Episode 26: Sexually Transmitted Diseases (STD’s)

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Episode Summary:

Sex is an easy way for infections to get from person to person when you think about it! An infectious disease doctor and a men’s health doctor give you the skinny on (STDs) that sexually active, and not-yet-sexually-active, folks should know about: chlamydia, gonorrhea, hepatitis B, herpes simplex virus (HSV-2), HIV, human papillomavirus (HPV), and syphilis. This knowledge will help you protect and care for yourself, and your partner.

Episode Guest: 

Margot Schwartz, M.D., Virginia Mason Medical Center, Seattle WA.

During This Episode We Discuss:

  • Common sexually transmitted infections; what are they, where do they occur, how they are transmitted, harms they can do to the body, evaluation and treatments.
  • Screening for at-risk individuals, even those without symptoms.
  • Prevention strategies.
  • How is testing done? 
  • Infections with lesions and without.
  • HPV vaccination.
  • Herpes.
  • Throat Cancers from HPV.
  • HIV.

Quotes (Tweetables):

“It’s important to treat these infections when we find them; to not have sex for about a week after treatment, so the person is not re-exposed; to treat the partners, and then to get follow-up testing.”

“We are seeing more resistant strains in gonorrhea, so the gonorrhea guidelines have really changed over the years.” 

“One of the most important things about HPV is the importance of vaccination because the HPV virus (and certain strains of the HPV- the 16 and 18 strain) can cause cervical cancer in women and also cause some rectal cancers.”

Margo Schwartz, M.D.

Recommended Resources:

Episode Transcript: 

Dr Richard Pelman (00:07):

Baseball game, day in a park with friends and family, fishing in a remote stream, work, travels, providing for loved ones, or heading out for adventures, whatever you do, whatever you enjoy, you need your health. The Original Guide to Men’s Health, as presented by the Washington State Urology Society, to help take you through the steps necessary to get the most out of life. If you have invested in a retirement plan for your future, why not invest in your body, after all it makes better sense to retire healthy and enjoy your future. These podcasts are a guide for how to take care of yourself. If you take care of your car and maintain it, why not do the same for your personal machine, your body, if you know you should, but haven’t yet, the information in these podcasts contains some easy recommendations for where, when, and how to get started. Follow the podcast, as we explore men’s health with renowned experts and embark on a journey towards better health!

Dr Pelman (01:25):

Welcome to this episode of The Original Guide to Men’s Health. Today, we’ll be exploring sexually transmitted diseases, STDs for short with Dr. Margot Schwartz. Dr. Schwartz is an infectious disease expert who practices at Virginia Mason Medical Center and clinics here in Seattle, Washington, Dr. Schwartz attended the Johns Hopkins Medical School and did her internship and residency in internal medicine at the University of Washington. She then did her fellowship in infectious disease at the University of Washington. She is board certified by the American Board of Internal Medicine, and also has a subspecialty board certification by the American Board of Internal Medicine in Infectious Disease. Welcome Dr. Schwartz. 

Dr Schwartz

Thank you. 

Dr Pelman

So for our listeners, we want to cover the gamut of infectious disease and we’ll talk about HIV. Though, HIV sometimes is not always an infectious disease of an STD type. It is sometimes acquired through non-sexual contact. So our STD talk today in the infectious disease world of STDs or sexually transmitted disease will be those that are required through sexual contact. So there are many, and we can start wherever you like and work through what signs and symptoms and diagnosis and treatment of sexually transmitted infections.

Dr Schwartz (02:53):

In men, they can usually be characterized by either genital ulcers or discharge from the penis or burning from the penis or urethra or burning with urination or rectal symptoms. The other things that we sometimes see in patients are genital sores or ulcers that can hurt or not hurt. And the other place where people can have symptoms from sexually transmitted infections is in the throat generally.

Dr Pelman (03:23):

And we’re talking about sexually transmitted diseases. We’re talking about those that are requiring through sexual transmission. So historically one of the oldest known to the history of mankind was syphilis characterized by painless ulcers.

Dr Schwartz (03:38):

If it’s early syphilis, it can be a rash all over the body, if it’s secondary syphilis, which is an intermediate stage or in later stages, as syphilis goes untreated, it can cause a whole host of symptoms, including neurologic symptoms.

Dr Pelman (03:58):

That’s very late stage.

Dr Schwartz (03:59):

Very late stage. The other thing we often see with syphilis is no symptoms at all. So it’s important to do screening for syphilis because we can pick it up before somebody has any symptoms. 

Dr Pelman (04:14):

So typically we’re just using syphilis as the introduction, but a lot of sexually transmitted diseases travel together. So when somebody presents with a concern, either they had an encounter that was risky behavior. And we’ll talk about that and or they have a lesion they’re concerned about; they don’t just get checked for that one sexually transmitted disease they’ll generally get screened for multiple.

