[Question #6819] Risks? Unprotected Oral and Apposition

13 months ago
Dear Doctors,I am hoping for your expert advice on my situation and what to do next.I am male, 30s, pretty active fit and healthy. Never had these issues before.Around 5 months ago  had a risky encounter with a woman I do not know and have no way of contacting. I received unprotected oral sex for several minutes. Also, whilst we were both naked, there was a couple of minutes unprotected genital to genital contact. Specifically, the exposed tip of my penis was rubbing against the opening of her vagina. We did not have full penatration but came close.Next day I noticed some redness on the tip of my penis. Over the week I felt increased urge to urinate and a heavy feeling in my abdomen. I got checked out at the GUM, urine sample was clear for WBC (I think? They dipped a stick in it). My urine sample was tested negative for Chlamydia and Gonoreah.Things cleared up over about two weeks. I felt reasonably normal for a few days then the redness returned, along with urge to urinate. My meatus became red and a bit swollen. The tip of my penis felt very sensitive to even the slightest touch.  Again, urine sample clear for WBC, chlamydia gonorreah negative.This has been happening for 5 months, I seem to have 2 weeks with minimal symptoms and then they always return for 2 weeks or so. The last 3 times it has happened, I experience a tingling like pins and needles in my testicles. Sometimes I feel spasms like flutters in my perenium. My anus becomes irritated and itchy and I get the feeling of pressure in my rectum. Then comes the urinary symptoms, redness on my glans and swollen meatus. I feel like after urination, I haven’t finished and more needs to come out. Also inside my urethra feels sore and irritated. What did I put myself at risk of from my encounter? I have to believe the negative C/G tests. I have not noticed any discharge. I know there are a number of others I have not tested for? Mgen? Herpes? 
Edward W. Hook M.D.
Edward W. Hook M.D.
13 months ago
Welcome to our forum and thanks for your question.  I happened to check the site soon after your question arrived and so you may receive this response somewhat sooner than is usual.  It may be that the recurring redness, urinary frequency, and other symptoms do you experiencing are unrelated to the encounter you describe.  Please bear with me as I offer some observations and suggestions.

The encounter you describe was relatively low risk for STI despite it’s casual nature. Receipt of oral sex is a relatively inefficient means for STI transmission and non-penetrative genital contact should that put you at risk either. The initial redness that you describe a day following the encounter is almost certainly not due to an STI. STI signs and symptoms simply do not occur within the first 24 to 36 hours following acquisition of infection. The redness may have represented non-infectious irritation related to the encounter or an unrelated process. Similarly with respect to urinary frequency, please symptoms are not a sign of STI.  The absence of WBCs in your urine and negative tests for gonorrhea and chlamydia also make this most unlikely to be in STI.

With regard to other STI’s, it would be unusual for this to be M. genitalium as it is it is rarely acquired through oral sex and typically has WBC’s present in the Urine when infection is present.  I understand that the recurring nature of the redness and tenderness may suggest herpes but in the absence of lesions this too is unlikely. A blood test for HSV would be of little use in this situation however in the future should the irritation occur a direct swab test from the area of redness would be helpful in ruling herpes out. 

At this time the recurring nature of her symptoms probably warrant further evaluation. Evaluation at a time when symptoms are not present would be of little help. I would suggest that when the symptoms recur, that you seek evaluation from a dermatologist as quickly as possible. There are many many non-STI general dermatological problems which could be described Which cause symptoms similar to yours.

I hope with this information is helpful to you. If there are further questions please feel free to use your up to to follow up questions for clarification. EWH

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13 months ago
Greetings Dr Hook,

Thank you for taking the time to reply and your observations.

I have to admit, given the nature of my risky encounter and the recurring symptoms I was beginning to resign myself to the fact this must be Herpes. I would find it hard to believe this is not something sexually related as I have never experienced any issues until this risky encounter occurred.

I have not noticed any lesions, just redness but from what I have read, Herpes can present in many different ways for different people. It sounds very difficult to say for certain with Herpes.

I wonder, does the frequency of occurrence, around 2 weeks of a flare up then 2 weeks with minimal to no symptoms, repeatedly fit in with Herpes? 

