[Question #5232] Syphilis transmission question

22 months ago
Hi there I have a question about syphilis transmission. A little over a month ago I received unprotected oral sex from a girl here in Miami. I think she is fairly promiscuous and possibly with guys who are bisexual. I recently got a sore on my penis i'm uncircumsized and its low down on the shaft. I'm waiting for the results of a blood test to find out what it is but there seems to be a good chance it's syphilis from what i've read. Unfortunately I had brief vaginal sex unprotected with my girlfriend about 6 days after the oral with the girl. The sex with my gf didnt last very long and I didnt ejaculate. I'm just wondering what the chances are that I gave it to her too? I've read that you arent contagious until the sore appears but I've also read conflicting advice that my pre-cum could have given it to her, or that even though i didnt have a sore yet she could still get it because the bacteria were active on my penis where the sore would appear several weeks later. I'm freaking out, please tell me what the risk is. Thank you.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
22 months ago
Welcome to the forum. Thanks for your question, which happened to arrive soon before I logged in. Most users don't receive nearly real-time replies!

Your research is good -- indeed syphilis is not highly transmissible before the chancre (the initial syphilitic sore) appears. Whether there might be slight risk before that isn't really known (but pre-ejaculate fluid is not necessarily a source). If your problem is confirmed as syphilis, your girlfriend will have to be informed and treated.

However, this isn't necessarily syphilis, even though the timing is right (apparent onset 2-3 weeks after exposure, right?). However, heterosexually transmitted syphilis is uncommon in most of the US -- the large majority of cases currently are occurring in men having sex with other men. That said, it's certainly possible she had it, especially if it's true that her sexual contacts include MSM. The location of your penile lesion doesn't quite seem to fit the exposure. Was her mouth in direct contact with the area where the sore appeared? Also, you don't say much about the sore. Can you describe it? Size? How sore is it? Open sore? Heaped up edges? Only one? Any swollen lymph nodes in the groin? The most common cause of penile sores is genital herpes. That would still have implications for your girlfriend, but not nearly as dangerous as syphilis.

If you can answer those questions, I can speculate a bit more accurately on the likely diagnosis. However, you definitely need to see a doctor or clinic ASAP, while the sore is active, before it heals. Ideally see a public health STD clinic, where they are most likely to have facilities for immediate accurate diagnosis (dark-field microscope) as well as the clinical experience in recognizing various causes of genital ulcer. You also need a blood test ASAP. I would advise not discussing any of this with your girlfriend until the diagnosis is known.

Sorry I can't give exact answers based on the information available, but hope these comments get you on track to prompt diagnosis. Good luck. Let me know the answer to my questions or if anything isn't clear.

HHH, MD
---
---
22 months ago
Thanks for your quick response. Much appreciated! I'll try to answer your questions so that you have a better idea of what is going on and the timeline. So the oral sex was about 6 weeks ago and the sore appeared about a week ago (about five weeks after the oral). Unfortunately it took me a while to get an appointment at the clinic so by the time I did the sore was pretty well healed, which I'd estimate took maybe 7 to 9 days. It was about a third of a inch long and maybe a quarter inch wide. Did not really have raised edges, it was a little scabby and slightly open toward one end. I'm sorry I know that's not a great description. While it was healing it had kind of a thin crack in it that was slightly bloody. But it wasn't ever wet or weeping. As I said, by the time I got to the clinic it was all but gone so they couldn't do a swab (they didn't even mention that actually, they just took my blood). And yes, just one sore.

I've also been wrestling with the location of the sore. To be honest I think her mouth probably was in contact with that location, but it would have to have been the inside of her lips or somewhere else toward the front of her mouth. The nurse at the clinic examined for swollen lymph nodes and said she didn't find anything, but that said I have been having occasional pain in that area, particularly the "crease" between my thigh and groin area. It started around the same time as the sore and has continued off and on even since the sore cleared up. 