Dr Schwartz (04:40):

Correct. Usually we take the opportunity if somebody has taken the time to come to clinic, to screen them for many STDs, which could be blood tests, urine tests, throat tests, rectal tests, or other swabs of other sites, if they have an ulcer or a skin sore there.

Dr Pelman (04:59):

So for going back to syphilis, you can swab an active ulcer or is it all blood tests?

Dr Schwartz (05:06):

It’s not all blood tests. Though that’s often the quickest test. There are tests where one can get a sample from the ulcer and look at it under the microscope, but it’s a very specialized microscope that is used for darkfield examination. So while that may be available at a syphilis center or a public health clinic that sees a lot of syphilis, most regular doctor’s offices won’t have that blood tests, or just how it looks may lead to treatment on the day of the clinic visit. And there is treatment. For all of the sexually transmitted infections that we’ll talk about there’s treatment, some of it’s curative and some of it is suppressive.

Dr Pelman (05:48):

Okay. So next in line would be gonorrhea, can you tell us a little bit about symptoms for gonorrhea.

Dr Schwartz (05:58):

Gonorrhea causes a urethritis in men. So it can cause a drip from the penis, usually a bit more of a yellow or a symptomatic drip than with some other sexually transmitted infections like chlamydia. It’s often a little more pus in the drip with gonorrhea, but it’s important to remember with gonorrhea or with the other sexually transmitted diseases that it’s not just in the urethra or the penis where we see it. It really depends on where at which sites the patient has exposure. So if they were performing oral sex, we want to make sure we screen their throat, or if they received rectal sex, or if someone else had their penis in the rectum that we screen the rectum, because there’s good data out there that a lot of people go to the office of their provider, and they might not share all the different sites where they had sexual exposure. And if we don’t screen the sites where there was exposure, we might miss them.

Dr Pelman (07:04):

Great point. So it’s important, first of all, to try to give your practitioner as much information so that you can be diagnosed appropriately. And for those who are healthcare practitioners to not just assume there was only one potential site of exposure.

Dr Schwartz (07:20):

Right. And to not be shy about asking the questions and having the conversation. Okay.

Dr Pelman (07:25):

So gonorrhea manifests, if it is in the urethra, as a discharge with usually some burning with urination, urgency maybe, but you know something’s different and the discharge can show up in the underwear. Sometimes it’s very visible, just looking it’s fairly abundant. 

Dr Schwartz (07:50):

If it’s in the throat or there are symptoms of a sore throat, but oftentimes there are no symptoms as well. So it’s important to screen people if they have risk behaviors, even if they have no symptoms.

Dr Pelman (08:01):

And rectal or their symptoms…

Dr Schwartz (08:06):

Discharge, it can be pain. Those are the most common ones.

Dr. Pelman (08:09):

Okay. And then after treatment, it’s important to go back and get retested to prove that you’ve eradicated the disease or not.

Dr Schwartz (08:20):

Correct, about three months later, it’s important to have follow-up testing because if one partner is treated, but others aren’t, people can get reinfected. So it’s both important to first treat these infections when we find them to also not have sex for about a week after treatment, so that the person isn’t re-exposed and to treat the partners and then to get follow-up.

Dr Pelman (08:48):

Yeah, that’s an excellent point. So it’s just not the individual being treated, but you don’t want to be passing it back and forth and back and forth. It’s a never ending. So if there was a reliable partner that you could find, you want to make sure that they’re aware and they get treatment.

Dr Schwartz (09:04):

Correct, and there are some newer guidelines for expedited partner treatment where the prescription can be given to give to the partner. Right now, there are guidelines to do that for female partners of male patients. If the female’s not having any symptoms, if the partner is a male, because of the high incidents of coexistence, HIV, or other sexually transmitted diseases right now, those protocols don’t involve expedited partner treatment for the male partners but get those partners into clinic to get tested.

Dr Pelman (09:45):

And then the other reason to go back and check and make sure there’s been adequate eradication, is there were some resistant strains. I think I read that there’s a significant resistant strain in Thailand.

Dr Schwartz (09:56):

Well, there’s now resistance with gonorrhea that initially we saw in some of the more resistant strains in Asia, but we’re seeing those strains here as well. And so the gonorrhea treatment guidelines have really changed over the years and we’re back to using shots for cases, and now using a shot plus a pill for cases of gonorrhea because of the increasing resistance.

