[Question #32] Concern of STI

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107 months ago
Hello, thank you for fielding my question.

I have been experiencing testicular pressure and mild pain for the past approximately 2-3 days.  Additionally, I feel mild pain on the tip of my penis, and have definitely had to frequently urinate small amounts.  There is a minor sense of burning when I need to pass urine, but after passing, this feeling lessens, and doesn't exactly burn AS I urinate.  I feel as if my testicles have redness and some swelling.  They are somewhat tender to the touch, but don't necessarily have extreme pain or anything like that.  Anyway, I have been concerned about this feeling.

About 2-3 days prior to the feeling, I had a intercourse with a woman.  She gave me protected oral initially, then we had protected intercourse, but during the intercourse, I was getting limp, the condom didn't slip off, but it was loose, so we decided to go back to oral.  She gave me protected oral for a while after intercourse, and then gave me unprotected oral.  It didn't occur to me that her mouth had been on the condom used during intercourse, and then during unprotected oral.  During the unprotected oral, I ejaculated into her mouth.

I underestimated the risk of unprotected oral so I did that, but it was an obvious mistake that I do not intend to repeat.  I started to worry about the situation shortly after it happened.  I felt like I felt some pain and itching earlier, but very minor and not really noticeable, so I waited.

It has been approximately 5 days overall, and the pain has been on and off, sometimes forgotten, but typically I do notice it, with the feeling increasing overall over the past few days.  It has resulted in a lot of discomfort.  I am hoping it is not an infection, but I wanted to get your professional opinion.

Thank you!
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H. Hunter Handsfield, MD
107 months ago
Welcome to Ask the Expert. Sorry for the slower than usual reply.

All things considered, I doubt your symptoms are due to any STD, but you should be professionally evaluated to be sure. Better safe than sorry.

Although the timing is right for gonorrhea (symptom onset usually 2-5 days), the symptoms started too soon for chlamydia and nongonococcal urethritis (NGU) (typically 1-2 weeks). And the symptoms themselves aren't right. The main symptom of all urethritis is abnormal discharge, sometimes with pain during urination, but not urinary urgency, frequency, etc. And if it were gonorrhea, by now you would have obvious pus dripping from the penis. These symptoms could be from a non-STD urinary tract infection, but UTIs are very rare in younger men (under 40) and are rarely if ever acquired sexually.  On top of all that, the risk was low for all these infections. Although condom re-use isn't recommended, it's probably not all that risky. The important thing is that the condom was in place for vaginal penetration. Oral sex is low risk for STDs; although NGU can result, it isn't common, and as already noted, both the symptoms and timing don't fit well. 

The most common explanation for symptoms like yours, especially following a regretted or anxiety-producing sexual exposure, is genitally focused anxiety, causing pelvic muscle spasm. The same mechanism often also causes pain to be referred to the tip of the penis. On and off symptoms also is strong evidence against infection but favors a psychological/emotional explanation.

This isn't a precise science, and there are potential exceptions to much of what I have just said, hence my advice you get professionally evaluated by a doctor or clinic with extensive experience with STDs, e.g. your local health dept STD clinic if you aren't confident your PCP is up to speed on STDs. But for al the reasons above, I predict negative results.

I hope this has been helpful. Best wishes--  HHH, MD
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107 months ago
Thank you for your response Dr. Handsfield.  I very much appreciate your feedback and patience in addressing my concerns.

One thing I have to say immediately, is that the pain/discomfort in my testicles is definitely there.  It may be a physical manifestation of a psychological/emotional feeling, but it is there, and its a new feeling I had without prior knowledge of what kind of feeling I would get.   I sometimes don't notice it if I am distracted enough, but it is unlike anything I have experienced before, and it has definitely been going on for several days.  There has been no discharge of pus, but I have noticed cloudy or slight discoloration in my urine.  Though for the past day or so, the urine and frequency seem to be more normal, though I still have the discomfort and mild pain in my testicles, and still some pain on the tip of my penis, occasionally feeling like the pain is over the entire penis/urethra.  I would really like to believe this is emotional and psychological, but the discomfort is already affecting me, and while I hope it isn't related to a possible STD, its existence, cause and coincidental manifestation is of concern.  One question that does come to mind though, is that if it is not STD-related, then what is it?

