[Question #2139] (Not) worrying about gonorrhea in the throat

47 months ago

Hello there.  I am a fan of your help from a previous forum.  My question here is about gonorrhea.  I have read that gonorrhea of the throat often has very mild symptoms, if any.  I've also read in a forum by one of you, I believe, that gonorrhea if undetected tends to resolve on its own after an unknown number of weeks.  Which leads to the possibility that we have gonorrhea of the throat more often than we realize, and that it goes away on its own.

 

I am a gay man and at times give unprotected oral sex.  There are times when I have more than one partner in the same month.  Sometimes after having a sexual encounter with someone, within a few days I'll have throat symptoms, such as a lump in my throat, throat tenderness, etc.  If I have the splotchy white "strep"-looking symptoms, I go to the doctor to be seen.  In more subtle cases, though, I'm not sure on a moral level what to do.

 

My question is, how concerned should I be about such mild post-oral-sex throat symptoms?  I am a conscientious person and would like to not risk passing along infections to others.  But it seems confusing, because it seems impossible to distinguish non-gonorreal throat infections (viral or bacterial), easily acquired from hooking up with someone (even just from the kissing), from subtle symptoms of gonorrhea – without getting a throat test.  Is the solution to get tested with a throat swab every time I have throat discomfort after oral sex?  That seems time-consuming and also potentially expensive.

 

Would be great to hear your opinion on this.  Is it ethical to simply be optimistic and not worry about it being gonorrhea, and go ahead and have another partner shortly after, should the situation come up?  Or should I make a policy of always getting it checked out?  Thanks in advance for your help.

 

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
47 months ago
Welcome to our new(er) forum. It's always nice to hear from MedHelp alums. Thanks for your question.

Your own summary is well stated, including the certainty (not only "possibility") that pharyngeal (throat) gonorrhea is more common than we know and generallly clears up without treatment. The only caveat is that the data on spontaneous cure are based on a single study almost 40 years ago (1979) and based on culture, i.e. diagnosis by growing the gonococcus from a throat swab, which we now know misses many infections that can be detected by modern nucleic acid amplification tests (NAATs). It is likely that infections detected by NAAT persist longer than the old study found. However, it probably remains true that most infections do clear up without treatment within a few months.

Plus another minor correction:  "Often has very mild symptoms" really should be "Usually causes no symptoms at all." Over 90% are entirely asymptomatic.

And one final factoid, which also starts to answer your questions: other data from the 1970s documanted that performing fellatio was associated with sore throat afterward, but that it could not be explained by gonorrhea or the genital mycoplasmas (https://www.ncbi.nlm.nih.gov/pubmed/27533624). (Chlamydia wasn't tested, but then and now oral chlamydial infection is rare and undoubtedly isn't the problem.) As the authors concluded, "The pharyngitis associated with fellatio remains a microbiologic enigma." It remains true today:  STD clinics see many patients like you, with unexplained sore throat after performing oral sex. (It seems to include some persons who have performed cunnilingus, but this has never been studied carefully.)

Accordingly, your sore throats are not useful indicators of gonorrhea or any other STD. It is good you are conscientious about it; if nothing else, perhaps you are protecting partners from comon colds, and it seems common sense to avoid exposing other persons until the discomfort subsides. In any case, the "solution" is defintely not to get a throat test for gonorrhea every time this happens. You are exactly right about time-consuming and expensive. Having said all that, it is also true that a small proportion of pharyngeal gonorrhea can indeed cause overt pharyngitis, even mimicking strep throat -- and I do think it reasonable to be examined and tested (including strep testing) whn you see white patches, if the sore throat is especailly severe, or if you have lymph node swellings in your neck or fever. But not for the more common mild discomfort you have described.

One final aspect about this is that pharyngeal gonorrhea is not easily transmitted. Some urethral gonorrhea in men is acquired by fellatio for sure. However, the efficiency of transmission appears to be much lower than by anal or vaginal sex. In other words, even in the slight chance you have pharyngeal gonorrhea, the likelihood you will infect a partner is relatively low.

There's a lot about this that isn't clear, and it would be nice if someone would repeat the McCormack/Boston study with modern testing methods. It is conceivable that the more sensitive testing methods would detect more gonorrhea than they found in the 1970s, and that an association with sore throat might be found. But this is the current state of knowledge and understanding.

