[Question #4520] Possible oral exposure

81 months ago

Hi Doctors,

I am happily married. 3.5 weeks ago whilst on a stag weekend I stupidly visited a sex worker in amsterdams redlight district - one of the 'window girls'. I was completely wasted drunk and so can't remember much of the incident but know for sure that there was no vaginal sex of any sort and the girl masterbated me without a condom.

My concern is IF she performed unprotected oral. I know that even if she had done this would be a low risk event and if I've not noticed any symptoms I can forget about it.

1) however, I have not been checking for symptoms. I am uncircumcised so don't see the tip of my penis as a matter of course, sit down when urinating so again don't see the tip of my penis and don't actively look when in the shower.

If I check the tip of my penis every two hours between 10am and 8pm today and tomorrow an d don't notice any pus/ discharge can I assume I am safe an no need to test or would symptoms have stopped by now anyway, given it's been 3.5 weeks?

2) I have just gone to the bathroom for a bowel movement and having checked the tip of my penis noticed a very small amount of white/cloudy secretion - assuming I don't see any further discharge today can I assume this was simply down to straining?

3) If I don't notice any abnormal discharge today/tomorrow, If you were me, would you continue unprotected sex with your wife with no fear for health?

Thank you

H. Hunter Handsfield, MD

81 months ago

Welcome to the forum. Thanks for your question.

From your description, it seems likely there was no oral sex. Why would you be confident there was no vaginal sex, have a clear recollection that she masturbated you, but not recall oral sex if it occurred? Of course you were there and I wasn't. In any case, you are correct there was no STD risk from the hand-genital contact (even if genital fluids or saliva were used for lubrication). I'll also add that registered sex workers in Amsteram -- which, as I understand from my Dutch colleagues, includes virtually all who work openly in the city's red light district -- get tested regularly, so it is unlikely your partner had a transmissible STD, including oral infections.

Having said that, I'll go along with your concern that oral sex might have occurred. Even if it did, and if she had an active oral STD, unprotected oral sex can be considered safe sex, with low transmission for all STDs and virtually zero risk for some.

1) You may have a basic misunderstanding about STD symptoms and need for self examination or inspection. Almost any STD that might be acquired by oral sex would cause overt symptoms that you would notice without paying special attention. There is nothing you would ever see on your penis that would not be uncomfortable or painful; or, in the case of urethral discharge, obvious dripping or at least underwear staining.

2) Your assumption is exactly right. During bowel movements, stool passing through the rectum, plus increased intra-abdominal pressure from straining, can squeeze secretions in the prostate gland or seminal vesicles (where semen is stored pending ejaculation) into the urethra, sometimes enough to appear at the meatus, even occasionally with overt dripping. This happens more frequently with some men than others, but in itself is not evidence of infection. Perhaps it has happened previously with you, but unnoticed until now because of your heightened awarenss.

3) With no abnormal discharge, painful urination, or penile sores, blisters, etc after 3+ weeks, you can indeed be confident you have no STD from the event, even if oral sex occurred. I see no reason not to resume unprotected sex with your wife, which is what I would do (would have done a couple of weeks ago or maybe even the next day) if somehow I were in your situation. This isn't a guarantee, of course; asymptomatic STDs can occur. But all things considered, this is exceedingly unlikely and I really wouldn't worry about it.

I hope this information is helpful. Let me know if anything isn't clear.

HHH, MD

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81 months ago

Thanks Doctor, that’s a great help. I agree that I probably would have remembered if she’d have put her mouth around my penis as I would have freaked out at the time I think.

A couple of final Qs if I may, just for final clarification.

1) Re. Noticing symptoms - I definitely haven’t felt any discharge seeping out of my penis, in the same way as I sometimes do with preejaculate I’ve been aroused, or any wetness in my shorts or indeed any sores or pain when peeing or burning etc. I’ve not been checking my shorts for staining as I didn’t want to confuse any preejaculate / ‘normal’ secretion staining with abnormal discharge.

1) Do you agree that even without checking my shorts for staining or looking at my penis tip I would have still noticed symptoms - uncomfortable feelings, feeling wetness in shorts etc so no need to worry?

