[Question #188] Gonorrhea diagnosis, treatment, recovery

37 months ago
Doctor:

I have been overseas for most of the last 8 months and have not had any sexual relations with my wife (or anyone else for that matter) during that time - with a single exception.  Two weeks ago, I received oral sex from a stripper in the United States.  The next day I began to experience almost constant urgency to urinate, with little urine.  After perusing sexual health forums, I chalked this up to genitally focused anxiety but when it continued for more than a week I decided to get tested.  Last Thursday, 8 days after the incident, I gave a urine and blood test for a full range of STDs.  

I tested positive for Gonorrhea, but negative for everything else.  The doctor to whom I was referred seemed surprised by the results given my limited exposure, but prescribed Suprax and Azithromycin, which I took orally last night.  I should note that while I have still not had any discharge at all, I recently began to experience soreness in one of my testicles (as well as lower abdominal and back pain), and have continued to have urgency to urinate.  Those symptoms have all mostly subsided today after taking the antibiotic last night.

I am finally returning home this weekend.  I would like to resume sex with my wife shortly, but obviously not at the cost of exposing her to any STD, including gonorrhea.  When is it safe for me to resume sexual activity with my wife?  Relatedly, would you recommend additional testing before doing so to ensure the infection is gone?  I understand that the treatments are generally effective, but considering my positive test without any discharge, I am concerned that I would have no way of knowing whether I am still infected absent a negative test result.

Thank you.  


H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
36 months ago
Welcome to the forum. Thanks for your question.

I share your doctor's surprise at the positive gonorrhea test -- not so much because of the exposure, since gonorrhea certainly can be transmitted to the urethra by oral sex, but because your symptoms were not typical for gonorrhea, which usually causes discharge and painful urination as the primary symptoms, not urinary urgency. On the other hand, the standard gonorrhea tests are highly accurate and false positive results rare, so we can be confident the diagnosis is correct. Prompt resolution of your symptoms after treatment also supports the diagnosis.

You really need not be worried about treatment failure. The official recommendations for gonorrhea are for an injection of ceftriaxone, rather than cefixime (Suprax) by mouth. However, the latter remains highly effective for the large majority of infections, and the addition of azithromycin further assures cure. There have been no documented cases of gonorrhea treatment failure in the US with the combination of cefixime with azithromycin. And as already impled, the quick clearing of your symptoms is further evidence you were cured. I don't recommend any further testing, and you can safely assume sex with your wife.

Probably it goes without saying, but if you are able to contact the stripper, please let her know of your diagnosis so she can seek treatment.

I hope this has been helpful. Best wishes--  HHH, MD
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36 months ago
Doctor:

Thank you for your response.   Unfortunately, I am feeling urgency to urinate  and (minor) testicular pain again today.  I assume that could be anxiety-driven, but the feelings are not different from what I experienced prior to treatment, so I am a bit concerned.

If I were to have a new round of testing done on Friday (3 days after treatment) or Monday (6 days after treatment), could I be confident that the results would accurately reflect my condition?  In other words, is it possible the treatment wouldn't have fully cured me yet such that I could still test positive?  Alternatively, if I tested negative, could I be 100% confident that I could not infect my wife?  The cost of a new test is a small price to pay to avoid further worry and anxiety, but certainly there's no point in doing a new test if the results won't provide useful information.

Also, I understand that people with gonorrhea have increased risk for other STDs.  Given my specific exposure, do you have any concerns about other STDs?  (The woman had no noticeable lesions or blisters on or about her mouth).  I assume your answer is no given your recommendation to eschew further testing, but wanted to confirm.

Thanks.  I apologize if any of this comes off as ridiculous (or as somehow disregarding your initial response), but obviously you're the expert so I'm working at an informational disadvantge.    
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
36 months ago
None of this is at all ridiculous. All reasonable issues and questions.

It's too soon to retest for gonorrhea; don't do it. The standard gonorrhea and chlamydia tests detect DNA, which can persist at least a week and sometimes up to 3 weeks. The bacteria are dead and the infection cured, but it takes longer for DNA to clear out. You definitely should not have any sort of retest before 2-3 weeks. But in fact, no retesting at all is recommended by any experts for patients treated with the recommended regimens, and cefixime+azithro qualifies. (Late retesting is recommended 3-6 months later, but that's a separate issue -- designed primarily to detect reinfection, which is common -- although not necessarily in all persons.)