The clinic said they'll have the results of the test in a day or so. Do you know how conclusive they would be at this point in time when I get them? They said that one would be a basic blood test to screen and then there would be a confirmatory one. The information online about when testing is conclusive is a little all over the map honestly!

Also, on the transmission point, would the pre-ejaculate be the only risk prior to the sore appearing or is contact with the penis generally a high risk even if the sore hasn't appeared yet? 

Thank you so much for your help.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
22 months ago
OK, that's helpful information. Probably not syphilis -- too long to onset (typically 2-3 weeks, 5 weeks not likely); the nature of the lesion doesn't sound syphilitic; it healed too quickly; and apparently no lymph node enlargement/inflammation in the groin. The standard syphilis blood tests are conclusive at 6 weeks. I'm betting it will be negative and you'll be home free in regard to syphilis. (If the screening test is negative, that will be conclusive. The automatic confirmatory test probably won't be done unless the initial screen is positive.)

As discussed, the chance of transmission before a syphilitic chancre appears is very low. But if and when there are exceptions, it's probably not so much from pre-ejaculate fluid as from the skin where the chancre is brewing. But we really don't know. If you have syphilis, there will be no getting around the need for your partner to be treated for it. Sounds like that's unlikely, but in the meantime there's no point in ruminating about it.

That leaves the actual cause of your penile sore unanswered. Your description is not typical for herpes, but it's still possible. Let's hold off on further discussion  until you can tell me the syphilis test result.
---
22 months ago
Thanks, Doctor! I'll let you know the test results when I get them. Would the pain in my inner thigh area indicate lymph node swelling you think? Even if not detectable by the nurse? Just seems a bit coincidental to me. No more questions from me until I get the test results back. Thank you again.
22 months ago
Okay so my test was negative (RPR). The clinic said essentially that although 6 weeks would typically be conclusive, it can take several weeks after the appearance of a chancre for the test to become positive and that I should test again in a couple of weeks. I guess I'm wondering whether you agree that the result is less conclusive in my case for that reason? 

The test was about 10 days since the lesion appeared. I could see that if a chancre appeared at 3 weeks, then a 6 week test would be conclusive, but if it appears at 5 weeks wouldn't 8 weeks be more like it for a conclusive test? I'm definitely getting odd groin pain in the extreme lower torso/upper inner thigh area. I'm having a hard time figuring that it's not related. What are your thoughts? I've been reading on the antibody production online and it seems that it doesn't really begin until the chancre appears (versus when you're infected). Am I right about that? I'm wondering if I should just ask to be treated since the symptoms seem so strong? Thank you in advance for your thoughts and response.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
22 months ago
If you are correctly stating the clinic's position, I respectfully disagree. The time to seroconversion (positive RPR) depends entirely on when the exposure occurred, not on timing of whan a chancre appears. With no typical chancre (plus lymph node swelling in the groin, usually present with syphilitic chancre) and negative RPR at 6 weeks, for sure you do not have syphilis. However, you are free to have yet another blood test if you find the negative result reassuring.

As for the biology of it all -- when antibody production begins etc -- once again the time since exposure is more important than onset of chancre. In any case, the actual time of the start of antibody production is highly variable from person to person and exposure to exposure. But it probably begins within a few days, although may not rise to detectable levels with RPR or other tests for a longer time. But really, there is no need to get into these weeds. The fact is that in my nearly 50years in the STD business, I have never seen a patient with syphilis in whom positive RPR was delayed more than 6 weeks. Don't worry about the biological reasons -- it just doesn't happen, or so rarely it can be ignored.

Finally, if "symptoms...so strong" means they are highly suggestive of syphilis, that's plain wrong. Your symptoms do not align well with syphilis, and neither does your exposure. See my replies above.

That concludes the two follow-up comments and replies included with each question and so ends this thread. If you get tested yet again, and if against all odds it's positve, feel free to start a new thread. But not if it's negative. I'm very confident you do not have syphilis.

I hope the discussion has been helpful. Best wishes.
---