The Complete Book of Men's Health - Part 1: Sexual Health

GONORRHOEA

Gonorrhoea is a sexually transmissible disease caused by the bacterium Neisseria gonorrhoea. In the UK, around 8,000 men contract gonorrhoea every year. The number of cases is falling, but a recent increase in rectal gonorrhoea among homosexuals is worrying as it implies a laxer attitude towards safer sex.

The risk of a man catching gonorrhoea following a single episode of unprotected vaginal intercourse with an infected woman is around 20 per cent. This rises to 80 per cent after four exposures. In contrast, a woman is 90 per cent likely to catch it from an infected man following a single episode of sexual activity.

Sexually acquired gonorrhoea can infect the male genito-urinary tract, rectum or throat. A sore throat occurs in 3­7 per cent of heterosexual males and is accompanied by a fever and swollen lymph nodes (glands) in the neck. The rectum is the only site of infection in 40 per cent of cases among male homosexuals. Infection is then asymptomatic in 90 per cent of cases. Only 10 per cent of males seem to develop a mucous-and-blood-stained discharge, itching or pain on opening their bowels.

The usual incubation period for gonorrhoea is two to five days, but sometimes infection remains asymptomatic. The bacteria stick to the outside of cells lining the urethra or other mucous membrane and, within 24 hours, penetrate inside the cell where they start to reproduce.

The usual signs of infection are a heavily pus-stained discharge from the penis and pain on passing water. This pain is commonly described as like peeing broken glass or razor blades. Symptoms seem to have altered within the West over recent years, with gonorrhoea now producing a milder discharge and less pain on passing water. Because of this, it is important to have even mild, transient symptoms checked out as early as possible.

Diagnosis is made by taking swabs of the discharge and examining them microscopically. Staining techniques reveal pus cells with groups of paired bacteria within. The bacteria are quite small and are easily missed. Additional swabs are therefore sent off for culture and to confirm infection.

Once diagnosed, gonorrhoea is treated with a single dose of antibiotics such as ciprofloxacin, ofloxacin or azithromycin. Penicillin-combination drugs given as intramuscular injections or courses of tablets are more traditional alternatives. Some cases of gonorrhoea are resistant to penicillin treatment, especially cases contracted in the Far East and Africa. Because of the possibility of inadequate response to treatment, all sexual activity should be refrained from until three sets of swabs, taken at weekly intervals, are subsequently reported negative.

Undiagnosed gonorrhoea can cause complications of prostatitis and epididymo-orchitis in up to 10 per cent of males. Chronic infection of the male genital tract can also lead to scarring and difficulty in passing water.

In 1 per cent of infected males, gonococcal bacteria spread throughout the body to cause a skin rash, gonococcal tendinitis and arthritis. Fever, shivering, loss of appetite and joint pains can occur, with severe pain on moving. The infection seems to flit from joint to joint initially, but if allowed to progress pus can build up and joint damage occurs.

Even more rarely, gonococci multiply within the bloodstream to cause septicaemia. This can lead to infection of the brain or heart valves, shock, and even death.

SYPHILIS

At present, syphilis is relatively uncommon. Around 800 males contracted the disease within the UK during 1992­93, mostly as a result of homosexual activity. The incidence of heterosexually acquired syphilis is expected to soar, however. Cases have increased 20­30 fold in parts of the US over the last five years, mainly in the inner cities, and a similar trend is likely in the UK.

Syphilis is a sexually transmissible disease caused by a spiral-shaped bacterium, Treponema pallidum. Within hours of infection the motile bacteria have entered the bloodstream and spread all over the body. Nine to 90 days later (usually an average of 21 days) a painless, shallow ulcer develops at the site of infection (this may be on the genitals, finger or tongue). The ulcer has sharply demarcated clean edges and a rubbery feel. It is highly infectious and is known as the primary sore, or chancre. It heals over the next one to two months, and leaves a scar.

After a further six to eight weeks, some people develop a mild flu-like illness and a dusky-pink skin rash. This may involve the palms of the hands and soles of the feet, and is usually accompanied by widespread swollen lymph nodes (glands) and ulceration of mucous membranes (e.g. in the mouth, genitals, anus). The hair may fall out in clumps, and large, flat wart-like growths may appear on the genitals. This secondary stage of the disease is highly infectious, even in patients who do not develop obvious symptoms.

If left untreated, symptoms improve and the disease becomes latent. The infected person is then no longer infectious. Between three and 20 years later, however, the next stage of tertiary syphilis develops. Tissue destruction occurs at various sites, with the production of lesions known as gummas. Classically, the bones, nose, tongue and other parts of the body get eaten away as if 'riddled with worms'. Thankfully, the discovery of antibiotics and diagnostic blood tests makes this end point rare in the Western world. Tertiary syphilis can cause heart complications or produce a form of madness from progressive brain damage and paralysis.

Syphilis is usually diagnosed and treated once the first chancre appears. Penicillin is the antibiotic of choice and is given as an intramuscular injection daily for around 12 days in the primary stage or for 15 days for treating secondary or latent infection. There is no evidence of resistance to treatment.

