[Question #7282] Oral Gonorrhea

7 months ago
Dear Drs (Hook or Handsfield)

I stupidly had a single exposed of bi sexual oral with another male which resulted in a diagnosis of oral gonorrhea for me! I asked all the questions and thought I was safe but no it was not.

I am now worried that I may have spread gonorrhea to my family from exposure to my saliva. I have oral gonorrhea and kissed my wife on the lips (no tongue) and my baby daughter on her neck and cheeks I also blew raspberries on my daughter exposed belly this was all prior to my diagnosis.

I have not engaged in any sexual episodes with my wife since my exposure. Ive read a lot of information from Melbourne sexual health services and it is very confusing and conflicting advice..  I have read that oral gonorrhea can be spread by deep kissing and that the infection is not in the mouth but in the throat and tonsils.

1. How long does gonorrhea last when exposed to the environment. If I had it on my hands and touch my wife or child are they at risk? If I change my daughter and had it saliva 

2. Does the above listed exposure put my family at risk at all?

3. Do i need to change my toothbrush and mouthwash?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
7 months ago
Welcome to the forum. Thanks for your question.

The quick answer is that there is absolutely no risk to your family; no worries at all! Details to follow.

You don't mention treatment, but  I assume you were treated -- I hope with ceftriaxone by injection, the only approved and highly reliable treatment for phrayngeal (oral) gonorrhea. If so, within 24 hr of the injection you were cured and could not transmit the infection sexually. So I imagine you're worried about the time between exposure and treatment.

Gonorrhea is not transmitted by nonsexual contact, and the household members of infected people -- whether with oral, genital or rectal infection -- never catch it, regardless of how much they share showers, toilets, towels, eating utensils, etc; and not by any environmental contact with any body fluids, including saliva. Social (nonsexual) kissing is risk free.

The Melbourne investigators are highly respected, but most STD experts globally do not agree that gonorrhea is frequently transmitted by kissing among men who have sex with men. This is a topic I know something about. A little over a year ago, during the Vancouver BC meeting of the International Society for STD Research, I had the privilege of being invited to publically debate the leader of the Melbourne research team about gonorrhea transmission by kissing. I am a scientist and will happily change my views if stronger scientific evidence emerges, but we're not there yet. Even if it turns out the infection indeed is sometimes passed by kissing, this is an issue only for MSM who engage in repeated, frequent, open-mouth kissing. Even the Australia group acknowledges there is no evidence of transmission by kissing in heterosexual relationships or from environmental exposure, or from social (nonsexual) kissing.

Those comments pretty well answer your specific questions, but to address them explicitly:

1. Since environmental transmission of gonorrhea doesn't occur, the biological reasons -- such as survival of gonorrhea bactera in the environment -- don't matter. In any case, for a hundred years it has been well known that gonorrhea bacteria die quickly outside the body, as soon as infected fluids dry out. 

2.  Your amily is not at risk and was not even before you were treated.

3. You don't need to change your toothbrush, mouthwash, bathroom drinking cup, or anything else.

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

HHH, MD
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7 months ago
Thank you Dr Handsfield, I certainly appreciate your response and thank you for putting me at ease.

Yes I had treatment as follows:
Ceftriaxone 500 mg in 2 ml of 1% lignocaine as a single intramuscular injection plus Azithromycin 1 gram as a single dose.

Yes I saw your debate review online and was happy to see your response as the experts to my question.

Can I ask what the general consensus is on transfer of oral gonorrhea to the vagina? And if you have any thoughts on the statement that oral gonorrhea is difficult to transfer to the gentials of either sex? 

Sorry ive been doing a lot of reading and I not a lot of people have conflicting response to the above.

Regards 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
7 months ago
Thanks for the kind words. FYI, Dr. Hook is an equally qualfied expert on oral gonrrhea; he co-authored a published critique of the Melbourne/kissing hypothesis. He was also the senior investigator on one of the few studies that bears on the risk of gonorrhea transmission by cunnilingus. Basically no risk -- very rare if any gonorrhea transmission. On the other hand, gonorrhea is quite frequenlly transmitted by fellatio, which accounts for many cases of urethral gonorrhea in MSM and a small proportion in straight men. 

The difference is simple anatomy. The locus of oral infection is the pharynx, i.e. the back of the throat. In women, genital infection is primarily in the cervix. It doesn't take a lot of imagination to understand that direct contact between pharynx and cervix is pretty much impossible, and there is little transmisison in either direction. (This also is indirect evidence that saliva doesn't easily transmit gonorrhea, which in many experts' view is one of the flaws in the Melbourne/kissing analysis.) In contrast, it's easy to understand direct penis-pharynx contact, which accounts for the large majority of oral gonorrhea and a moderate proportion of urethral infections.

And you're certainly right about many online resources, including some generally good ones. Most educational resources take a dichotomous perspective:  there is or isn't risk, without consideration of the degree of risk -- and most sites simply say "yes oral sex can transmit gonorrhea and chlamydia". (It's even more inaccurate for chlamydia, which rarely infects the oral cavity at all and, when it does, is rarely transmitted.) 
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7 months ago
Thanks Dr, one last question its been over seven days since I had treatment but my tonsils are still sore and my swallowing still feels like there's some swelling. Could my tonsils still be residually swollen? I've also been getting red sores and ulcers on the top of my mouth and near my tonsils.. they are painful. 