Do you think it is a concern that her mouth was on the condom during protected oral after which we went to unprotected oral?
  Meaning that her vaginal fluids may have been present in her mouth during unprotected oral and ejaculation.  This is admittedly a large portion of my concern.  She was licking a lot, and while there was no cuts/trauma on my end and I didn't notice anything wrong with her mouth, I did not examine closely enough for cuts or gum bleeding from her.  I don't know and can't find out her health status, but defensively I believe that she likely had one or more of Gonorrhea, Chlamydia, Herpes, and HIV, considering her overall disregard for safety.  She had piercings and tattoos, and I would not be surprised if was a drug user that involved needles, or had other risk factors.  Again, this is my defensive sharing of concerns, not a passing of judgement or irrational paranoia.  These things did not occur to me till after the fact.

Since I made this posting, I have noticed that I have been feeling more feverish, with regular sweats, and including last night where I woke up several times drenched in sweat.  I also have distinctly noticed tightness and aches in my muscles and joints.  Some pain in muscle and joints is normal for me, but I've noticed occasionally stronger pain in my knees, with severity unlike before.  Sometimes I will be standing or sitting and feel a sharp pain in my knee.  And then I sometimes feel shaky while walking as if my knees might give out on me.  I've also felt stiffness in my neck and back.  While moving, I notice abnormal amounts of cracking sounds in my joints, such as my shoulder or back or knees, while otherwise doing normal motions or simply walking.  I've tried to feel for swollen lymph nodes, but have not felt anything, but admittedly I don't know exactly what to feel for.  Also, I feel as I have had an upset stomach all week, initially unaware of its possible relevance.  While some of these feelings are somewhat normal, and I may not even notice or attribute them to anything normally, the occurrence of them now is making me very concerned that these maybe signs of an HIV infection.  I know that these too could be psychological or emotional, but again, the severity and general nature of it being a new feeling makes me think it is unlikely that I'd be able to manifest the feelings mentally.

Do you feel a Herpes or HIV infection is possible or likely?  The fever and aching a possible symptom?
Is it possible to get fever symptoms from Gonorrhea or Chlamydia?

I absolutely intend on getting tested, likely several times.  I actually got a test 2 days ago, right after I made this posting out of concern, and am anxiously awaiting results.  I know the window was short to get it so soon, but considering my symptoms, I felt it would be ok to try and get some reassurance that way.  I was also told that in another week or two, I could get the RNA test for HIV for further testing of this concern, which supposedly has high accuracy for a 2 week window?  Anyway, my point here is that I definitely intend to get tested, but I'd still like your expert opinions on the matter.

Thank you again for your time and patience, it is much appreciated.
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H. Hunter Handsfield, MD
107 months ago
None of these comments change my opinions or advice.

I know the pain is real and I didn't say or imply otherwise. I gave the most likely physiological explanation, including response to your question "what is it". (Minor clarification: "spasm" wasn't the best word. "Tension" is better.) It's the same mechanism by which tension headaches are painful -- in that case involving muscles of the scalp, neck, etc. Nobody denies that such headaches are truly painful, even if the origin is stress, anxiety, etc. It's no different for genitally focused anxiety and genital area pain.

I saw and took into account the potential for cross-contamination of secretions in this way. There is no way sufficient vaglnal fluids could be in her mouth to allow STD transmission.

You give no evidence partner had an "overall disregard for her safety". Certainling tattooing, piercings, etc don't justify such a conclusion, and she used a condom for vaginal sex (or agreed to your choice to use one). Most likely she knows (correctly) that oral sex is low risk. Don't get me wrong:  she might have such disregard; I have no way of knowing. But if you read my initial reply, you should understand it doesn't matter. Your partner could have HIV, syphiiis, gonorrhea, chlamydia, or herpes -- or all of them -- but the exposures, as you describe them were safe. That doesn't mean totally risk free -- but low enough that any infection was very unlikely.

Your other new symptoms don't concern me at all. No STD would cause any of them. And as for your genital discomfort, saying these symptoms have a psychological origin doesn't mean they aren't real. (Although I'm pretty sure some of them are magnified in perception because of your concerns about STD etc.)