Dr Pelman (10:23):

And then there’s no skin manifestation with gonorrhea

Dr Schwartz (10:28):

In general. No, unless somebody has a disseminated or widespread gonococcal infection. If gonorrhea goes untreated or certain patients might have more risk factors, the gonorrhea can actually get into their bloodstream and infect their joints. And those patients can have fevers. And also some characteristic skin lesions.

Dr Pelman (10:49):

Yeah. Interesting. Another common STD is chlamydia. Chlamydia for men can manifest again as a chlamydial urethritis with burning what we call this urea, perhaps some urinary changes and the discharge is a little different, as you said, from the gonorrhea.

Dr Schwartz (11:10):

It’s often a little bit whiter than the discharge with gonorrhea. And again, patients can have no symptoms at all, but they could be passing on the chlamydia to their partners and like gonorrhea patients can also have rectal infections or throat infections or eye infections with gonorrhea or chlamydia.

Dr Pelman (11:31):

Now it used to be that you could only get a diagnosis of gonorrhea and chlamydia through a urethral swab. And of course, everybody was concerned about having something put in the penis and, or the urethra in females. Now there’s some urine tests that can be done.

Dr Schwartz (11:49):

There are urine tests that can be done. And they’re also techniques for the testing where we, many years ago, were doing mainly cultures. Now we’re doing more nucleic acid amplification tests, which is looking at DNA of the various organisms. And they’re much more sensitive tests, meaning they can pick up the test, pick up the organism when it’s there, a much higher percentage of the time. So they’re very accurate tests.

Dr  Pelman (12:18):

So some patients have had negative urine DNA test, but still feel they’re symptomatic. So we still have to look, they’re fairly reliable.

Dr Schwartz (12:27):

Yeah. They’re fairly reliable. They’re also very sensitive. So if the infection is there, we’re very likely to pick it up. Whereas with some of the older culture techniques, not only did they take longer, but often the infection was there, but the test or the culture test would miss it. 

Dr Pelman (12:46):

Any rules for the urine collection for say chlamydia, like not have just recently voided* or what do you tell somebody?

*Urinated

Dr Schwartz (12:53):

When usually its best if they haven’t voided in a couple of hours and the other thing that’s different from a urine collection when you’re looking for urinary tract infection is when you’re looking for gonorrhea or chlamydia, you want the urine from the first part of the stream, the first bit of urine that comes out. Whereas when you’re looking for a urinary tract infection, usually you discard the first bit of urine and then you collect the middle urine that comes out.

Dr Pelman (13:21):

And the chlamydial test for throat and rectal is a swab.

Dr Schwartz (13:28):

It’s a swab and a DNA based test, with the caveat that the chlamydia tests aren’t actually approved in the throat though, some providers still do them in that site, but it doesn’t have an official licensure approval to use in the throat. Both tests can be used in the rectum.

Dr Pelman (13:46):

And again, looking at adequacy of treatment, there are resistant chlamydial strains. So you do want to go get retested after, when would somebody go back? 

Dr. Schwartz (13:57):

Similar to gonorrhea. It’s three months for repeat testing.

Dr Pelman (14:00):

We also want to have partners treated and make certain that both have refrained during treatment. So it’s not passing back and forth now in an overall prevention strategy. So far, we’ve talked about syphilis gonorrhea and chlamydia.  Are condoms the best for prevention?

 Dr Schwartz (14:23):

Yes. Condoms still work, not everybody accepts condom use. And it’s important to ask patients about condom use and discuss it, but it is one of the best ways to prevent transmission of these sexually transmitted infections. 

Dr Pelman (14:39):

If patient asks and says, “well, I’m being treated, can I use a condom and have sex?”

Dr Schwartz (14:44):

Best to wait a week.

Dr Pelman (14:47):

Stay away because they’re not full proof?

Dr Schwartz

Correct, not a hundred percent.

Dr Pelman

 Then we move to looking at, and I’m going to go into something that’s a little more rare, but still gives a urethral discharge in men and their chlamydia and gonorrhea may be negative, but they still have a thin discharge. And this is ureaplasma. I don’t know if I absolutely put that as an STD, but I think it can be classified that way.

Dr Schwartz (15:13):

Yeah. The ureaplasma data, they’ve been less clear over the years as to how much of a cause of urethritis. There is some data that suggests it can definitely be a cause of one’s first episode of urethritis. So the first episode of ureaplasma, the first time you have this infection, it can cause urethritis, but the organism can be present and it’s not clear that that’s a cause of ongoing urethritis. Another organism that’s become much more in the forefront of urethritis is mycoplasma genitalium, which is somewhat similar to the ureaplasma organisms. And it’s now thought when more recent data that that can cause 15 to 30% of urethritis and accounts for more of the patients who come back to your clinic after they’ve not responded to standard treatment, that the mycoplasma among other things like trichomonas is an important organism to consider in treating urethritis.

