[Question #1634] Oral with Cold Sore

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87 months ago
I (male) received unprotected oral for approximately 1-2 minutes from a girl who ended up having a cold sore on her upper lip. I didn't notice it until we entered another room with better light, and I freaked out, made an excuse, and left. I did ask and she said "Yea, it's a cold sore; it showed up yesterday." There was no kissing or anything else leading up to it.
Day 3: tingle in thighs
Day 4: lower back pain
Day 8: 7/10 pain in in left testicle
Day 9: At this point I went to the doctor, and explained what I was feeling. He preemptively gave me a prescription for Doxycycline 100mg 2x per day for 14 days without testing or anything.
Day 10: There is redness on the glans. 5/10 tingling and burning feeling down the right side of my glans, but mostly on foreskin just below glans (I am circumcised). That night I would say I had about 8/10 pain burning from my urethra, and I noticed a small amount of clear discharge from the urethra.
Day 11-13: Clear discharge in morning; urethral pain is gone. off and on left testicle pain; glans still very red.
Day 14-16: clear discharge for these days, no pain.
I decided to go and get testing done on day 16. I'm still waiting on results for Gonorrhea, Chlamydia, Syphillis and HIV. The clinic I went to could not do full exam that day, and I'll return next week for testing for possible NGU.
Day 17: My glans is excessively red, especially for about an hour after bathing. There also looks to be pinkish splotches of skin on the glans.
I woke up with pain around the left side of my urethra, probably 1/2 centimeter from the opening, it looked like there might be a small red dot; I can't tell
Through this whole process I've had 0 burning urination, and I have not seen any obvious lesions/blisters anywhere on my genitals.

1: What are the chances/does this sound like this is gonorrhea or NGU?

2: Does this sound like it could be herpes? I'm very concerned today about the redness/spot next to my urethra

3: Could doxycycline be causing the redness on glans?
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H. Hunter Handsfield, MD
87 months ago
Welcome to the forum. Thanks for your question and your confidence in our services.

Obviously it was alarming, for good reason, when you learned of your partner's oral herpes outbreak. Potentially quite high risk for transmission of HSV1; the risk probably is highest for an outbreak of only 1 day duration. OTOH, half of all adults have positive blood tests for HSV1 due to past infection, typically in childhood and most often without symptoms. In other words, even if you have never had symptoms of oral herpes (cold sores etc), there's a good chance you have had HSV1. If so, you are immune (or at least highly resistant) to a new infection, in which case there is little chance you would catch genital HSV1.

As for your symptoms, they are not at all typical of new herpes. Some infections are entirely without symptoms, but those with symptoms typically have obvious penile blisters that become open sores. Nerve tingling in the area -- genitals, legs, etc -- commonly precede recurrent herpes, but are almost never symptoms of new herpes. The penile blisters/sores occur first; and usually there would also be prominent swelling and pain in the groin (both sides) due to lymph node inflammation. HSV can infect the urethra, and causes 2-5% of NGU cases. However, herpetic urethritis is usually quite painful, often excrutiating; a couple of patients I have seen described it as the worst pain they ever experienced. The subtle dischage you describe doesn't sound like herpes. Redness of the glans, without ulcers, is very unlikely to be herpes. Accordingly, I very much doubt you acquired genital herpes or that HSV explains any of your symptoms.

Your symptoms also are not typical for gonorrhea, chlamydia, or NGU. Had you come to my clinic, we would not have treated you with doxycycline (or anything else), certainly not without examination and testing. Since you were not examined for abnormal discharge or urethral white blood cells, I cannot guarantee you didn't have NGU, but I doubt it. Most of your symptoms are quite nonspecific -- the sorts of things we see all the time in entirely healthy men, sometimes related to anxiety over a regretted sexual experience (I'm thinking of your scant clear discharge, testicular pain, back pain etc). My guess is that your anxieties are affecting your perception of redness. Doxycycline isn't the cause. For those reasons, I expect all your test results to be negative. If you have been taking the doxycycline, you can also expect any further evaluation for urethritis to be normal. Whether or not you had NGU to start, all tests should be normal after a week of treatment. (NGU is properly treated for 7 days; you don't need 2 weeks treatment.)

I think those comments address all three of your questions. But let me know if anything isn't clear. Best wishes--  HHH, MD

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87 months ago
Thank you so much for the reply!

Yes, I know that my anxiety is causing a lot of psychosomatic issues. I'm trying to keep that in check, but I do think some of the symptoms are real. My urethra is inflammed, and I've never had discharge of any sort. It is definitely making me nervous about my test results!

Unfortunately, from an igg test 2 years ago, I'm negative for HSV of both types. Based off the assumption that is still true, what is your best educated guess about my risk of acquiring it from this?

