[Question #791] Cured gonorrhea, then it returned?

53 months ago
Hi Doctor,

A few months ago, I had severe rectal inflammation (which I had for more than 2 weeks before it was treated) which was caused by rectal gonorrhea. I'm a male and an escort performed analingus on me which led to the gonorrhea infection (my STD doctor said he's never seen a gonorrhea infection happen on the rectum through analingus before even though it is theoretically possible.... so I guess i'm just EXTREMELY unlucky).

Few days after I did the treatment for the gonorrhea (shot in the buttocks and pills), I was 100% back to normal and have been that way for 3 months now.

Starting a a few days ago, I started to be unable to "finish" defecating and am starting to have the same symptoms like how it was back then when I had rectal inflammation caused by gonorrhea.

I didn't engage in ANY possible risky sexual activity (and literally none in the anus) so I should not have been infected again.

Is it possible the first treatment failed, even with my symptoms completely going away after treatment, and the gonorrhea has returned?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
53 months ago
Welcome to the forum. Thanks for your question. You present a rather interesting case: if you were in my clinic, I would ask your permission to permit residents and/or medical students to particpate in your care, for the teaching value.

Going straight to your main question, your rectal gonorrhea probably has not recurred. It isn't impossible, but very unlikely following what sounds like standard treatment with ceftriaxone (the injection) and either azithromycin (if the pills were single dose) or doxycycline (twice daily for a week).

Assuming your intitial infection was documented by proper testing, i.e. a possitive nucleic acid amplification test (NAAT), then for sure you had gonorrhea. However, it was not necessarily the cause of your symptoms at the time. Proctitis -- inflammation of the rectum -- has many causes, both sexually acquired and others, and although gonorrhea can cause severe procitits, usually it does not; most cases are asymptomatic or have only mild symptoms. Accordingly, it is possible you had proctitis due to something else and gonorrhea coincidentally present. The treatment you had, especially doxycycline or azithromycin, could have temporarily suppressed some of the other possibilities. (By the way, I agree analingus is a rare source of anal gonorrhea; in my 40 years in the business, I don't think I've ever seen it. If you had any other anal exposures in the several months before diagnosis, one of those events might have been the source. But if the analingus event is the only option, there is no reason it cannot occur on rare occations.

At this point, it is important you be professionally evaluated by an expert who understands STDs and proctitis. Your rectum should be tested for chlamydia, including the form called lymphogranuloma venereum (LGV), syphilis, and herpes, as well as repeat testing for gonorrhea. If none of these pans out, you probably should be evaluated for inflammatory bowel disease, i.e. ulcerative colitis/proctitis and regional enteritis (Crohn's disease). As implied above, I would be very surprised if gonorrhea is found again. I have no way to judge the likelihoods of the other possibilities mentioned, although I would point out that herpes is a more likely infection from analingus; tends to cause severe proctitis; and often recurs. Try to get evaluated in the next couple of days -- the sooner the better for accurate herpes testing in particular, and for effective treatment if it turns out to be herpes. (That said, I'm not really predicting herpes as the cause -- the other causes remain equally plausible.)

Thanks again for your question. I'll be very interested to hear how this turns out.

Best wishes--  HHH, MD

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H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
53 months ago
I also meant to say that the STD doctor you saw last time seems quite knowledgeable, based on your treatment and his awareness of issues about gonorrhea transmission by analingus. Sounds like a good bet for expert evaluation this time as well. Whether you see him or someone else, consider printing out this thread as a framework for discussion during your visit.


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53 months ago
Thanks for the help doctor - definitely a bit scary for me that this is a rare enough situation that warrants studying but I really appreciate the extra help (I'm in the Bay Area, but if I was in washington I'd love to see you).

Just to give a bit more information - I'm very young, healthy and straight and have never had any bowel movement issues and never did ANYTHING sexually with the anus prior to that one time having the escort perform oral-anal on me,  so to have the proctitis symptoms start a few days immediately after that incident was why, I'm assuming, the doctor decided to give me the gonorrhea treatment (even though it would have been so rare to acquire it that he thought it was a false positive). I did the rectal swab test and tested negative for chlamydia and positive for gonorrhea. 

