[Question #9118] Follow-up on Question #9041 (Dr. HHH please?)
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36 months ago
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Greetings! I should clarify right away that my addressing the question to Dr. Handsfield is only for me to get a broader opinion on the issue, and not because of any personal preference between doctors. I'm also aware that ASHA cannot honor such requests.
So, here is the thing: My UTI or NGU follow the receipt of unprotected oral sex (so it is believed), resolved pretty quickly once I started taking the antibiotic. Actually, the physician who saw me, couldn't determine whether I had UTI or NGU based on my symptoms (some occasional minor urethral discharge mixed with a somewhat burning sensation on urination and shortly after) and the test results (some WBC in the urine and higher-than-usual levels of Leukocyte esterase). Less than a month following the risky exposure and symptoms/tests that followed, I find myself confused on a few things.
1) Without questioning that my symptoms were triggered by the encounter with the CSW 4 days before, why do some doctors in the medical community don't consider NGU an STI?
2) Is there a precise difference between UTI and NGU? (e.g. only NGU relates to sexual exposures...)
3) Since I tested negative for Chlamydia/Gonorrhea, was the only cause of my symptoms the contact of my penile urethra with the woman's saliva or back of the throat? The fellatio lasted several minutes and included some deep throat.
4) Are CSWs more likely to cause NGU-like symptoms to a male partner during oral, or even oral sex with one's regular female partner carries the same risks (NGU-wise)?
5) My symptoms were pretty mild. Did I really need an antibiotic, or they would have cleared anyway without it?
6) Do you know of NGU symptoms that have been debilitating to
patients? I mean, a scenario in which the mouth bacteria could cause something
worse than Gonorrhea or Chlamydia...
(Continued below...)
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36 months ago
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(Sorry, I couldn't type the entire message before, for some reason)
7) If oral Gonorrhea can be checked with a throat swab (I assume this is correct), is there any way to make sure any partner does not have harmful bacteria in her mouth?
8) Is using a condom the only, absolute way to prevent transmission of NGU and/or Gonorrhea?
9) If a condom is put on with the mouth, can the small amount of saliva that comes into contact with the penis/urethra also cause NGU and/or Gonorrhea?
10) My last question for now is whether the risk of NGU from sex is enough of a reason to switch to protected oral sex, or still, Gonorrhea is much more of a reason to do so. My understanding is that NGU wouldn’t infect one’s regular partner during unprotected sex, right?
Thanks so much for this!
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H. Hunter Handsfield, MD
36 months ago
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Welcome back. As I think you know, it's just by luck I am responding and not Dr. Hook again. I reviewed your last discussion with him, and agree with all he said.
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The reason you couldn't post all your question is the character limit. Users are asked to ask no more than fits in the original space provided. But these are succinct, so here goes. I'll start by saying I don't really understand why all the sense of mystery and uncertainty in your question a couple of weeks ago, or on the part of the person who treated you. There is no question that you had sexually acquired NGU from the oral sex event.
1) STI training in health professions schools, residencies, etc is meager in most institutions. Many don't understand that there are causes of STI other than those that show up on standard tests (gonorrhea, chlamydia, etc).
2) Since NGU is an infection in the urinary tract, it can be considered a UTI. But in normal usage by knowledgeable providers, they are entirely different conditions with different risk factors and bacterial causes.
3) With all available technology, the specific cause of NGU is not knowable in about 30-40% of cases in general; and in 90% of those cases acquired during oral sex. It is a logical assumption that normal oral bacteria usually are responsible, but no specific research has proved it.
4) This is an interesting and more complex question than you might realize. I doubt CSWs are more likely to be sources of NGU by oral sex than other female partners, but not for the reason you might be assuming. It is interesting that busy STI clinics rarely see men with NGU following oral sex with their spouses or other regular partners, only with new partners -- whether CSWs or others. One possibility is that with time, men's urethras acclimate to their regular partners' oral bacteria, but exposure to new bacteria (or combinations of bacteria) are more likely to cause inflammation. Here too the research so far hasn't provided answers.