Could this be something else?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
7 months ago
Uh-oh. This is the first you said you had symptoms. You're not going to like my reply and next round of suggetions.

Oral gonorrhea almost always is asymptomatic. A few infected persons get sore throat, but over 90% have no symptoms at all, and gonorrhea doesn't cause sores or ulcers. The combination of sore throat with "painful sores and ulcers" in the mouth and throat and perhaps tonsil enlargement strongly suggests a viral infection -- and the single viral infection most likely to cause these symptoms, especially after the sexual exposure you had, is newly acquired herpes. If you only performed oral sex, probably it's HSV2; if you also kissed your partner, HSV1 is also possible.

You need immediate evaluation for oral herpes by a knowledgeable provider -- someone with experience in recognizing and diagnosing it. If the doctor or clinic you see isn't highly experienced, assure that evaluation includes a throat swab for PCR for HSV, including a request that, if posistive, the virus be typed to distinguish HSV1 from 2. Do it ASAP, preferably within a day or two:  with a week having passed, the chance of detection by PCR may already be declining. If you are in touch with your male partner, ask him whether he has a past history or either genital or oral herpes; and if so, if he had an outbreak near the time of your contact with him.

If the clinician you see agrees HSV is possible, you should immediately be treated with an anti-herpes drug, such as valacyclovir (Valtrex) or acyclovir -- without waiting for your test result.

This situation also alters my reassurance about risk for your household members. Gonorrhea transmission still isn't an issue. However, if you have newly acquired oral herpes, kissing your wife (especially sexual kissing) or cunnilingus defnitely could infect her. Typical snuggling and social kissing of your wife and kids is low risk, but perhaps not zero, because viral load typically is high during the initial infection.

Threads normally are closed after two follow-up exchanges. In view of this development, however, I'm leaving this open for continued discussion. If herpes is confirmed, we can close it out at that time and transfer you to the wise counsel of Terri Warren, who manages herpes issues on the forum. I'll ask her to take a look at this discussion for any additional advice she may have at this time.
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Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
7 months ago
Hello, and thank you Dr. Handsfield for the heads-up on this discussion.  I completely agree with Dr. Handsfield that your throat should be evaluated by a clinician that knows about herpes.  And the sooner the better.  Do you have any history of cold sores, ever in the past?   Have you ever had genital sores in the past? 
I'm also curious about how you were diagnosed with gonorrhea in your throat - was a culture/swab test done or was this a visual diagnosis?   Sometimes, when a swab test is done, the test that is done can look for multiple organisms, including, sometimes but not always, herpes.  This type of testing is more common in women than in men, but worth checking.  I'll be interested in your responses.

Terri Warren

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7 months ago
Thanks Dr Handsfield, welcome Nurse Terri.

The only symptoms I had was a dry throat and swallowen tonsils. I struggle with my tonsils and they are often swollen or irritated i am due to have them removed in the new year. The ulcers are also an ongoing issue for me i get a lot of them. 

I will follow up with my doctor who is a sexual health officer aswell. 

Nurse Terri I was tested with a PCR Swab and then a culture for Antibiotics Resistance which all came back as non resistant to the above mentioned treatment.

Interestingly my symptoms have some sided this morning and I feel better.. could the stress, lack or sleep and general exhaustion be causing this? 
7 months ago
Sorry Nurse Terri.

No to cold sores and genital sores. The recent sores look more like trauma caused by damage from food and general only last a few days. My tonsils swell around this time every year and I often have to take multiple antibiotics to get them under control.

I went yesterday to see my doctor and she examined my throat after telling me my results she didn't seem concerned and chalked it up to stress and lack of sleep.

As mentioned I will call today.
7 months ago
Oh Dr Handsfield I should clarify that approx 3 to 4 days after my exposure to the gentleman my tonsils swelled and there was visible pus on  just one of them I had little pain but felt like something was caught in my throat. That is why I sort treatment and asked the question regarding oral swab testing. Just thought I would add that for your records.

Thanks again and ill post the result from my meeting with the doctor.
7 months ago
Oh and all symptoms have been on and off for 6wks.
7 months ago
Update: I meet my Dr this afternoon they examined my tonsils, throat and mouth and advised that there does not appear to be any signs of herpes.  They advised that my tonsils are very damaged and show significant scaring and that they need to be removed. My Dr advised that blood tests give to many false positive/negatives and advised they only  swab active ulcers or sores of which there was none. 

My Dr also stated that if I did infect have an initial hsv 1 or 2 infection that I would expect to experience sufficient pain and that they sores/ulcers would not clear within a day or two.

As this is the case they recommend that i monitor and review my symptoms. However in their opinion they feel I should move on and just get some rest.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
7 months ago
It seems you exaggerated your symtoms. I'm glad you were professionally examined and herpes apparently isn't an issue. You were not tested for it, but probably it doesn't matter. ("PCR Swab and then a culture for Antibiotics Resistance" probably did not include a herpes test, just gonorrhea and maybe chlamydia.)

That concludes this thread. I hope the discussion has been helpful. Best wishes and stay safe.
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