[Question #13318] Syphillis concern

12 days ago

Hi Doctors, thank you for all you do.

Exposure- unprotected oral with CSW (2-3 mins) at a massage parlor 30 days ago

Tested negative for c&g 18 days post exposure and tested negative for HIV Syphillis 27 days post exposure .

I today started experiencing pain in the urethra (more pronounced with urination and ejaculation) as well as a rash on my inner groin. Attempting to see in the urethra, I guess it may look swollen but as you can imagine it’s difficult to tell.

1)Could this potentially be a chancre developing in the urethra?

2)How accurate can a rpr test expected to be at 27 days?

3)With a new development of new symptoms described above, when would you advise to retest?

4) Would you suggest to abstain from sexual activity until that retest can be completed?

H. Hunter Handsfield, MD

12 days ago

Welcome; thanks for your question and your confidence in our forum. I was online when your question came in: most users should not expect nearly real time replies!

You were at little risk for any STI from the exposure described. Unprotected oral sex isn't entirely risk free but there's a low chance of any STI and truly zero risk for HIV. In addition, your negative gon/chl tests were conclusive and the others nearly so.

It is unlikely your symptoms have anything to do with the sexual exposure a month ago, but not impossible. Urethral pain (without discharge) usually does not indicate any STI, and a rash in the groin never does. You are correct it is "difficult to tell" by self examination whether the urethra is normal or not -- but if it were syphilis, you would expect to have an obviously visible open sore (chancre). That said, if there is tenderness along your penis -- i.e. a sore spot if you gently squeeze the shaft -- that could go along with syphilis (or herpes). If you have anything like this, see an experienced health care provider, ideally an STI clinic or urologist. To your numbered questions:

1. Possible chancre in your urethra? very unlikely but see my comments above.

2. RPR is positive 80-90% of the time after 27-30 days, so your negative result makes syphilis even more unlikely -- but it isn't proof.

3. See above; get examined now if you have tenderness along your penis. I would also advise evaluation if your current symptoms remain unchanged 2-3 more days, or if you start to develop discharge from the penis or other symptoms like penile sores or a tender lump in your groin.

4. It makes sense to avoid sex for the time being, to avoid the low chance of exposing your partner(s).

Another option should be considered as well. If you can contact your CSW partner, explain the situation and ask her to consider being tested. You could consider paying for it and perhaps go together for testing.

I stress that I doubt you have syphilis, herpes, or anything else from the event 4 weeks ago. But better safe than sorry, so check it out if the symptoms persist. I look forward to hearing the outcome as the next few days progress.

HHH, MD

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12 days ago

Thank you for the prompt response doctor.

I have had HSV 1 from childhood so I am less concerned about that.

Regarding my 27th day negative result would that mean I was not potentially infectious to a partner in the time leading up to that test?

Would a urethral presentation of a chancre be considered rare?

Confirming that 6 weeks would be considered conclusive?

Lastly I am trying to be as pragmatic as possible and not letting anxiety overwhelm me. I understand using population stats and expert experience driven guesstimates (no matter how expert) is not applicable to single exposures with so many unknown variables. But is the below assessment of risk a reasonable reflection of the risk of this exposure?

1/1000 (.001)she had Syphillis and 2/10(.2) that I would be falsely negative at day 27

Approx 1 in 5000?

H. Hunter Handsfield, MD

12 days ago

I agree you're not at risk for HSV1, which takes herpes off the table. Yes, urethral chancres are rare. And yes RPR is conclusive at 6 weeks.

Your odds calculation doesn't consider the likelihood (if she has syphilis) that it would involve her mouth and be transmissible by oral sex. That's probably no more than 1% -- so my calculation would be 0.001 x 0.01 x 0.2 = 0.000002 or one chance in 500,000. I really wouldn't worry about syphilis, but still it makes sense to have a final RPR at 6 weeks.

If you have syphilis, it could be transmitted before the RPR is positive, in which case your regular partner would be at risk. But for all the other reasons discussed, I really wouldn't worry about this.

Some anxious persons in your situation frequently massage or "milk" the penis looking for discharge etc -- and sometimes causing urethral pain. Is there any possibility of that for you? If so, hands off for the next week and see what happens.

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3 days ago

Hi again Dr Handsfield.

I went to a urologist with my concerns and although he seemed very skeptical of my concern he did inspect my urethral opening, albeit briefly and concluded that it looked normal. He also ordered a urinalysis which came back clean (no WBC) and out of an abundance of caution another RPR, which was 37 days since exposure and negative again. He surmised that my symptoms were rooted in anxiety.

I can see how that might be true, I no longer have this discomfort and over the past week experienced things like lower back and abdominal pain, weird sensation in testicles radiating towards the anus. All things that fit with a lot of what I’ve seen under the “CPPS” umbrella.

I am no longer experiencing (or briefly when my mind is not occupied) those symptoms. But still very anxious and constantly checking my palms and soles of my feet.

1) Would the 37 day test as opposed to the one 10 days earlier increase the expected accuracy?

2) Anxiety driven or not had those symptoms described earlier (a week ago) been Syphillis, would this test have shown that?

3) lastly I plan to test next Monday on day 44,I assume you agree with and advise this right?

H. Hunter Handsfield, MD

3 days ago

Like the urologist, I also am confident your symptoms are "rooted in anxiety". I'm not a believer in anxiety creating symptoms, but for sure it can dramatically magnify trivial symptoms or even normal body sensations that otherwise would be ignored or not even noticed.

1. Yes a negative syphilis test at 37 days is nearly 100% rlelalbe, compared with pretty much worthless at 10 days.

2. Yes.

3. I doubt you really need testing, but in any case another negative RPR at 44 days will be consultive.

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

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