5,6) Many experts, I and Dr. Hook included, believe little or no harm would come in not treating NGU not caused by established STI bacteria. However, it is impossible to know without research that would have to involve withholding treatment from some men, some of whom might have complications that we don't yet know about. Some professionals (generally not STI experts) believe NGU might lead to later prostatitis, for example. In addition, most cases occur not in your situation, but in men with more than one possible source, including vaginal or anal in addition to oral exposures; and treatment decisions usually are necessary before lab test results are available. For all these reasons, it is rare if ever that treatment should be withheld or delayed. Some men are psychologically pretty devastated by unexplained or ongoing urethral symptoms, another reason for routine treatment. Herpes urethritis can be exceedingly painful. Otherwise, in the absence of gonorrhea and chlamydia serious symptoms or complications of sexually acquired urethritis (e.g urethral stricture, epididymitis) are exceedingly rare if they occur at all.
7) Pharyngeal (throat) gonorrhea is the only known likely cause of urethritis for which testing is available. (Chlamydia testing is of course available, but it rarely infects the throat and almost never is the cause of NGU from oral sex.)
8) Probably yes.
9) Maybe. Who knows? It would be exceedingly difficult to learn the answer and it certainly would not be worth valuable research dollars.
10) For the reasons above, gonorrhea is the main urethral infection to be concerned about from oral sex. Probably NGU from oral sex isn't harmful to one's regular sex partners, but as discussed, we don't know for sure. In any case, don't forget those STIs that don't commonly cause urethritis -- herpes and syphilis are clear risks from oral sex, for example, and maybe sometimes HPV. And an extremely low risk (but probably not zero risk) for HIV. All in all, condoms are a much lower priority for oral sex than for vaginal or anal sex, but they do provide a measure of protection and reassurance.
HHH, MD
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36 months ago
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Thank you for your detailed reply, Dr. Handsfield, even more so as you also had to review my previous exchanges with Dr. Hook on the matter.
Well, the sense of mystery and uncertainty on my part generated from my not knowing what was really going on with those symptoms, especially since nothing similar had happened to me before. The physician who treated me, on the other hand, doubted during the initial evaluation that I may have caught Gonorrhea or even NGU. He said that when discharge is present, there is quite a lot of it and NOT only upon milking the penis. Then, based on the urine test results (I mentioned the findings yesterday), his PA told me that I need to be treated for UTI. This makes me wonder whether my symptoms met the perfect definition of NGU (provided there is one!), or may have been too mild, after all, to make any big fuss (like I did) out of them...Even the burning sensation I experienced was on and off (more off than on) and not so severe. I wonder whether a urine culture test could make a better distinction between UTI and NGU, on the base of which bacteria are found then.
I'm surprised to hear that there is still such lack of deep studies on the less standard STIs that don't accurately show on certain conventional tests. But at the same time, if there is no specificity on the oral (and non-oral I guess) bacteria that may trigger NGU (like in the case of Chlamydia and Gonorrhea), then I'm not surprised that some doctors in the scientific community don't even consider NGU an STI.
Your reply to my 4th question was really interesting to read. If CSWs are no particular source of NGU, then one could get the same symptoms receiving oral sex from several virgins in a row, am I correct? I confess that I did assume CSWs are more likely to pass that because of their exposure to multiple partners and bacteria.
Anyway, if condoms provide a perfect protection to this and the more serious STIs, I may consider using them for oral sex as well. About my question #9, I wonder, though, how much saliva would be needed to potentially trigger NGU in the process of putting on a condom by mouth. Anything you can elaborate on this?
And lastly, I'm aware that there are other risks involved with unprotected blowjobs. It's not that I'm not aware of them, but from what I've read on this website over the years, such risks (e.g. syphilis, HIV...) would appear in the same likelihood of being struck by a lightening (unless I've misinterpreted everything). For example, both you and Dr. Hook, from what I recall, have never recommended HIV testing for the receipt of unprotected fellatio, as there seem to be no documented HIV cases acquired via this sexual practice, right? If I hadn't read these many threads before, I would have worried yesterday reading about the "probably not zero risk" with regard to oral sex and HIV.
Many thanks again.
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H. Hunter Handsfield, MD
36 months ago
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"when discharge is present, there is quite a lot of it and NOT only upon milking the penis". That's definitely wrong and reflects the lack of STI knowledge by the person you saw. Discharge often is scant in NGU. From your description, in my clinic we would have confidently diagnosed NGU, without suspecting UTI or testing you for it.