Repeated STD testing would be a mistake. Gonorrhea testing is valid any time 2+ days after exposure, and chlamydia by 4-5 days. Blood tests take a few weeks, but only need to be done once. As noted below, you also need in person evaluation by a qualified health care provider.

Really, mellow out. You're far too worked up than called for based on the exposure described. There's simply no realistic chance you have anything at all. Believe it.
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107 months ago
Thank you Dr. Handsfield for your response.  I read it several times, and found much comfort in it.  I did not mean to indicate that your assessment of it being psychological as an insult, but to the contrary, it is comforting, but I have to be defensive about such a possibility.  Sorry for my delayed response, but I wanted to go ahead and wait till I got my test results to have my follow-up question, here they are, and again, these would have been approx 4.5 days after possible exposure.

My immediate concern after seeing my results is the <0.90 for the HSV 1 and 2 results.  Does the fact that they say "<0.90" vs "NOT DETECTED" mean that there were traces of the antibody found? 

Same for Hepatitis C, with the 0.01 value instead of a "non-reactive" or "not detected," does this mean that the virus is present?

Does this mean that I have likely been exposed to the virus, and should have concern for HSV1, HSV2, and Hepatitis C, as I have developed some antibodies, but not enough yet?

Why would I have any trace of these antibodies if the viruses were not present?

What would you recommend as the follow-up test?  Would you recommend following up with any medications?  I intend to see a doctor, but I wanted to be sure to get your advice as well.

Also, regarding your point about a discharge from the penis; isn't it possible that I wouldn't actually discharge, but it would simply come out in the urine itself (thereby causing the cloudiness or discoloration)?  I ask this partially with concern regarding NGU.

Also today I noticed a new symptom, and it has scared me.  Yesterday morning I had some pretty bad diarrhea.  I had to wake up in the middle of the night to go, and then I believe the second time I went, I felt itchy (but I was still sleepy), and so I wiped really hard, and I noticeably felt a pain.  Then I had to go 2 more times in the day, both times also diarrhea-esque.  I didn't pay much attention to it throughout the day but the irritation built up.  Then when I got home, I looked at myself, and I had a small cut/tear near my anus.  No blood or anything like, but a small tear on the skin near the anus.  Is this cause for concern?

And then today while examining my groin area, I felt like I noticed some swollen lymph nodes.  Again, I am not certain what to look for, but I feel like today there are some bumps near the groin.

Doctor, please, tell me straight, do I probably have Herpes?  Or anything?  I would really like to believe that the exposures were safe, but I had probably several minutes of unprotected oral, during which my penis and the tip were extremely exposed to saliva and whatever other fluids may have been present, and then ejaculation in the mouth also.

Also, is it possible to continue to pay for this conversation?  I again appreciate your patience in the matter, and understand that I am likely focusing too much on it, but it would be very helpful to have a reliable avenue of conversation.
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H. Hunter Handsfield, MD
107 months ago
Those results are entirely negative. The HSV and hep C tests are a different technology than a titered antibody test, and unlike a titer test (such as RPR for syphilis), any number below the cut-off is negative and does not indicate a "trace" of antibody. You could test the same blood specimen 10 times and it would give 10 different numbers, which might be anywhere from 0.1 to 0.5 to 0.85. All are totally negative, with no different meaning between them.

I don't recommend any further testing, with the possible exception of repeat syphilis and HIV at 6 weeks. Even those are superfluous based on the exposure, and you can expect negative results. If you have a regular sex partner, you can resume regular contact without putting him or her at risk. (That's what I would with my wife, if somehow I were in your circumstance.)

You clearly are obsessed over this to a very abnormal degree. I'm pretty sure repeated reassurance that your various tests are negative, and that the exposure was low risk, aren't going to sink in until and unless you deal with the underlying mental health problem that is so evident. You should consider professional counseling. I suggest it from compassion, not criticism. in the meantime, stop any online searching about STD risks, testing, etc.

This will end the discussion. You could start a new thread, for the usual fee, which would cover the initial question plus two follow-ups. However, I recommend against it. I guarantee the replies will be no different, and for the most part will just refer back to statements in this thread, with perhaps a few other terse words. But it's your money, so feel free.

Best wishes.