I hesitate to add my usual "let me know if anything isn't clear":  much of this is inherently unclear. But I look forward to any follow-up comments or questions you may have.

Stay safe--  HHH, MD

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47 months ago
Hi Dr. Handsfield.  Thank you very much for your thorough reply.  I'm usually a pro at follow-up questions, but I barely have any.  The combination of knowing the high frequency of pharyngeal discomfort after oral sex, very very often non gonorrheal, combined with the information that I wouldn't have a great likelihood of passing it on from my throat even if it were gonorrhea, definitely puts me at ease.

As you can guess, I write this question now because it's one of those moments.  The oral sex was 10 days ago, and after a couple days I developed a lump in my throat that tended to start either during the night when my mouth was dry, or in the evenings, when my body was a little run down.  After a good sleep and breakfast, it would go away for the rest of the day.  After a week it's still with me but I sense the symptoms lessening.  There's no white patches or anything visible to me in the throat that seems wrong.  I tend to assume that I caught something minor from the person, and that my body is fighting it and it's fading.  No other symptoms to accompany it.

Since I do have the follow-up, I'll pose this related question.  Last fall, I had the splotches, and my doctor diagnosed strep and put me on Z-Pak.  I've never had issues with that antiobotic, but I'm in my late 30s now and perhaps things change... within a couple hours of beginning the medication I had fluid diarrhea and it stayed with me for 2 months.  I took plenty of probiotics to stop it, but nothing worked immediately.  In the aftermath, now 4 months after the diarrhea stopped, my weight still seems to be about 5-7 pounds more, consistently, than it was before.  Despite gym/good diet/very similar style of life.  I ask this because it's related to gonorrhea treatment, should it ever come up (or should I catch strep again, which seems more likely).  Do you see unpleasant reactions to antibiotics sometimes?  Are these staple drugs not as easy on the body as we tend to think?  Thank you again!
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
47 months ago
Thanks for the thanks.

This is a general medical forum, not one that attempts to diagnose anything, and we cannot be in a position of seeming to provide direct medical care. For the reasons above, it is unlikely that your symptoms are due to gonorrhea. A gradually resolving minor viral infection, as you suggest, seems reasonable. In some cases, symptoms like these are the physical manifestations of anxiety, nothing more. But I cannot be sure there isn't a treatable infection. If the symptoms continue or you otherwise remain concerned, you'll need to get care and, most likely, testing for gonorrhea and perhaps strep throat.

Azithromycin is a notorious drug for causing gastrointestinal irritation, and a bout of diarrhea a couple hours after a dose is a typical symptom. It's generally harmless and can be prevented, or symptoms less severe, if taken with food instead of an empty stomach. 
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47 months ago
Thanks for your comments on my symptoms.  I take them as you give them -- as a possibility but not a diagnosis.

To just close this out with my one remaining follow-up... regarding the azithromycin, it would have been nothing had I had one case of diarrhea a couple hours after starting the medication.  But indeed I didn't have a solid bowel movement for two months after.  They were very liquid.  It also coincided with a noticeable weight gain, as I mentioned before, which has hung around still.  This may of course just be age-related changing metabolism, though the coincidence of having gut problems and seeing a change in metabolism is hard to ignore.

I realize this is a bit out of the purvue of the STD conversation, so I was simply curious to know, if I wanted to explore the potential changes to my metabolism related to that azithromycin Rx, and how to help my gut recover its normal flora if indeed they are related, what kind of specialist would you recommend that I visit?  Gastroenterologist?  Dietician?

My final thanks for your really valuable service, once again.  I'm glad I googled a little longer after I saw that the Medhelp forums were no longer active, to find you're still helping people out.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
47 months ago
Sorry, I saw the 2 hr comment then spaced on 2 months. Clearly not the antibiotic. There are too many potential causes of chronic diarrhea to speculate on the causes. However, gay men have especially high rates of various intestinal infections, including amebic and bacterial dysentery, camplyobacter, and others. OTOH, the most common overall cause is irritable bowel syndrome. But after two months, it makes sense to have it evaluated. You can start with your PCP, it seems to me; s/he might or might not refer you to a gastroenterolgist.

Thanks for the thanks about our service. We're always glad to help.
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