It is true that your symptoms and your gonorrhea are entirely separate issues, with genitally focused anxiety, or some sort of physical irritation from the exposure, plus asymptomatic gonorrhea. But it's really not possible to be certain. For the reasons just cited, I would still not recommend retesting at this time. But if your symptoms are persisting at 2+ weeks after treatment, get retested then. In the meantime, if your symptoms are prominent, you'll need to consider the possibility of prostatitis, i.e. more than genitally focused anxiety. But then we would have to explain the coincidence in timing, since prostatitis isn't an STD and not known to be acquired by oral sex. But coincidences can happen.

It's also true that people with gonorrhea (or any STD) have higher rates of other STDs. However, oral sex is in a special category. You are at essentially no risk of HIV, HSV2, trichomonas or chlamydia; and only low risks of HSV1, maybe hepatitis B, and nongonococcal urethritis (NGU) other than chlamydia.

Only one other thought to consider, in view of your atypical symptoms and sexual history. Your opening statement says no sex with your wife for 8 months. Is that definitely true? If you and your wife have in fact had sex, you'll need to consider the possibility that she has had other partners during your overseas travels and that she, not the stripper, is the source of your gonorrhea. I'm not impugning your history -- just addressing an issue that we would always clarify for a clinic patient in your situation.


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36 months ago
Doctor - 

Thanks for your prompt response.  The sexual history previously described is accurate.  No sex with anyone other than the stripper for 8 months.  Unless I've had asymptomatic gonorrhea for 8 months, there is only one possible source of the infection.

From an STD perspective, it seems my risks are:  

(a) "Persistent" gonorrhea infection.  You say there are no reported cases of treatment failure in the U.S., so this seems like something I should not worry about (though given my low risk initial exposure and apparently rare asymptomatic diagnosis, I have a heightened concern about "low" risks).  If this is something I should not worry about, I won't, but my treating physician made reference to getting the shot if for some reason this treatment did not work, so he seemed to think it was at least a possibility.  (You, however, are the expert).  Also, to clarify, what do you mean by "reinfection?"  A quick perusal of the relevant literature suggests it requires exposure to another infected person, but please clarify if I'm mistaken.  I'd hate to think this could just come back on its own.  Assuming I don't have "persistent" infection, assuming I have only one partner going forward, and assuming my wife has no other partners (of course, I can't know for sure), am I correct that the there is no risk of "reinfection"?

(b) HSV1, hepatitis B, and nongonococcal urethritis. Are these realistic risks?  When would testing for these be accurate?  Would I have symptoms already?  I tested negative negative for at least the first two already.

It seems the best course is to, at a minimum, wait a few days to see if my symptoms go away.  
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
36 months ago
a) I agree with your doctor's probable reasoning. It sounds like he probably knows that cefixime is not as highly recommended as ceftriaxone (both with azithromycin). But assuming he's not an STD expert, may not have an in-depth understanding of actual effectiveness, and thus was being appropriately cautious in advising you. And yes, you correctly understand "reinfection". The infection will not "come back on its own". This is why I hedged a bit in my comment above about late retesting at 3-6 months ("not necessarily in all persons").

b) Depends on what you mean by "realistic". The risks of all three are very low and testing is not recommended for them after single exposures of this sort, in the absence of symptoms of infection -- which you have apparently not had. And there is no reliable test for asymptomatic NGU anyway.

That's your second follow-up comment and reply, so that will end this thread. In closing, the important things are 1) If your symptoms (urinary uregency, testicular discomfort) persist, see a doctor to be safe; but 2) otherwise don't worry about any STD from this event and don't have any further STD tests unless/until recommended by your doctor. If somehow I were in your situation, I can guarantee you I wouldn't have any more tests of any kind and I would resume unprotected sex with my wife now, without the slightest concern I could infect her with anything from the oral sex encounter.

Best wisjes and stay safe--


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