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Yes, I would imagine NGU could be acquired from sexually inexperience persons, especially by oral sex.
I have no clue how much saliva exposure would carry any risk of infection. Probably little or none -- saliva inhibits or kills most bacteria (which is why kissing rarely transmits STIs).
The lightning strike analogy is probably about right for the chance of HIV from oral sex, but I would put the risks of NGU, gonorrhea, herpes and syphilis from oral sex a lot higher than that. Still a lot less risky than vaginal or anal sex, but all STI clinics regularly see these STIs in men who likely acquired them by oral sex.
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H. Hunter Handsfield, MD
36 months ago
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And our treatment would have been doxycycline (or maybe azithromycin), not ciprofloxacin. Cipro is commonly used for UTI but not NGU, because it isn't active against chlamydia. But it might work fine for nonchlamydial cases, especially for those orally acquired, because it would be effective against oral bacteria. So it was the wrong choice technically, but was clinically reliable and obviously worked for you.---
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36 months ago
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Many thanks again for your responses. Wow, that was a pretty surprising mistake then, from someone who advertises himself as an STD specialist. Pretty sad. Actually, I only used the Cipro antibiotic for 1.5 days because I felt uncomfortable with some of its potential side effects (about tendons, but I won't get into this now). So, I did an additional 5 days of sulfamethoxazole-trimethoprim DS tablets. Again, my symptoms didn't persist, luckily, and hope I don't have to fear any relapses now.
Interesting to hear that NGU can be acquired from people who have never had sex before. This, actually, makes me think of something else totally different now: may my NGU have been acquired from all the massage gel that inevitably made its way into my urethra (during body to body massage), or this is totally impossible?
It's also interesting to me that while saliva inhibits/kills most bacteria, yet it can be responsible for the introduction of them into the penile urethra during fellatio...unless there is a major difference between some saliva drops that touch the penis and plenty of saliva entering the urethra during a blowjob. But maybe what I'm saying doesn't make sense at all.
As far as syphilis and herpes via receptive oral sex are concerned, I had somehow put my mind to rest a while ago - based on what I read numerous times on this same forum - but hope I didn't misunderstand any major aspect of how the transmissions may occur. I thought that for syphilis to occur via oral sex, there has to be an active chancre in the mouth coming into contact with the penis. I don't know in this respect whether there should be any bleeding or scratch in the penis, too, for the transmission to happen, but can you please clarify this for me? I also thought syphilis is more common in homosexual partners, with a very low percentage in female CSWs. I personally have problems imagining that a woman wouldn't notice she has a lesion in her mouth, let alone her engaging in a blowjob.
As for HSV-1, I also believed that it's pretty unlikely to lead to infection via oral sex in the case of an asymptomatic carrier (should it be the case), no?
Do you still think that having condom-protected oral sex and vaginal intercourse is the safest and most effective way not to incur in any of the above mentioned STIs?
Much appreciated.
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H. Hunter Handsfield, MD
36 months ago
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This is getting a bit more involved than normal. This will close out the discussion.
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NGU isn't caused by chemical irritants in the urethra. Soaps and spermicides in the urethra can cause a bit of pain for a few hours, but that's about it.
I don't know that saliva can successfully introduce bacteria into the urethra to cause NGU. Possible but unlikely; I didn't mean to indicate any more certainty than that.
Many syphilitic lesions other than chancres can transmit syphilis, and such infectious lesions can be in the mouth with no symptoms and minimal visual abnormality. This is probably a much more common cause of orally transmitted syphilis than chancres are -- because (obviously) most people with obvious oral sores stop having sex. It is true that syphilis is currently much more common in men who have sex with men. It's not common in women, but certainly not absent -- which is why congenital syphilis (babies infected in utero) is rising dramatically nationwide. Also true that HSV1 transmission is a lot less likely in absence of oral herpes outbreaks, but it happens.
Condom protection surely is the most certain way to be entirely safe during oral sex. The overall risk without condoms is low, but it's up to each person to figure out his or her own risk tolerance.
That concludes this thread. Please note that repeated questions on the same topic are discouraged, and if excessive are subject to deletion without reply and without refund of the posting fee. This being your second about your NGU issues, it should be your last. Thanks for your understanding. Best wishes and stay safe.
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