Also, over the last 3 times this has flared up I have experienced itchy and irritated feeling in the anus and pressure in the rectum, as if I am sitting on a foreign object. Quite often I will feel twitches in my perenium.  Do you have any thoughts on a link here? 

I understand M Gen is not likely from Oral sex, how about the genital to genital contact?

Many thanks 
Edward W. Hook M.D.
Edward W. Hook M.D.
13 months ago
You are correct that herpes can be quite variable it it’s presentations but what you are describing would be outside the norm for HSV.  Following acquisition of HSV-2 a first recurrence typically occurs about a month later and over the next year persons have, on average, 3-5 recurrences.  The frequency of your recurrences, the absence of visible lesions, and the nature of your exposure all may HSV unlikely.  As I said above however, the best was to rule out this possibility would be to have a swab specimen taken for the area of irritation for PCR testing at the time of your next recurrence.  Blood tests will not be helpful in this situation.

I don’t have good answers for your anal symptoms.  While in theory this could reflect HSV recurrence, as I said above, there is no good evidence that this is HSV.

M. genitalium is acquired through penetrative sexual contact, not frottage.  EWH 
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13 months ago
Greetings Doctor Hook and thank you for the additional insight.

If I may, I’d like to follow up again. So what I am going to take away from our conversation is that an STI is unlikely here. 

How would your risk assessment change if there was brief penetration of just the penis tip for a couple of seconds?

I understand due to the recurring nature of my symptoms, HSV is a likely cause which needs to be ruled out?

With recurring HSV outbreaks, is it usual for symptoms to occur at multiple locations, for example anal symptoms and penis symptoms at the same time? I have read about Herpes outbreaks being unilateral or something like that.

I have read many accounts online of people who report similar symptoms and it is believed that bacteria can be deep in the prostate which means urine testing is not conclusive. Have you heard of this?

I have been through a lot of anxiety and guilt over this encounter. Also, I would really appreciate your opinions on whether any of this can be linked to stress, anxiety and feelings of guilt over a regrettable encounter? 

Thank you for your time.
Edward W. Hook M.D.
Edward W. Hook M.D.
13 months ago

As I read your reply, it appears that you are assuming the worst and that this IS genital herpes.  That is NOT my message to you.  I think that I would be misleading you if I did not acknowledge that some of the symptoms you describe are somewhat (but not very when considered in context) suggestive of herpes but the likelihood that this is herpes remains low.  Further, acknowledging your comment regarding guilt and anxiety, I need to tell you that it is quite common for us to find that guilt and the resulting anxiety over a possible STI can amplify awareness of what are otherwise normal sensations and lead to spiraling anxiety and concerns.  Regarding your specific follow-up questions:

How would your risk assessment change if there was brief penetration of just the penis tip for a couple of seconds?
No, my assessment would not change at all.  Your tests are strong evidence that you did not acquire the most common STIs from your casual partner.

I understand due to the recurring nature of my symptoms, HSV is a likely cause which needs to be ruled out?
Given your anxiety and level of concern, it is my sense that if you do not rule HSV out, you will continue to worry. 

With recurring HSV outbreaks, is it usual for symptoms to occur at multiple locations, for example anal symptoms and penis symptoms at the same time? I have read about Herpes outbreaks being unilateral or something like that.
HSV recurrences tend to occur in the same place time and again. Each person has their own pattern.  For you to be having simultaneous recurrence in two locations without lesions would be quite unusual.  I have never seen such a thing.

I have read many accounts online of people who report similar symptoms and it is believed that bacteria can be deep in the prostate which means urine testing is not conclusive. Have you heard of this?
Prostate infections may be difficult to diagnosis but typically there is some evidence present in the urine.  Your follow up question however does bring to mind a genital discomfort syndrome called the Chronic Pelvic Pain Syndrome or CPPS.  This syndrome which is NOT an STI. is well described on Wikipedia

I hope this information and perspective has been helpful. This is the 3rd response to your questions, thus, as per Forum Guidelines this thread will be closed shortly without further comment.  Take care. EWH
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