[Question #6035] STD transmission

19 months ago
Hi Everyone
I am a male and in a relationship  where sex almost does not exist. Unfortunately from time to time I have resorted to seeing  a sex worker. Upper class for what it is worth. Sex was always protected except for once that the condom broke (I was tested for all std’s afterwards and was clean) and unprotected oral on a few occasions.  

Some time ago my partner and I had sex (unprotected).  Around a month later she mentioned that she had a blister directly on her clitoris that itched. I had a look but I could not see it so I cannot give more specific details on it. 

Obviously I am  very concerned and guilt ridden that I got infected at some point and I have now infected her.  

Questions:
What are the main STD concerns based on above?
What should I get tested for?
What are the odds that I have contracted something and given it to her?

Thanks

Edward W. Hook M.D.
Edward W. Hook M.D.
19 months ago
Welcome to the Forum and thanks for your confidence in our assessments.  I'll do my best to help.  As I begin to think through your problem, I have to say that having an itchy blister on the clitoris is quite an unusual complaint and a problem that really does not raise questions about any STI.  While I realize that the word "blister" elicits the specter of genital herpes, the situation and limited data you describe do not fit.  Initial herpes infections rarely present as a single blister and if you had unknowingly acquired HSV and then transmitted it to your partner,  an outbreak would typically occur within 10-12 days of exposure, not a month later.  What you describe really does not fit HSV.

Additional comments.  CSWs, particularly those who are higher end, "call girls" tend to be cautious about STIs and are rarely infected (the risk for acquiring an STI is far higher following sex with a non-professional, one-night stand picked up from a bar than with a professional whose business is to provide pleasure without risk.  Further, even if your CSW partner had an STI, transmission typically does not occur following a single exposure.  Thus, in answer to your specific questions:

What are the main STD concerns based on above?
Your risk for STI is low. In my opinion, your regular partner's recent symptoms are unrelated to your dalliance. Thus the purpose of testing is to provide you with reassurance that you have no infected your partner.  STIs such as chlamydia, gonorrhea and trichomonas typically do not cause symptoms but our goal here is to make you confident that you did not inadvertently infect the person you are in a relationship with  (n.b. I did not call her a "regular partner, that is another issue)
 
What should I get tested for?
Testing for the common STIs is warranted- gonorrhea, chlamydia, trichomonas.  I hesitate to suggest hat you have a blood test for HSV because there are problems with the test (false positives, difficulty in interpretation of a recent positive test, etc.)
 
What are the odds that I have contracted something and given it to her?
Very, very low.

Finally, I am not a relationship counselor but there seems to be a problem here.  My sense is that sex is more important to you than your partner.  Hopefully there are other elements of this relationship which make this relationship rewarding to both you and your partner.

I hope this commentary is helpful to you.  EWH


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19 months ago
Hi Dr. Hook
Thank you very much for the reply, it was very helpful. Just a few follow up questions.

Could you possibly give a rough idea of what you mean by the chance of me infecting my partner is very, very low. Would you say that means 1/100, 1/1000? I know it’s far from exact but I am more of a numbers guy.

Could you please give more details on the HSV blood test. HSV is one of the main concerns for me although I have never had symptoms. What do you mean by difficulty in interpretation of a recent positive test? Could it be that we have both had it for years and only now she shows symptoms?

Lastly, HPV... if my partner decides to do a full STD test, what test would be done for Hpv? I assume it is quite likely that both of us have Hpv and that such a test would come back positive?  We have been in a relationship for more than ten years so it would be difficult for me to explain a positive Hpv test assuming that she had no other sexual partners during this 10 year period?
Edward W. Hook M.D.
Edward W. Hook M.D.
19 months ago
I'll try to clarify things for you but since your do not know much about your partner's symptoms and you have not been tested, any guess (and that is precisely what it would be) as to whether you had infected your partner is nothing more than a guess which in my estimation would be.  

In persons who have never had a blood test before, falsely positive tests are common and in some settings, nearly one-third to one-half of positive test results are falsely positive.  Further HSV blood tests can take 3-6 months to become positive.    Persons who have had HSV-1 (the cold sore virus, and more than 50% of adults have had HSV-1, most of whom are unware that they are even infected) are more likely than those who have not to have a false positive test although plenty of persons who do not have HSV-1 infection have falsely positive tests as well.  From the little you could escribe about your partner's lesion, it does not sound like an initial HSV outbreak.  Again, I recommend against testing in your situation as there is a substantial chance it will not be helpful.  

Testing for HPV is now common when women have routine evaluations.  I agree that it is likely that you and your partner have HPV.  When tests are positive, one cannot reliably say who was infected.  Over 50% of sexually active adults have acquired HPV within 6 months of becoming sexually active, even if monogamous and over 80% of sexually active adults are or have been infected.  As far as I can tell you do not know if she has been tested before or what her results showed.

My sense is that your combination of guilt and your partner's vague description have set of a cascade of "what if" questions that you are not going to be able to get good answers for.  Your risk of any infection, following the single unprotected exposure you described is low, particularly with your subsequent negative tests, and your partner's risk of having been infected is lower still.   Sorry.  EWH 
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19 months ago
Hi Dr. Hook
Thanks for the reply.
My partner insists that I have a test done for HSV2 as she is certain I was unfaithful and gave it to her. She complains of itching, burning when urinating and a ‘blister’ on the one side of vulva and another one on the other side of the vulva and another on the other side. She showed it to me and it does not resemble herpes from what I can see. What else can have a blister like appearance? The itching etc started literally 12 hours after we had intercourse. I read what you said about the herpes tests. I understand that the IgG could take time to show a positive result but does it also have a high probability of false positive result? I thought that was an IgM issue.
Edward W. Hook M.D.
Edward W. Hook M.D.
19 months ago
 It sounds to me like your partner is convinced she has HSV-2.  Has she had a test?   Has she seen a dermatologist  or other healthcare provider who has perform tests on her? 

 If you have a test for HSV-2 and it is positive it does not tell you what your partner's lesion is.   There are many different dermatologic conditions which can cause genital lesions. Your description does not allow me to guess what might be going on with your partner. If you have a test for HSV-2 antibodies she should too.  Further, and importantly, having HSV-2 antibodies does not tell you what is causing her blister. She should have a PCR test taken from the lesion to determine if it is HSV although as I've said earlier it does not sound like it.  

 It would be virtually unheard of for the illusion of herpes to appear just 12 hours after infection. Typically this process takes somewhere between three and 10 days.  

 How common false positive serological tests are depends on the population and the situation. In some settings as many as 50% of recent positive tests turn out to be falsely positive. Knowing the index value used to determine whether the test is positive or not  May be helpful in determining whether the test is falsely positive or not.   Virtually all experts will tell you that the IgM test is of little value both for determining whether an infection is recent or not and is troubled by very very high falsely positive rates. The rates are substantially lower for the IgG test but there are still relatively common. 

 As this is my final response as part of this thread, here is my advice. Your partner needs a diagnosis. She should be seen by a gynecologist with expertise and dermatologic processes or a dermatologist. If herpes is being considered her lesion should be tested using a PCR type test.   If you both choose to pursue blood testing please avoid IgM tests and you should both be tested using an IgG assay for HSV-2.

 Is iamb confident you know that we provide up to three responses to each client's questions. This is my third response. Therefore as per forum guidelines this thread will now be closed. I hope the information I have provided has been helpful. EWH 


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