[Question #640] STI Concern

101 months ago

Dr Hook/HHH – I’m from India – 25M

Last year I made a series of bad choices – 4 handjobs from Massage worker, 3 times condom protected sex with CSW and 1 time unprotected oral and frottage with a massage parlor worker

I developed lesions on my hands and thighs 6 weeks after the frottage/oral event and flu like symptoms. Worried I visited a skin specialist – he told me to get tested for HIV( Duo +PCR RNA), Hep B ( HSbAg) and Syphiillis (VDRL). All came back negative. Lesions ultimately went away with scabies treatment though I keep on getting small red warts on arms/thighs which go away in 1 week.

8 Weeks after the Frottage/Oral event I was in the US and developed painful urination, was unable to pass completely and pain in penis/testis and groin. The doctor found e.coli in my urine analysis – but gonorrhea/chlamydia and trichmonias tests came back negative. There were 3-4 WBC and 5 RBC in my urine rapid test. He put me on doxycycline.

Alarmed by this I came back to India. I had realized that my initial testing for STIs was incomplete and began reading extensively online for all STIs. I started my treatment with a very experienced Urologist and prominent STI/Skin expert and disclosed the above activities to both.

Urologist –repeated the urine culture - came back sterile but with 3-4WBC/pus cells and 5 RBC. He said that this should not be related to an STI but is prostatitis and put me on 6 weeks of Ofloxacin. My symptoms have subsided 2 weeks into the treatment currently (now its almost 12 weeks since last exposure)

The STI expert – says that I’ve been tested extensively for STIs. For Herpes he says that I would have had noticeable symptoms by now and should not get tested. He said I should not be concerned about HPV.

Prior to this I’ve had a monogamous relationship with my girlfriend for 5 years, I was her first partner. In the past year we have engaged in frottage 5-6 times– mostly with me wearing a condom and she sometimes had her underwear on as well.

Q1. Is there a loose end in my testing. Should I get tested for Herpes /HPV? Could the urine/skin problem be an STI ?

Q2. What is the HPV risk of the above activites ? No warts as of now

Q3. I fear I may pass on HPV/STI to my GF if I haven’t already. Should I abstain for sometime or leave her to keep her safe from cervical cancer. I will ask her to get a Pap smear/HPV test. Please help I’m unable to eat or sleep.

H. Hunter Handsfield, MD

101 months ago

Welcome to the forum. Thanks for your question.

I am confident you do not have, and never had, any infection of any kind from those events. At any point in time, most of even the highest risk sex workers don't have any transmissible STD. Second, these were all low risk exposures, even if one of your partners was infected. Hand-genital contact and frottage are totally risk free, and condom-protected vaginal intercourse and unprotected oral sex both are very low risk. So those facts alone indicate you needn't be worried. As for your symptoms, they are not typical for any STD, except perhaps scabies, which apparently was the diagnosis of your rash. While it was reasonable for you to be tested for both HIV and syphilis to be on the safe side, those results proved without doubt that you didn't have either of those infections. (Whatever the bumps on your arms that went away in a week, they were not warts -- which cannot clear up in under a few weeks or months. And anyway, sexually acquired HPV infections and warts do not involve non-genital areas like the arms.)

As for your urinary symptoms and lab findings, for sure you did not and do have have gonorrhea and chlamydia. Those tests are very reliable, and in any case the chance of either of these from the exposures you had was zero for all practical purposes. So it's an interesting coincidence that you developed an E. coli UTI and perhaps prostatitis when you did, but that's clearly all it is -- a coincidence. These problems are not sexually acquired. That is your urolgist is exactly correct. He also prescribed entirely appropriate antibiotic therapy -- on top of which, if in the extremely unlikely chance you in fact had gonorrhea or chlamydia, the ofloxacin would have cured either one. I also agree with the STI expert you saw, concerning herpes and HPV.

To your specific questions:

Q1) I do not recommned any other STD testing. The urine and skin problems are not sexually acquired.

Q2) There are no data on HPV risk for any particular exposure, except that there is little or no risk from hand-genital contact; little or none from oral exposure; and low risk from condom protected vaginal sex. But happily, the large majority of HPV infections remain asymptomatic and never cause detectable health problems, either in infected men or their female partners. And it's such a common infection, even in people with no apparent STD risks, that appearance of an HPV problem in either you or your wife will not be something that can be traced to these or any other particular sexual exposures. That's especially the case if you and/or your girlfriend have ever had sex with any other person, any time in your lives.

Q3) Every woman should have pap tests from time to time, according to national or regional public health recommendations. But not because of these particular activities on your part. You should not sexually abstain; whether you do or not will make no difference in her low risk of cervical cancer in the future. Having paps, regardless of apparent risk, is far more important than abstaining.