2) Finally, I have been urinating an awful lot for the past week or two and very frequently (ie. up several times per night) and today have a slight ‘pulling’ feeling in my lower abdomen. There is no burning or pain when peeing and I don’t feel an immediate urge to go again.

I’ve researched other responses you’ve given and just wanted to check that I am right that frequent urination is NOT a symptom of any STD and what I describe above are symptoms of a ‘normal’ urinary / UTI infection not caused by an STD?

I’m not really one for testing for reassurance sake as i feel it’s a waste of resource and money of the NHS. I think through my reading and your responses I know there’s nothing to worry about, your final responses to my questions above will put things to bed however.

Thanks again for your excellent service.

H. Hunter Handsfield, MD

81 months ago

1) I'm very confident you would have noticed any symptoms, especially given your obviously heighted alertness due to concerns or anxiety about the event.

2) Urinary frequeny is rarely if ever a symptom of STD. It is, on the other hand, highly typical for genitally focused anxiety. And really not typical of a non-STD UTI. The main symptoms there are painful urination, great frequency (often every few minutes, not a few times a night); urinary urgency, i/e/ "immediate urge to go again", as you aptly state; and often pain and tenderness over the bladder (just above the pubic bone).

Given all that you have said, including your agreement that oral exposure was unlikely, there is just no chance you have any STD from that event. It's far more likely that all the minor symptoms you are noticing are due to anxiety over a sexual decision you obviously regret.

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81 months ago

Thanks Doctor. The non-UTI symptoms describe below are exactly what I have - yesterday and today. It has got worse over the past week or even two weeks. I am going to the loo every few minutes and a tenderness and pulling sensation over my bladder. When i said ‘not immediate’ I meant literally seconds but it’s within 5 - 10 minutes.

I went to the doctor this afternoon, NOT a GUM clinic and he did a urine test and confirmed the presence of white cells and prescribed me trimethoprim.

Various sites say that frequent urination can be a symptom of NSU so I am now confused.

Given this news my final questions are:

1) would you still say that the risk of std is miniscule and I can rely on this being a NON-STD caused infection, take the trimethoprim as prescribed and NO need for me to be tested at a GUM clinic for ghonnoreah and NSU and no need to tell my wife anything, from a medical risk perspective?

2) If you think I should go and be tested for ghonnorea and nsu, I won’t be able to get to the GUM clinic until Monday which will be 4 weeks and three days since the ‘possible’ exposure in Amsterdam.

I have read in other posts from you elsewhere that ghonnorea and nsu clear themselves over time with an average for ghonnorea of 6 weeks in the pre-antibiotic era.

If I test on Monday, 4 weeks and 3 days later do you think there’s a good chance that any infection will be cleared and anyway and thus my wife already infected?

3) I assume if I should test on Monday I shouldn’t take the trimethoprim tonight as they could lead to innacurate result?

4) If I have a swab test done and they don’t see white cells on Monday and the ghonnorea test comes back negative, can I relax, despite the doctor finding white cells in his urinalysis?

Thanks Doctor, I hope you can understand my concern.

H. Hunter Handsfield, MD

81 months ago

I agree your symptoms indeed sound suspicious for UTI. But not, in my opinion, for NGU. Urgency, frequency, and suprapubic (bladder pain) all go along with bladder inflammation, which is the norm in non-sexually acquired UTI, and it not a feature of NGU. As the name implies, the inflammation in NGU is limited to the urethra and a number of research studies have documented only urethral discharge and painful urination (varying from very mild, or no more than a somewhat itchy feeling during urination), but not urgency or other bladder-like symptoms. This is a little controversial, however, and some investigators, especially in the UK but few in North America, believe urgency etc may occur with NGU, perhaps indicating the prostate gland is involved. But other evidence argues against prostate involvement in NGU, and there definitely is no evidence at all that prostatitis is an STI.

Your evaluation must include not only STI testing, but urinalysis and a urine culture nor non-STD bacteria like E. coli etc. If these confirm UTI, you also should see a urologist for evaluation for underlying urinary tract problems, like prostatitis, kidney stone, and various urinary tract congenital malformations. In men under age 40-50, most UTIs are evidence of such an underlying abnormality. Spontaneous UTI can occur, but is quite uncommon under age 40-50.

