.

* When some gon/chl tests were being developed, the manufacturers decided to study patients whose last exposure was 2 or more weeks earlier, and therefore that is the interval approved by FDA for marketing the tests. That doesn't mean the tests aren't accurate earlier, only that formal research hasn't been done. 20-30 years of clinical experience indicates that 2-3 days is plenty for gonorrhea and 4-5 days for chlamydia.

Many thanks, Dr. Handsfield. That is a relief to hear. This forum has been an incredible resource the past few days. 

I do have a question regarding mgen. This is more for my own curiosity, and less of a concern for me, personally.

Based on what I've read, my dose of doxy-pep makes mgen infection essentially impossible, is that assumption correct? Since you were not concerned or even me tiomed mgen, I'm assuming this is the case.

I understand research is ongoing, however I found a thread where Dr. Hook stated mgen is not spread via oral sex. That particular question was a few years ago. The CDC's website indicates research is currently ongoing whether or not oral transmission is possible. Is it known whether mgen is spread through oral sex, or is research still ongoing?

Finally, based on what I've read (and please correct me if I'm wrong), mgen is a relatively 'new' STI. Are there any other 'new' STIs that have been discovered or studied in the past couple years? Again, I am taking your advice and letting this incident go, but since I have a follow up or two I figured I'd ask for my own knowledge, rather than Google and read something that is sensationalized, or might not even be true. 

Many thanks, Dr. Handsfield. I cannot stress how great a resource this forum is.

Thanks for the thanks about our services. Best wishes and stay safe.