In summary, all is well and no further testing is warranted. And you shouldn't be at all worried. And based on all you say, I strongly suggest you stop searching the internet about all this. Like many anxious persons, it appears you are being drawn to information that inflames your fears and missing the equally reassuring information that also is present. And for goodness' sake, don't make a habit of changing international travel plans on account of things like this! Life is too short to get overly worked up over what are mostly trivial health problems. (You probably didn't think you'd find an STD expert putting STDs in a "trivial" category. But most STD infections truly are exactly that.)

I hope this has helped. Best wishes-- HHH, MD

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101 months ago

Thank you Dr HHH for the prompt response. You and Dr Hook are doing a commendable service to anxious people like me worldwide. I wish I new about the risks of all STDs and not only HIV/HepB before engaging in such activities, which I though could be averted by condoms. I would have completely abstained. Now that the hedonism has ended ( some bad company and series of bachelor parties) I feel responsible for cutting the risk for my GF to the minimum as I had long term plans with her (I want to disclose this to her with the right risk information and need your perspective).

I had a few follow up thoughts/questions :-

Q1. The 2 doctors have examined my penile and scrotum area and don't see anything of concern. The STI doctor gave me an anti-fungal pill and topical cream for the penile area. I see some minor bumps on near the urethral opening on very close inspection. Is this something that I should ask them to inspect in my follow-up visit ?

Q2. While getting a handjob in one instance, the worker also massaged my anal area with oil. Not inside but near the boundary. This was maybe 5 months ago. I have itching in the anal area. The Skin/STI doctor took a brief look and said I don't have an infection but have abrasion from rough cleaning near the anal area. He recommended antifungal cream + fucidic acid cream. Do you think this can be a scenario of Anal HPV and should ask for a more sophisticated/deep examination (an Anal PAP smear ?) than just visual examination. Is there a treatment for pre-cancerous anal growths ?

Q3. During mostly outercourse exposure with my GF, on some instances I have exposed my penis to her anus as well. In India pre-martial sex is low and we have been exclusive till last year. At this point I'm ready to put in the cost and effort to reduce her risk to the minimum.

A) Planning to abstain from her genital area for next 1.5 year till marriage (its 3 months since my last exposure), my hope is that there will be a high probability of HPV infection being cleared from me, if she hasn't caught it. Also if warts were to appear, should appear by then.

B) Getting a Pap smear done for her - Anal + Cervix - one now and one a year later (preferably annually from now) in combination with a HPV test.

C) Getting her the Gardsil vaccine (she's 26).

Any thoughts on the above and if I can do anything else, Dr. I'm ready to be very cautious here.

Q4. My family has a lot of people in medicine research/doctors whom I can ask for help. I know that there are no sanctioned HPV test for men in the market. But is there a way I can be tested in clinical environments, even if there is significant cost involved/is uncomfortable - for Penile/Anal HPV. I'm ready to put in the effort/cost. What tests should I request for ?

Q5. As you pointed out, HPV infection rate is difficult to quantify, what are the chances of HPV progressing to anal/cervix/throat cancer by your experience/knowledge. When they say that 90% of infections clear by 2 years. Will the remaining lead to cancer. Or they take longer to clear and the progression rate to cervix/anal/throat cancer is lower than 10% - its just that people don't take a chance and get treatment done after 2-3 years. Also what is the survival/cure rate in cervical/anal precancer lesions if detected early ?

Thanks

H. Hunter Handsfield, MD

101 months ago

Thanks for the thanks about our services.

Q1) Probably the doctor will examine the affected area, but remind him if he doesn't do it spontaneously.

Q2) Anal itching is one of the most common symptoms experienced frequently by all human beings. The usual cause is simple pruritus ani (but the fancy name only means "itchy anus", which doesn't help much!) and the treatments you have had are typical. Improved hygiene (cleaning well after bowel movements, for exampe) is the most important prevention. Almost certainly this has nothing to do with the sexual exposure 5 months earlier.

Q3) Without anal pentration, this too carried little or no risk for STD.

Q4) I'm sure you can find doctors' offices or online resources that will offer HPV testing. But what will you do with the result? Since the tests are not approved for use in men, interpretation of the result is difficult. If positive, it might be false, and even if true won't change risks for your partner and cannot be treated if there are no visible lesions. And if negative, it won't prove you aren't infected.

Q5) Even with the highest risk HPV types, the risk of cancer (cervix, penile, anal, throat) is low. Progression of cancer to a non-curable stage is always preventable by early examination and testing, e.g. pap smears. In other words, deaths from HPV related cancers are very rare -- much less common than other cancers like breast, prostate, lung, colon, and so on. This really isn't something to be worried about. You should look at genital HPV as a normal, expected, unavoidable aspect of being a sexually active human. It happens to everyone. Don't get so worked up about what is almost always an asymptomatic or trivial health problem.

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