[Question #6027] Unprotected Receptive Oral Risks

18 months ago
Hi Dr Handsfield,

1) 11 weeks ago I had a brief unprotected oral sex encounter with a CSW. She went down on me for a total of maybe 30 seconds before I stopped the encounter. 

2) I have been tested at 10 days, 16 days, 4 weeks and 6 weeks for the HIV (PCR & 4th Gen), Hep B, Syphillis, Gonorhea, Chlamydia and HSV1/2 (Urine sample PCR). All negative.  Again at 8 weeks for HIV 4th gen only, also negative. 

3) Around 4/5 weeks I developed some urinary urgency and frequency symptoms. This persisted for about 2 weeks. I retested HSV via urethral swab DNA - negative.

4) It's now 11 weeks after this exposure, and I have had mild to moderate meatitis for the last 2/3 weeks and intermittent burning sensation on urination. I saw a GP and she ordered a urine microscopy and culture - no evidence of infection at all, but there were calcium oxolate crystals and a low urine PH.

My questions are as follows:
1) Am I at risk for any STD given this encounter, testing and symptoms?
2) Can I confidently exclude HSV and HPV given the above?
3) Do you recommend any further testing that I can use to put my mind at ease? 
3) There is woefully little information about crystaluria and urethritis/meatitis out there, could this be a potential cause of these symptoms?

Thanks
18 months ago
A few pieces I left out:

1) I was treated with Azithromycin 500mg x 3 days and doxy x 5 days a few days after exposure for “in case”
2) no discharge present
3) had fluconazole 150mg a week ago to rule out candida
4) I have a history of pelvic floor dysfunction, although that has not been an issue for a few years. 
Edward W. Hook M.D.
Edward W. Hook M.D.
18 months ago
Welcome to our Forum and thanks for your questions.  I'll do my best to help.  The encounter you describe was very low risk for STIs- most CSWs do not have STIs, when they do oral infections are uncommon and most exposures to infected partners do not lead to infection.  Your tests prove that you were not infected and the "just in case" treatment you received was probably not needed but if it was, would likely have cured infections if present.  Urinary urgency and frequency are not symptoms of STI but may be a symptom of a non-STI urinary tract infection or anxiety.  Your urinalysis results suggest that there is not a urinary tract infection present.  Thus, in answer to your specific questions:

1) Am I at risk for any STD given this encounter, testing and symptoms?
See my comments above.  At this time you have ruled out STIs.  No further testing is needed.

2) Can I confidently exclude HSV and HPV given the above?
Yes, your risk for HSV is exceedingly low.  As far as HPV is concerned, this is rarely acquired from receipt of oral sex.  As a sexually active male, odds are that you already have HPV (80% of sexually active adults have HPV, most of which is not visible warts).  Finally, there is no recommended test for HPV and were you to test, in the absence of lesions, there is nothing to do about it.  My advice is not to worry further about HPV.

3) Do you recommend any further testing that I can use to put my mind at ease? 
I think it is time for you to work to believe your tests.  No further testing is needed.

3) There is woefully little information about crystaluria and urethritis/meatitis out there, could this be a potential cause of these symptoms?
Crystaluria is normal in many persons and not a concern unless you have kidney stones.  As for meatitis, you have ruled out infectious possibilities.  OTOH, we often see irritative meatitis in persons who have repeatedly examined themselves. The urethral meatus is, as you know, a sensitive area and easily irritated by self examination.  My advice at this time is to do your best to not repeatedly examine yourself, to be confident that you have ruled out STIs, and to allow these symptoms to resolve on their own.  I can assure you that you do not have an STI from the exposure you describe.  EWH

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18 months ago
Thanks for the response doc, and for helping put my mind at ease over this.

I still have lingering doubts over this and looking for further guidance. The left side of the opening of my meatus is red and slightly swollen. It has been for a few weeks, some days worse some days better. This is the only really bothersome symptom and I struggle to let this situation go because of it. I don’t really squeeze or play with it much at all so I don’t think that is an issue. 

I don’t think I’m imagining this symptom, despite my anxiety over the situation - which is very real, given it was an act of infidelity That caused the anxiety. I want to be 100% certain that there is no infectious cause but I’m not sure how to get there psychologically. My remaining doubts are as follows:

1) The MCS was done on urine. Although negative, does this rule out urethritis or should i repeat with a urethral swab? I often read about an MCS or smear done to “prove urethritis” before finding a specific organism. My local lab uses urine as go-to for all STI testing, although most things I read suggest it is not accurate and swab should be used. 

2) I did a urine urethritis dna panel for myco, urea, trich - all negative. Can I trust this is reliable or should I repeat with urethral swab?

3) given all the testing I’ve done, are there any remaining infectious possibilities? Is this a possible presentation of HPV from this exposure and if that is the case - what should I do next considering I have a partner? 

4) can I consider multiple Urine based DNA HSV tests and a single urethral swab test (all negative) as conclusive for not having HSV?

I want to put this behind me and move on but I’m struggling because of this lingering symptom constantly reminding me. I’m hoping it resolves on it’s own fairly soon which will help, what is your take on this situation (or any non-typical urethritis) resolving on its own and the timeframe?

Thanks again! 
Edward W. Hook M.D.
Edward W. Hook M.D.
18 months ago
Your questions are a bit repetitive and will not change my answer.  You need to believe your tests.  They are there to rule IN or OUT infection.  On to your follow-ups-
1.I'm not sure what you mean by MCS.  While urine tests are very slightly less sensitive than swab. the difference is not statistically significant and goes away entirely when a person has been tested multiple times as you have.  

2.  See above.  Once again, you should believe your test results.  Einstein once said, in effect, "one definition of insanity is to do the same thing again and again and expect different results."

3.  No!!!!!  HPV is typically asymptomatic and takes several months to become apparent.

4.  Urine tests for HSV are a waste of time and money.  The proper test for HSV is a swab taken from a sore or, in some cases, a blood test for antibodies to HSV.  

I hope these responses will let you move forward.  EWH
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