Dr Pelman (16:22):

So in the spectrum of STDs, there is a test for mycoplasma.

Dr Schwartz (16:29):

There is a test that was just approved last summer for mycoplasma.

Dr Pelman (16:35):

Typically, would that be in the first round of screening when somebody comes in with discharge?

Dr Schwartz (16:39):

Okay. Generally not. They would do tests for gonorrhea and chlamydia, and then often test for the mycoplasma if somebody wasn’t responding to treatment.

Dr Pelman (16:51):

So somebody say, comes in with a discharge, some urinary symptoms, they get the DNA tests for the urine. Chlamydia is negative. Gonorrhea is negative. And we’ve done blood work for syphilis because we screen everything, probably also screen for HIV. Would people be treated empirically* or would, if those tests come back negative where they say, “oh, no, you’re not infected with that.”

*Empiric treatment is when it is still unknown what exactly the problem is for sure, but the patient will be treated anyway using therapies for what the illness is likely to be.

Dr Schwartz (17:17):

So if somebody comes in with symptoms that are obviously urethritis, we would treat them on the spot even before we had tested that culture.

Dr Pelman (17:25):

Okay. So that patient’s instructed to come back if symptoms aren’t better and resolved within at least a couple of weeks, they’re definitely coming back in three months for follow-up.

Dr Schwartz (17:37):

But they should come back much sooner if they’re still not feeling right.

Dr Pelman (17:39):

Right. So they still have symptoms, still have discharge. It’s been seven to 10 days. That’s where we now look and go.” Well, we have to look for some of the rarer issues like Mycoplasma and trichomonas.

Dr Pelman (17:54):

And trichomonas is a little different in that we see that by a urine test. 

Dr Schwartz (18:03):

Yes it’s a little different in women and men. In women, you can test the discharge and there are newer techniques that are much more sensitive than the old wet mount microscopic techniques where we look for the organism. The tricky part with men is that the DNA based tests, like the tests that we use when we do nucleic acid amplification for gonorrhea and chlamydia is approved for women and it’s not approved for men. So it’s a good vaginal test. It’s not a good urethral test or urine test. So sometimes for men, we wind up empirically treating for trichomonas, if the patient’s not getting better.

Dr Pelman (18:53):

 Okay. Again, I don’t think there are skin manifestations for a mycoplasma or for the trichomonas.

Dr Schwartz (19:01):

Not for trichomonas unless someone has so much discharge that it’s irritating the skin and for mycoplasma. In general, no.

Dr Pelman (19:13):

Okay. Now moving on to other STDs, that would be pretty common and really difficult. Sometimes it is something that the HPV, human papilloma virus, would cause. And we’re looking here for skin lesions, but they’re not always present. So this has always been difficult for urologists as patients go, “do I have HPV human papilloma virus,” for instance, a guy would come into clinic and say that his significant other female on her pap smear was told she had HPV. Do I have it? You look and you don’t see anything. So let’s go through it, human papilloma viruses, and just kind of take everybody listening through that a little bit.

Dr Schwartz (19:57):

Okay. So with the HPV unless there’s a lesion on a man. It is hard to diagnose and they’re not specific tests that we would generally do. The one of those important things about HPV is vaccinating because these HPV viruses and certain strains of the HPV, especially the 16 and 18 strain can cause cervical cancer in women. And also cause some rectal cancers in men. So it’s important to look for these and women have had much more long-established screening for these types of cancers with pap smears. And now they can do HPV testing for men. The screening is in general, more for symptoms. If they have warts. The one thing I would add to that is some people will do anal pap smears on high-risk men, especially men who are having and receiving anal sex. And there are some screening programs specifically for anal cancers that some centers are doing here in Seattle and in other cities where men get a high-resolution endoscopy* to screen for anal cancers, which can often be HPV related.

*Essentially, an endoscopy is a little tube with a camera and flashlight on the end that physicians can use to get a better look inside a patient.

Dr Pelman (21:28):

And you brought up a good point when you said warts, a lot of people refer to HPV as venereal warts, in men they’re manifested and if they’re raised it does look like a wart. Now there can be other skin lesions on the penis. So it’s important to go to somebody who knows how to diagnose an HPV infection. There are… I remember a breakdown of some HPV that were called flat lesions. So with good magnification, sometimes you can see these things, but again, going back to the scenario or somebody says their partner had an abnormal pap smear and they have nothing that you can see on the penis. There are rare urethral implants, but those men generally had something on the skin that was carried down the urethra. It’s rare. I don’t even know if I’ve ever seen a case where there was only urethral HPV.

