[Question #7135] Could these symptoms be an STD?

6 months ago
Thanks for all of the support you provide on this site.

I am a gay male from London, UK.  About 2 weeks ago I had unprotected oral sex (receptive and insertive), protected anal sex (receptive) and unprotected analingus (receptive) with another man.  He claimed to be negative of all STDs and recently tested.

For the last 4 days, so since 10 days after exposure, I have had some gastro symptoms:  nausea, diarrhoea and urgency mostly, but also early satiety.  I even (worryingly) has some nocturnal diarrhoea in the middle of the night.  No fever (I have been checking regularly), no rash but minor headaches from time to time.  My rectal area does feel a little sore, but I have suffered from anal fissures for years and it feels like those have flared up a little.   I have not seen any visible mucus or blood in my stool and it is a normal brown colour. 

Given the timing of onset of these symptoms in relation to my exposure, I am trying to reassure myself as to STD likelihood and have thought the following:

(A) HIV - obviously my biggest concern but seems unlikely given: (1) I was compliantly taking PrEP at the time (and for 2 days after); (2) the condom did not break (I checked); (3) these symptoms do not seem like typical ARS even though the onset timing would fit with ARS.  Thoughts?

(B) Rectal gonorrhoea / chlamydia - one online "symptom checker" website actually suggested gonorrhoea as my most likely condition.  However, I am confused as, although some respected websites do state diarrhoea is a symptom, other state only mucus / discharge and itchiness as symptoms.  Can either of these cause stomach discomfort, nausea and diarrhoea? 

(C) Syphilis - "urgency of defacation" seems a common symptom so I am really worried about syphilis.  However I do not see any visible sores. Does this seem likely?

(D) Anal Herpes - don't see any sores or blisters so seems unlikely?

(E) Anything else ????

Thanks so much for your help.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
6 months ago
Welcome back to the forum. Thanks for your continued confidence in our services.

In looking over your previous discussions with Dr. Hook, plus these questions, I see a pattern. In the days or weeks after a sexual encounter, you tend to link various day-to-day common symptoms and body sensations with that encounter. My response now parallels those of Dr. Hook previously -- that your symptoms have nothing to do with the sexual encounter 2 weeks ago. Lists of STD or HIV symptoms often aren't very helpful. To your questions:

A) Congratulations for your continuing use of PrEP; as before, I assume you're using it on demand, which is my favored approach for folks who have potentially risky exposures but not all that frequently. To my knowledge, there has never been a reported failure of on-demand PrEP to prevent HIV. In addition, you had very safe exposure, since oral sex and analingus both are extremely low risk for HIV transmission. You also describe a partner who is unliekly to have HIV. (As Dr. Hook said, people rarely lie about HIV status when asked directly.) Finally, as you say yourself, your symptoms do not suggest ARS.

B) The only symptom you describe that could have triggered a prediction of anorectal gonorrhea is the soreness in your rectal area, and you have an obvious alternate explanation for this.

C) The secondary stage of syphilis could include some of the nonspecific symptoms you mentioned, but that stage begins 3 months or more after acquring syphilis.

D) I agree anal herpes is unlikely.

E) As implied above, I'm pretty sure you're just experiencing minor body sensations that, except for your anxiety, you would ignore or perhaps not even notice.

For reassurance, you could consider STD/HIV testing, i.e. anal and throat swabs for gonorrhea and chlamydia (valid any time) and an HIV and syphilis blood test (6 weeks after the encounter). In the meantime, I see no cause for worry or concern.

I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD
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6 months ago
Thank you for the prompt and very helpful reply.   You are correct that I followed the "on-demand" PrEP regime for this encounter.  A few follow-up queries:

(1) Just for my own peace of mind, are you saying that neither ARS, rectal gonorrhoea nor rectal chlamydia would typically cause diarrhoea, nausea and loss of appetite on their own (i.e. in absence of fever, sore throat and any other symptoms)?

(2) I will test for gonorrhoea and chlamydia next week but waiting 6 weeks for the HIV test will be torture for my anxiety; out of interest what is the estimated accuracy of a "5th-Gen" Ag/Ab HIV test at 3 weeks?  And if these symptoms really are ARS presumably a test taken next week (at 3 weeks post-exposure, 1-week post-symptoms) would be positive?

(3) Out of interest, are you aware of any research or studies relating to the use of PrEP for oral sex only?  I know I had protective receptive anal sex on this occasion, but this was actually the first (and likely only) time in many years and I expect my future encounters would just be oral sex again.  I know the risk is already low with oral but I still usually take "on demand" PrEP anyway; however, if PrEP does not offer any protection for oral sex (the only info I have found online refers to its protection in anal sex) then perhaps I should not bother.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
6 months ago
1) All correct. Those symptoms don't suggest either ARS or rectal gonorrhea.

2) The supposed 5th gen test is a misnomer, a marketing ploy by the manufacturer. It's no different than other AgAb (4th gen) tests. It would detect around 80% of new infections at 3 weeks. So moderately reassuring, but nowhere near conclusive. (A negative result would prove your symptoms aren't ARS, but would not be conclusive for a new asymptomatic infection.)

3) Oral sex itself is so low risk for HIV that the effectiveness of PEP (or PrEP) in preventing it can't be studied. (How do you determine that something that carries only 1 chance in 10-20,000 is still lower?) There's no reason to believe it would not be just as effective as for anal or vaginal intercourse. however.

Alternatively, why not speak with your partner and both be (re)tested? If both are negative now, you'll both know neither could have infected the other, no need to wait for additional testing at 6 weeks or any other time.
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6 months ago
Thanks again for the helpful responses.  On (1) you didn't mention rectal chlamydia - is that because my symptoms and/or onset timing *ARE* typical for that?

Also, I've now started worrying immensely about a potential hepatitis infection as I have read numerous symptom descriptions and case studies which sound similar to mine.   I'll be tested for hepatitis A, B and C alongside my other tests but does it sound a possibility from your perspective, based on my symptoms, timing of onset of symptoms and exposure?  

In particular, for my own reference going forward, how risky is giving unprotected oral sex from a hepatitis standpoint?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
6 months ago
Gonorrhea and chlamydia symptoms are pretty much identical, except chlamydia's tend to be milder and more commonly it's asymptomatic. Otherwise, my comments about gonorrhea also apply to chlamydia. Nothing in your symptoms suggest any STD at all.

You need to stop focusing on symptoms. Every symptom you describe fits with innumerable medical conditions, or none at all. Some patterns of symptoms are helpful, but individual symptoms almost never are. For example, I'd bet that even among the most highly at-risk MSM with nausea, hepatitis is the cause in under one in many thousand.  I wouldn't recommend the tests you mention, but assuming you go ahead with them, you can expect negative results.

Analingus risks hepatatis A for the oral partner, but few or any other STDs. And since there is no chronic carrier state for hep A, the frequency of hep A in outwardly healthy persons is nearly zero, assuming your city or town isn't in the midst of a hepatitis A outbreak.

Since you're apparently quite worried about hepatitis, I hope you have been immunized against hep B. If so, you're not at risk from any exposure. If not, consider doing it.

That completes the two follow-up exchanges included with each initial quesiton and so ends this thread. This being your third along these lines, it should be your last. All three discussions have been more or less the same, and you can expect similar replies if the same sort of concerns arise again. I do hope this (and the others) have been hellpful. Best wishes and stay safe.
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