Dear Doctors,

15 days ago I had an encounter with a sex worker. She placed a condom fully to the base before any oral contact. Oral sex was performed with the condom on and there was no saliva contact with uncovered skin. We then had vaginal intercourse with the condom on the entire time (to the base). During penetration she kept her hand between our bodies so the penis could not enter fully and there was no pubic skin contact. The condom appeared intact when removed.

About 8 days later I noticed mild irritation at the tip of the penis. Symptoms are mild burning/discomfort at the tip, sometimes slightly internal. No urethral discharge and no burning with urination.

Given the protected exposure, how realistic is risk for chlamydia or gonorrhea? Could these symptoms represent urethritis?

Thank you.

You've asked several questions about obviously zero risk events. This one actually is higher risk than your previous ones, because intercourse occurred. However, with the condom for both oral and vaginal sex, the STI/HIV risk was close to zero. The symptoms you describe are not likely due to any STI. However, it would make sense to wait another day or two and be certain that painful urination or discharge do not appear. Assuming they do not and the mild discomfort clears up, I would just ignore the whole business and not worry further and would not advise testing. (FYI, my colleague Dr. Hook was the lead investigator on one of the best research studies that found that symptoms like yours generally do not have positive STI tests and later evidence of urethritis does not develop.)

Those comments pretty well cover your two specific questions, but to assure no misunderstanding:  "...how realistic is risk for chlamydia or gonorrhea?" I would guess well under one chance in thousands if not millions. "Could these symptoms represent urethritis?" Almost certainly not -- but play it safe and do get examined directly if you notice visible discharge or worsening pain, particularly with urination.

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

HHH, MD

Dear Dr. Handsfield,

Thank you very much for your reply. Your comments are very reassuring, especially considering the expertise they come from.

I always try to keep my sexual encounters as safe as possible, and this is partly thanks to the work you and your colleagues do on this forum. Over time I have learned a lot here about risk reduction, and even in this situation I tried to limit any possible exposure as much as possible.

The reason I became concerned is that the symptoms I am experiencing now are new for me and had never occurred before. Also, the timing made me worry because they started about a week or so after the encounter, which seemed compatible with an incubation period. I should add that I was not even particularly anxious about the encounter beforehand because it was all safe for me. 

May I ask one additional question? In your opinion, is there any potential weak point in the encounter I described that could realistically have led to an infection? The only thing I keep thinking about is the condom: I checked it briefly after removing it but did not examine it very carefully to be absolutely certain it had not broken. It was a “strong” type condom, but I cannot say I inspected it thoroughly, also because I removed it using tissue paper.

Otherwise I cannot find any plausible explanation regarding what could have been a window of transmission. Even if her hands or my glans had somehow been minimally contaminated with genital secretions (without me noticing), from what I have learned here that kind of indirect contact would not realistically lead to transmission. Everything was really covered, and the girl seemed even more careful than I was.

Thank you again for your time and for the valuable work you do helping people better understand STI risks.

Best regards.

One plausible explanation for your symptoms is anxiety about the exposure, making you more aware of minor symptoms or even normal body sensations that otherwise would not be bothersome and maybe not even noticed. Irritation from a spermicide incorporated into the condom can do this, but in that case the symptoms would occur immediately, not a week later. As implied above, such symptoms sometimes can be the first symptoms of urethritis. If so, it will progress within a day or two to include discharge and perhaps painful urination.

Another possibility I didn't think to mention til now:  when did you last have sex (including a regular partner) prior to this event? It is conceivable you're noticing symptoms from an infection acquired before the most recent one. But only if you've had other sexual exposure(s) within the last couple of months.

Even without discharge, if the current symptoms continue a few more days I would advise you be examined in person by an STI expert, which might include gon/chl testing. Better safe than sorry!

Dear Dr. Handsfield,

Thank you again for your reply.

Regarding your question about previous exposures: the few encounters I had before this one were already discussed with you and your colleagues on this forum, and there was nothing considered relevant from those situations. Apart from those, there has only been this most recent encounter. All sexual activity with my regular partner would not represent a risk, as it is not possible she has other partners.

I have just a few remaining questions:

1. Do I still need to wait another 1–2 days as you suggested, considering that these symptoms have already been present for about 5–6 days now?

2. Can the psychological component really go so far as to mimic symptoms to this extent?

3. Aside from chlamydia or gonorrhea which, as you explained, would be difficult to reconcile with the exposure I described, could these symptoms be due to something else?

3. Non sexually transmitted urinary tract infection or prostate problems can cause such symptoms.

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.