Dr Schwartz (22:16):

It can happen, but you know, I think the most important thing here is if you see a lesion, then address it for men. It’s hard to address it without a lesion. And one of most important tools we have available now is immunization. And the HPV vaccine in adolescents and young adults has been shown to decrease cervical cancer in women and decrease transmission of the virus. They’ve recently, until the vaccine was really approved up to age 26 initially in women, and then they added young men and recently got approved up to age 46. It’s not a blanket indication for everybody, but certain at-risk groups should continue immunization against HPV.

Dr Pelman (23:13):

And that’s a series,

Dr Schwartz (23:15):

It’s a series in general of three shots for the nonvalent vaccine though. If an adolescent really starts on time and starts early often, they’ll give just two shots and it’s still immunogenic.

Dr Pelman (23:29):

Good. Moving on to another rare suspect. It would be a STD causing lesions.

Dr Schwartz (23:39):

Genital ulcers. The most common genital ulcer in the United States is herpes. That’s the most common genital ulcer that we see. So those are ulcers that can hurt, and they can recur. The one other type of painful genital ulcer is chancroid, which has had a resurgence in certain areas. But again, here in the Northwest where we’re not seeing much of that. In other parts of the world, they certainly see more chancroid. And then there’s some types of genital ulcers that don’t hurt. So the classic one is syphilis.

Dr Pelman (24:22):

Non-painful? 

Dr Schwartz

Correct

Dr Pelman (24:24):

I was going to get to herpes because that is obviously a very, very, very common lesion. And there being two main displays of herpes, people would always think the oral versus the genital, is there a crossover? So we’re going to have a long discussion about herpes for everybody because people have a lot of questions about that. If I have one and can I get the other, can I give somebody this? And so we’ll cover all that. Let’s go to herpes now and just break down a little bit about herpes simplex one and two, and where we are with that.

Dr Schwartz (24:55):

Genital herpes can be either HSV1 or HSV2. And as I just mentioned, the classic symptom is a ulcer that can hurt. Sometimes they just itch. They don’t always hurt, but they can be irritating. They usually last several days, often someone will have an outbreak that keeps coming back in the same spot and that’s pretty characteristic of herpes. And they will scab over on their own. In most cases, especially if someone has a good immune system, but treatment can help shorten the duration and decrease the transmission. And the tricky part with herpes, like other viral sexually transmitted infections, is that they’re not curable, but we can suppress them and control them. And the other part for patients to know is that a lot of people have herpes without knowing it, and they can transmit herpes without knowing it because their bodies can shed the virus and pass it on to another person, even when they’re not having an outbreak.

Dr Pelman (26:06):

So let’s break down the oral herpes. Somebody has a typical blister, around the oral cavity. Is that something that can be transmitted to the genitals?

Dr Schwartz (26:18):

Yes. So classically the herpes type one has caused cold sores typically, but if someone has oral sex, they can clearly pass it on to another person. And so the rates of genital herpes that are caused by herpes type one, rather than herpes type two, are likely higher than we have appreciated in the past.

Dr Pelman (26:47):

And then the herpetic outbreaks that we see we’re talking about this blister circle that can occur this lesion, that’s painful on the penis, but it also can occur in the rectum.

Dr Schwartz (27:00):

It can occur on the genitals because that skin, the genital skin, and the oral mucosa is more susceptible to it, but it can occur on the butt cheek or really anywhere on the body though, much more likely on the genitals, in the rectum, or in the mouth.

Dr Pelman (27:20):

And some patients for their first herpetic outbreak do manifest more of a syndrome.

Dr Schwartz (27:27):

They can be sick or they can have fever, headaches, they can feel flu-like, they can have meningitis symptoms with the initial episode. That’s usually worse and thus requires a longer course of treatment than the recurrent illness.

Dr Pelman (27:42):

And the opportunity for recurrence is lifelong? 

Dr Schwartz

Correct.

Dr Pelman

 It’s not something that can actually be eradicated?

Dr Schwartz

 Correct. 

Dr Pelman

So going back to what you said earlier, we can suppress it and there are then strategies for controlling outbreaks to shorten them or recognizing when a patient might be more likely to have an outbreak.

Dr Schwartz (28:09):

So when patients take medicines for herpes, they can take it episodically, just when they have the initial symptoms of an outbreak, which could be tingling even before they feel one of the blisters coming on. But, if somebody is having more than a few outbreaks a year, or if they’re having just a few, but those outbreaks are really bothersome then rather than just treat for that one episode, we’ll treat them suppressively where they take one of the antiviral medicines for herpes every day. And those medicines are very well tolerated without a lot of side effects and without a lot of resistance. So that does exist. And we’ll just keep them on the herpes medicine to keep the outbreaks away. The other reason why, especially couples may choose for one of the partners to, take herpes suppressive medications if one of the partners has herpes and the other one doesn’t. They may want to, if they’ve never had an outbreak, the negative partner may want to have blood tests because they may unknowingly already have herpes.