1) "would you still say that the risk of std is miniscule and I can rely on this being a NON-STD caused infection...?" That's my best bet, unrelated to your Amsterdam adventure. More below about additional testing and whether and when to start the trimethoprim.

2) If your symptoms are due to gonorrhea or chlamydia, for sure a test will show it. You can't have persisting symptoms without continued active infection detectable by testing.

3) The doctor or clinic who prescribed trimethoprim should have done gonorrhea/chlamydia testing and a non-STI urine culture. STI testimg is widely available in the UK outside GUM clinics. If they did not do those tests, I suggest contacting them and requesting them before you take trimethoprim, which indeed could screw up testing for all of these. (If they didn't do complete testing because you didn't give them a full history, i.e. were unaware of your STI concerns -- well, you should correct that impression as well.) One of the last things you want, which would only prolong your anxiety and enhance uncertainty about all this, is to have negative test resuts that may not be reliable because of the trimethoprim.

4) Let's not speculate on next steps. Have the additional tests and let's take it from there.

Threads normall are closed after two follow-up comments and replies. However, I'll leave this open for a final comment after you have either returned to your current doctor/clinic for additional testing and advice, or after your GUM clinic visit in a few days. Don't take the trimethoprim until gonorrhea, chlamydia, and UTI culture tests are done. (Try to get them done soon. If you have a UTI, you don't want to wait several more days before starting treatment.)

My final comment is to urge you not to interpret my recommendation for gonorrhea/chlamydia testing as meaning I believe you could have caught them from the events described. I do not. But all things considered, I think you're going to need those test results for reassurance and for comprehensive understanding of what's going on.

I look forward to your final comment in the next few days.

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81 months ago

Hi Doctor,

Firstly, I’d like to say thank you for your kind gesture of keeping this thread open for final comment post testing, that’s very much appreciated.

The doctor yesterday at the GP surgery took a urine sample from me which he said was being sent away ‘for tests’ - he was very unhelpful and didn’t go into detail about specifically for what but I assume e-coli etc. He did confirm it wouldn’t be for any STD check and I would need to visit the GUM clinic for that.

I have been to the GUM clinic this afternoon and the doctor took a swab for NSU and urine for ghonnorea and chlamydia.

The swab was completely clear of puss cells so no NSU diagnosed and ghon/chlam results back next week but clearly expecting those to be negative. The doctor said she thinks the bladder infection diagnosed yesterday could be a culmination of a build up over the past week or so but clearly isn’t std related.

So it seems I can now relax and take the antibiotics prescribed yesterday for the UTI.

Final questions:

1. Why would a urine test by the dr yesterday pick up leuokolytes (he explained these are white cells) and the swab today pick up nothing? Or is what is detected for a ‘normal’ UTI different to an STI Infection ?

2. I assume there is no chance an sti could have cleared since yesterday without being detected by the swab? It’s been just over 3.5 weeks since the ‘possible’ exposure so wondered if any STI bacteria could have cleared on own it could have been since yesterday afternoon? I’ve not had the same need to urinate every few minutes today and no bladder pain.

I assume this there is no chance of this being the case and I can be sure there was no STI?! (For all practical purposes).

2. I’d held my urine for 3 hours before the dr swabbed me for NSU. Is this enough time for an accurate swab result?

Thank you again for your help and extremely useful advice yesterday.

Enjoy your weekend.

H. Hunter Handsfield, MD

81 months ago

Thanks for the follow-up. Glad to hear my expectations have been confirmed. (But I remain surprised that the non-GUM doc didn't feel he could test the urine for gonorrhea and chlamydia....)

1) Urethral swabs will not detect increased WBC (pus cells) originating in the bladder due to UTI. To put it another way, their presence in urine but not the urethra confirms no urethritis (as they told you at the GUM clinic) and that your problem originates higher in the urinary tract.

2) That's a very unlikely scenario, especially since you never had symptoms that suggested a urethral infection or inflammation. Plus the zero risk nature of the sexual event.

3) Yes, 3 hours is plenty of time.

It sounds like you're in capable hands. That will have to concludes this thread. The GUM clinic can advise you about the Amsterdam event or other STD related question. Best wishes and stay safe.

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