I'll talk to my doctor immediately to get tests for LGV chlamydia, herpes, syphilis and gonorrhea. 

I'm jsut extremely frustrated that something like herpes and gonorrhea is even possible because I read the STD charts before seeing the escort and it wasn't listed even as a known possibility: http://www.sfcityclinic.org/stdbasics/stdchart.asp.

I don't want to take up to much of your time but I guess a follow-up question to what you've stated is: if it was herpes, would the ceftriaxone  and azithromycin fix the herpes outbreak and return me to normal like it did or was that purely coincidental? And do I need to use protection for penis-vagina sex with my SO?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
53 months ago
Thanks for the additional information. With no other exposures, LGV is extraordinarily unlikely; chlamydia of any type is rarely carried in the mouth and not known to ever be acquired by analingus. Also, for some reason I had the impression your escort partner also is male, but apparently not. (I don't know why I assumed it; I see no clue in re-reading your question.) LGV is pretty much strictly a problem in gay men at the present time. So all this leads me to move my bet to the herpes column. The antibiotics last time wouldn't have helped herpes, but the natural course is clearing at around 2-3 weeks, so you might have been on the verge of spontaneous resolution.

I am unaware of any formal research anywhere on analingus risks for transmission of any STD. Those listed in the city clinic chart are logical but no data are available.

There are plenty of resources in San Francisco for the sophisticated care you need, every bit as good as we would do, including the city STD clinic. In any case, I no longer have an active practice.

As for unprotected vaginal sex with your partner, I see little risk. OTOH, it isn't all that rare for herpes to involve more than one anatomic site, and maybe for infectious virus to be in the anal area externally during an active rectal infection. If I were in your situation, I would hold off at least until I had been examined, if not for lab test results.


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53 months ago
Hey Doctor,

Went to the city clinic first thing in the morning and got blood tests for syphilis and herpes 2, and anal swab tests for herpes 1 and 2, chlamydia and gonorrhea.

The nurse there did an anoscopy and didn't see any lesions, or notice any bleeding (my doctor didn't see either of these the first time I had the more severe proctitis outbreak either) but I do believe that she saw inflammation. She said that it would definitely be rare for it to be herpes without any rectal pain, lesions or bleeding but she wasn't sure.

Without any active lesions in the anus or penis, would I still be infectious if I do penis-vagina sex?

Also, I should have the full test results back within 5-7 business days so I'll update you the minute I get it.

Thanks for all the help.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
53 months ago
We're at the usual forum limit of two follow-up questions and replies, but I'll keep the thread open pending your results. But be certain to wait until all pertinent results are available. Looking forward to chatting then.

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53 months ago
Hey doctor,

My test results came in today and I'm negative for rectal gonorrhea, chlymidia, PCR herpes test and the IGG HSV2 test. 

I'm pretty confident I don't have HSV2 in the rectum but could it be possible that I have HSV1 as I didnt have any visible lesions and this is outbreak #2 so I'm not sure how accurate the PCR test would have been. 

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
52 months ago
In thinking about the overall picture, I'm suspicious your initial gonorrhea test was falsely positive and that something else was responsible for your apparently recurrent proctitis. Herpetic proctitis is unlikely without overt ulcerations seen on anoscopy and negative PCR, but I can't say for sure you did not have it (due to HSV1), perhaps resolving by the time this reexamination was done, especially if your symptoms are now improving again. Another problem with herpes as the cause is that herpetic proctitis usually is accompanied by external lesions as well, i.e. blisters, sores, or ulcers of the anus, not only inside the rectum.

So while I cannot rule out past gonorrhea or recurrent herpetic procititis, my guess is that this problem has nothing to do with your sexual exposure a few months ago, just coincidence -- and that you have a limited form of inflammatory bowel disease of the rectum, i.e. ulcerative colitis or Crohn's disease. If your current symptoms clear up entirely, it shold be safe to continue to sit on the problem (pun slightly intended), but if there is a recurrence, then you should immediately (within a day or two) see your personal physician and/or a gastroenterologist. Both HSV testing and visual diagnosis (by anoscopy or proctoscopy) will be most accurate the sooner they are done.

Best wishes.

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