Dr Schwartz (29:20):

But if they’re really negative for herpes, then one can have the partner with herpes, take the medicines chronically to prevent transmission to the other partner. And there are two good reasons why that should really be considered. One is if one of the partners has HIV because HIV transmission is higher in the setting of active herpes outbreaks. And the other good reason is if a male partner has herpes and he has a female partner who is pregnant, who has never had herpes, there is some risk to the female getting herpes close to the time of delivery and passing that on to the neonate. 

Dr Pelman (30:08):

So populations who have herpes exposure and have had herpes episodes, are they at risk for always transmitting herpes, whether they have an outbreak or not? You’re suggesting that if they’re taking the suppressive dose, that they’re not going to have an outbreak that they’re not able to transmit?

Dr Schwartz (30:27):

The likelihood of transmission will go way down, it may not be zero, but it will go way down in the setting of taking the antiviral medicine.

Dr Pelman (30:37):

So if it was, somebody, as you said, who hasn’t had herpes exposure, at least to their knowledge should definitely avoid contact with a lesion, again, prevention through condom use, or just avoidance during the outbreak.

Dr Schwarz (30:51):

Or both, it’s best not to be sexually active during an outbreak, but patients also need to understand that there can be transmission even when there’s not an outbreak. And so condoms are important.

Dr Pelman (31:04):

Yeah, there are some patients who have frequent outbreaks during periods of stress. I always use students who are studying for finals up all night and all of a sudden have outbreaks. So sometimes they can use the medication during stressful periods.

Dr Schwartz (31:18):

They can if there particular stressors that usually bring on their outbreaks, but more of those folks, I would say, if they know that they’re predictably going to get frequent outbreaks, we’ll just keep them on the suppression rather than just take the medicine during a stressful period.

Dr Pelman (31:38):

And are there any major health risks outside of the inconvenience of having an outbreak and the pain and discomfort? Any major issues associated with herpes besides a pregnant woman who’s about to deliver?

Dr Schwartz (31:51):

So there are rare cases of meningitis. I mentioned that with the first episode of herpes, but herpes type two can cause a recurrent type of meningitis that some people are more prone to than others. That’s one of the more common ones, rarely people can get herpes in the eye and it can cause keratitis and some difficulties there. So if somebody with herpes has symptoms in the eye, that’s important to see the ophthalmologist.

Dr Pelman (32:21):

To distinguish between herpes that we’re talking about, which is sexually transmitted and herpes zoster herpes zoster is not included in this category.

Dr Schwartz (32:30):

Correct. That’s shingles. Which comes from the chicken pox virus.

Dr Pelman (32:34):

So even though herpes is a name, they’re different diseases.

Dr Schwartz (32:37):

They’re all in the same family, but not the same virus.

Dr Pelman (32:41):

 I just want to make sure that people listening understand that. And again, there’s a way to diagnose herpes. You can swab the lesion.

Dr Schwartz (32:49):

So we traditionally used culture techniques. The Culture’s a little bit slow, and it’s not as sensitive as newer techniques using PCR. So a lot of clinics have switched to using PCR on a swab from a swab specimen to diagnose the herpes.

Dr Pelman (33:08):

And then the blood tests, what do they tell you?

Dr Schwartz (33:12):

The tests tell you if you have previously been exposed to one of these viruses and we don’t routinely recommend the blood tests, there are certain situations where it may be important. And some people are just dying to know if they’ve had herpes, but on the flip side of that, getting a blood test when someone has no symptoms that they would need to take medicines for sometimes causes anxiety in patients. And so I don’t recommend doing that in every patient. So we were a little more selective about when’s the right time to do that. And that takes a conversation between the doc and the patient.

Dr Pelman (33:49):

I can imagine somebody picking up a potential life partner and saying, I’ve never had it. I want you to go get a blood test and prove you’ve never had it. What if it comes back positive? What does that person do?

Dr Schwartz (34:01):

Right. I mean, you must understand that you could pass on the herpes even with no symptoms, but it can, it can definitely cause some more stress rather than less stress to get the tests now getting tested for sexually transmitted infections. Just getting a full screening before starting a new relationship is a great idea. So getting HIV tested and you know, gonorrhea, chlamydia and so on, syphilis screening is a great idea and especially in higher risk populations.

Dr Pelman (34:39):

So let’s talk about at-risk populations. And then I also want to talk about the fact that STDs are not exclusive to young people. So who’s at high risk?