1: How reliable would a negative igg test be if I get one done at 6 and 12 weeks post exposure?

2: is there any chance that the doxycycline could give me a false negative? Should I retest a couple of weeks after it is finished?

3: if I can make it to day 22, or 3 weeks and 1 day, with no obvious lesions, is it safe to say I won't have a primary outbreak even if I did get   HSV?

This forum, as well as the medhelp threads, have been extremely helpful. I've read about 100 of them in the last 17 days. Thank you very much and thanks in advance for the answers to these questions! I'll reply again with my results when I get them. 
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H. Hunter Handsfield, MD
87 months ago
That some of your issues are anxiety driven doesn't mean the symptoms aren't real. I have no doubt they are. But just as tension headaches are truly painful, they still have a basically psychological origin. In both tension headaches and genitally focused anxiety, the physiologic mechanism is increased muscle tension or spasm, in scalp and neck muscles in one case and pelvic muscles in the other. As for apparent inflammation of your urethral meatus, in my experience the large majority of men who are quite certain of this in fact appear entirely normal on exam. If a health professional has examined you and believes your urethra is normal, it probably is.

1) Being HSV1 negative means you are susceptible. But it doesn't mean you were infected, which remains unlikely. If you have repeat HSV blood tests, negative results 6 weeks would be 80-90% reliable and 12 weeks nearly 100%.

2) For the most part, antibiotics don't cause false negative tests for bacterial infection. They turn tests negative by curing the infection. There is no point in retesting.

3) If you were going to get typical primary herpes -- which is what I described above (multiple lesions, inflamed lymph nodes, etc, usually with fever) -- it would have happened by now and definitely would happen within 3 weeks.

I'll add that if you acquired genital herpes due to HSV1, it probably would never be an important issue for you. Having read this forum and MedHelp, you probably have seen discussions about it, but the bottom line is that recurrent oubreaks and subclinical viral shedding are rare, and sexual transmission to partners also appears to be rare.

I would consider repeat HSV blood testing optional, by no means required. But we'll keep the thread open a few weeks more to allow you to post your 6 week test result, should you decide to do so.

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86 months ago
Instead of posting my 6 week results, I wanted to use my final post for some clarification. My test results for Chlamydia, Gonorrhea, syphilis, and HIV were all negative at 16 days post exposure.

1: Can I definitively say that gonorrhea and chlamydia are ruled out at 16 days negative?

8 days ago (roughly 3 weeks post exposure), I noticed a single, approximately 1mm, bright red spot towards the bottom of my shaft/scrotum. It is painless, seemingly flat (maybe slightly raised, it is hard to tell) and has been unchanged since the morning I noticed it over a week ago (i.e no pus, oozing, or changing size). I've looked at the CDC stats, and I know syphilis is exceedingly rare, but it is called "the great imitator", and I'm worried. The nurse practitioner looked at it briefly last week (no light or magnification of any sort), and said "eh, probably heat rash." She was very dismissive. 

2: Could this spot be a syphilis canker?
3: Can syphilis cankers appear that small? All images online show something that is at least .5cm
4: Would herpes present in this manner?

I'm confused about Herpes IGG testing and it's accuracy at detecting HSV-1. Terri Warren posts that it misses around 30% of HSV-1, but I saw a post from 2013 where you said a negative, is a negative, is a negative. I also think I read that WB test is used more to confirm/deny a low positive, is that true? Given my exposure, would a Western Blot be appropriate, or should I accept at negative IGG at 6 and 12 weeks?

Thank you in advance!
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H. Hunter Handsfield, MD
86 months ago
1) Yes, those results are conclusive.

2-4) Your description of the spot on your penis is not consistent with syphilis, herpes, or any STD. I can't comment on the "heat rash" idea, but most likely the NP is highly experienced in recognizing skin lesions of STD, so you probably can at least be confident that it's not an STD problem. My best guess is that you're just looking too hard out of anxiety and noticing things, perhaps normal variations in your penile skin that have always been present (probably same for your apparently reddened glans penis). As for syphilis as a "great imitator", that really applies only to later stage of the disease, not the initial chancre or other early manifeatations. And for sure not herpes either.

You're reading older posts from Terri W. More recent research, in which she was one of the investigators, show the HSV1 tests miss no more than 5% of infections. You should not have herpes testing of any kind, based on your exposure and symptoms. RE-read my comment above ("I'll add that if you acquired...") about why it won't matter if you did acquire HSV1 from this event, if you're not having outbreaks.

That competes the two follow-ups included with each question and so ends this thread. I hope the information has been useful and that you can move on. If you remain nervous, I would recommend you carefully re-read all my comments above.

Best wishes and stay safe.