Dr Schwartz (34:50):

So anybody who has sex is at risk for a sexually transmitted infection. For many of the STDs and we’ve seen rates going up significantly the past few years, especially for syphilis, gonorrhea, and chlamydia. Men who have sex with men are at higher risk for several of these sexually transmitted infections. So just general screening without symptoms is absolutely recommended for men who have sex with men at least once a year, but up to every three months, if they have ongoing high-risk behavior and multiple partners. For a heterosexual man, that’s really more symptom driven or if the patient requests it, for reasons that we discussed starting a new relationship or other personal reasons, but not once a year at the general physical visit with the physician.

Dr Pelman (35:49):

Or somebody had an encounter.

Dr Schwartz (35:52):

Absolutely. If they were exposed if they were contacted by another person or if they were contacted by the health department, because often the information comes through the health department for contact tracing. That’s definitely a reason to get screened and often treated, to see if they had unknown exposure to one of these infections.

Dr Pelman (36:14):

Then we would look at older patients now as still being a risk. I remember reading about the amount of STDs being diagnosed at a nursing home. So a little bit about the fact that just because you’re older doesn’t mean you’re immune. right?

Dr Schwartz (36:27):

Right, and it brings up the point that it’s important to talk to your patients about what their risk behaviors are, no matter what their ages are, what their sexual preferences, it’s important to talk about it. So you can figure out who deserves to be checked.

Dr Pelman (36:45):

Is there anything we haven’t covered yet? 

Dr Schwartz (36:48):

Think the other thing to address with prevention is addressing what are the other risk factors? So having sex is a risk factor, using drugs and having sex is a bigger risk factor. Often, some of the increasing rates and some of these sexually transmitted infections is tied to either drug use or poverty and lack of access to healthcare. Because if you have people with these infections and they don’t get in and get tested and treated, then they’re more likely to spread it to another person.

Dr Pelman (37:24):

And while you’re bringing that up, I just went back to human papilloma virus. I like to emphasize to men that there is a potential of throat cancer. So they’re thinking, “well, I don’t have anything on my penis,” but if they’ve had oral sex and been inoculated, we’re now seeing a lot of the human papilloma virus causing really devastating throat cancer, oral cancer. So they need to be aware and be checked for that.

Dr Pelman (37:56):

And the main way to check is with a physical exam, right? There’s not a good protocol yet for just routine HPV testing at different sites.

Dr Pelman (38:14):

And another argument for young people getting vaccinated. 

Dr Schwartz

Absolutely. 

Dr Pelman

Cause we’ve seen a real rise in that, the ear nose and throat surgeons and seeing an abundant amount of HPV related throat cancers. Well, let’s talk about HIV again. Isn’t always sexually transmitted, but can, where are we in this day and age with HIV

Dr Schwartz (38:39):

There EW still new cases being diagnosed every day in the United States and they’ve been looking for years for a vaccine. We don’t have a vaccine yet. I would say the two biggest things in preventing HIV now, besides counseling is one: getting people with HIV into clinic and tested and on treatment right away, because they’re good data that if patients with HIV have undetectable HIV viral loads, meaning they take their medicines, it suppresses the HIV in the bloodstream. Then they’re not going to transmit it to somebody else. And there’s still a lot of people out there with HIV who don’t know it. So people should get tested for HIV, especially if their risk factors then get more frequent testing and get on treatment because that’s going to prevent the spread. The other thing that’s new in the past few years is what we call PrEP, which is pre-exposure prophylaxis.

Dr Schwartz (39:47):

So if somebody’s having high risk sex, especially if it’s having sex with other men, if they have multiple partners, if they have partners of unknown HIV status, then they can be treated with an antiretroviral, one of the anti-HIV medicines to help prevent acquisition of HIV from a partner who might have HIV. And those studies show that it’s very effective. If you take the medicine, if you get the prescription, but don’t take the pills, it’s not going to work, but if you actually take the pills, there’s a good chance that that’s going to help prevent HIV. Now, one thing that people have seen since we’ve been using prep is people can be very confident that they won’t get anything. And the HIV prep medication won’t prevent the other sexually transmitted diseases. It has some hepatitis B activity, but it won’t prevent one from getting herpes or gonorrhea or chlamydia or syphilis. So they should still use condoms and get screened regularly for other STI’s.

Dr Pelman (41:05):

And HIV is a blood test, correct? And there is a subsequent, if you’re at risk or somebody comes up negative after recent exposure, it takes a while. 

Dr Schwartz (41:17):

 It does. Not as long as it used to. So the older tests, we didn’t trust that they would turn positive soon after an exposure. And, you know, weeks to months out, we would still worry that we could get a negative test. Somebody who really recently exposed and turned positive, the newest generation of HIV tests can pick it up within two to three weeks. But if there’s any question that they’re still in that window period where the regular HIV test won’t pick up infection from a recent exposure, then we would do a different type of HIV test called a viral load test.

Dr Pelman (41:57):

And the monitoring of HIV for somebody who’s acquired. It is fairly irregular.

Dr Schwartz (42:05):

First people need to know that there are many good medications available for HIV now. And HIV care is dramatically different than it was 20 years ago. When people had to take a handful of medicines to help control it. A lot of HIV patients can be treated with a regimen that has one pill once a day. Often there are three medicines in one pill, but it’s much easier to take than it used to be. And then it can work pretty well in most patients. So we just need to get all the patients who don’t know that they have HIV into the clinic, so we can get those folks treated too, to help prevent them from getting sick and prevent spreading the infection to other people. 

Dr Pelman (42:52):

And if in some instances it can be non-sexually transmitted, like we said, it isn’t always an STD exposure type of inoculation.

Dr Schwartz (43:02):

Correct. So if somebody is sharing needles with another person who has HIV, they can get HIV that way. And so there are other preventive measures such as needle exchange programs and treating the people with HIV, which will help prevent the transport. 

Dr Pelman (43:21):

Then you mentioned hepatitis B briefly, not typically something that people put together with STDs, but again runs in the same circle sometimes.

Dr Schwartz (43:30):

Correct, and hepatitis B is actually easier to transmit than HIV, both sexually and from a blood exposure. Now there is a vaccine available and it’s been available for over 30 years and all young people and all people who anticipate having new sexual partners in their life really should get a hepatitis B vaccine, which is quite effective.

Dr Pelman (43:55):

So in looking at our STD world, somebody who hasn’t acquired it, but has taken on a new partner. Advice?

Dr Schwartz (44:05):

Okay. It never hurts to get screened and to check your immunizations. And we’ve now our kids who are seen by pediatricians and those who agree to get their vaccines, which we hope most do, they get both hepatitis B and hepatitis A vaccines and hepatitis A can be sexually transmitted as well. It’s usually the food borne hepatitis, which has a fecal-oral route of exposure rather than from blood or sex. But if somebody is engaging in rectal sex or oral rectal exposure, they can get hepatitis A. So all gay men should get the hepatitis A vaccine in addition to hepatitis B vaccine. 

Dr Pelman (44:52):

Then also just to have an honest talk with your partner and with your healthcare practitioner, absolutely don’t hide things.

Dr Schwartz (45:02):

Correct. And that conversation goes two ways. The patient coming into the medical visit should share things, but the physicians and other providers should always ask because you’re not going to get the information or figure out what the person’s risk factors are. If you don’t ask.

Dr Pelman (45:18):

Excellent. If you could pass on perhaps something where the listening audience could go to for resources. Where are some really good resources on public health.

Speaker 3 (45:30):

So the CDC website has a lot of information about sexually transmitted diseases. Their website is cdc.gov, and you can click on whichever type of STD you want information about, but that’s extremely helpful. Most state and local health departments have public health clinics and often there’s good information online. King County Public Health, where we live, has a really good website for sexually transmitted diseases for some of the viral diseases and especially herpes. The University of Washington has a viral disease research clinic, and they have great herpes information and information about studies online. So I don’t know that actual website, but if you look for University of Washington viral disease research clinic, that’s a great resource for herpes.

Sexually Transmitted Diseases – Information from CDC

Communicable diseases, epidemiology and immunization – King County

Welcome – The University of Washington Virology Research Clinic

Dr Pelman (46:24):

And then somebody who’s concerned can see their local practitioner, but there are also public health clinics that they can go to.

Dr Schwartz (46:30):

And they’re often walk-in clinics that have a sliding scale for payments and the best place to go for a STD screen is a place you can get into quickly and a place that’s going to do the appropriate screening and a place where you’re comfortable talking to the provider. 

Dr Pelman (46:49):

Well I appreciate your sharing the information with us and spending time, Dr. Schwartz. Thank you.

Dr Schwartz (46:54):

 Thank you. Thanks for the opportunity.

Dr Pelman :

This completes another podcast chapter of the Washington State Urology Societies: “The Original Guide to Men’s Health.” This is Dr. Richard Pelman reminding you to take care of yourself. The Washington State Urology Society wishes to thank all contributors, who volunteered their time and knowledge. The information presented is the opinion of the speakers. The Society also wishes to thank Sean Fox for his invaluable technical assistance, music theme “San Juan Bells” written and performed by Dr. Dave Whiting, the podcast is the property of the Washington State Urology Society.  Reproduction and use without the express consent of the Society is strictly prohibited. For more information about men’s health visit wsus.org or visit your physician or care provider.

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