Half the people treated with penicillin suffer a reaction within 6­12 hours of the first injection due to the poisons released by the large number of Treponema bacteria killed. This reaction is usually mild (headache, fever, malaise) but is occasionally severe.

HEPATITIS B

Hepatitis B is well known as a disease that is transmitted via contaminated blood. It is also known as a disease that is sexually transmissible during certain homosexual activities. What is less widely appreciated, however, is that hepatitis B is now one of the major STDs among heterosexual males. It is highly infectious and, for patients who survive the acute attack, there is the possibility of long-term serious consequences such as cirrhosis, liver failure and even hepatic (liver) cancer.

Worldwide, the World Health Organization estimates that 2,000 million (2 billion) people are infected with the hepatitis B virus (HBV) ­ while those infected with HIV is several orders of magnitude less, at 10­12 million.

In the US, around 75,000 cases of heterosexually acquired hepatitis B occur every year. In the UK, this figure is closer to 500 cases per year.

HBV is transmitted in a similar manner to HIV. It is 100 times more infectious than HIV, is transmitted 8.6 times more efficiently and kills more people. It causes an acute inflammation of the liver with jaundice and severe systemic illness. One per cent of patients with acute hepatitis B infection die from overwhelming liver failure. Of those that survive, 10 per cent remain highly infectious, with viral particles present in their blood, semen and saliva. These carriers are the source of other sexually-acquired infections.

Of chronic HBV carriers, up to 50 per cent eventually develop cirrhosis of the liver and they are also 400 times more likely to develop liver cancer than uninfected males. Half of all carriers will eventually die from the long-term complications of their illness.

HBV and its effects are the ninth most common cause of death worldwide, with 2 million people dying each year. Disease surveillance studies in the US have found that approximately 35 per cent of patients with HBV are infected by their sexual partners. Since 1985, the number of cases of HBV in homosexual males has dramatically reduced by over 60 per cent. In contrast, the number of cases of hepatitis B in heterosexuals has increased by 38 per cent, and heterosexual activity now accounts for at least 25 per cent of new cases.

In studies in which heterosexual partners of patients with acute hepatitis B are followed for up to 12 months, the risk of catching the disease through normal heterosexual intercourse is quoted as between 20 and 42 per cent.

The risk of catching HBV is related to the number of sexual partners, duration of sexual activity and personal history of other STDs. Men who have had more than 10 sexual partners throughout their lives have a sixfold risk of catching HBV compared with men who have had two or fewer partners.

HBV is more prevalent abroad than in the UK. In parts of Africa, Asia and the Pacific, 20 per cent of the local population are infectious carriers of HBV. Sex while abroad ­ especially unprotected sex ­ is a high risk activity for HBV as well as HIV.

HBV is a frightening disease yet, unlike HIV, it is largely avoidable through vaccination. If you are at risk of coming into contact with blood through your occupation, your employer is obliged to inform you about the risks and to offer vaccination. You are well advised to take the offer up. Vaccinations against HBV are safe. The most modern form is genetically engineered and produced by yeast cells ­ it is not a blood-derived product.

If you are at risk of HBV through sexual activity (heterosexual or homosexual) it is also worth having vaccination to protect yourself from this dreadful disease. This is not an alternative to practising safer sex, but a safety net to increase your level of protection.

Vaccination Against HBV

• The standard course anti-HBV immunization takes six months. One injection is given straightaway, a second injection one month later and a third injection six months after the first. Adequate immunity may not develop for a further six months after the course is completed.

• An accelerated HBV vaccination schedule is available for travellers. The third dose is given two months after the first and a fourth, booster dose given 12 months later.

• For post-exposure prophylaxis, specific HBV immunoglobulin can be given along with an HBV vaccination within 48 hours of exposure to infection.

• Always have a blood test six months to a year after the course of injections to make sure it has 'taken'. The rate of protection is 90­95 per cent in healthy young adults, but males, the elderly and the overweight may need further booster shots.

Sexual Behaviour Risks for HBV

High risk:

• anal or vaginal intercourse without a condom

• oral contact with semen (fellatio with ejaculation)

• sharing sex toys without a condom

• any activity that exposes you to contaminated blood, such as sharing toothbrushes, razors, needles; unscreened blood transfusions; dental or medical interventions abroad.

Medium to high risk:

• anal or vaginal intercourse with a condom

• fellatio without ejaculation

• wet kissing (e.g. intimate mouth-to-mouth)

Lower risk:

• mutual masturbation

Minimal Risk:

• dry kissing (e.g. mouth-to-cheek)

HIV AND AIDS

The Acquired Immune Deficiency Syndrome (AIDS) is caused by infection with the Human Immunodeficiency Virus (HIV). This invades a type of white blood cell known as a CD4 (helper) lymphocyte and damps down the body's immune response to infection and rogue cancer cells.

There are two different types of HIV: HIV-1 and HIV-2. Some people are infected with both viruses. As the virus can mutate readily, different strains of HIV-1 and HIV-2 are constantly being identified.

Worldwide, at least 13 million people are HIV positive. The largest number of cases occur in sub-Saharan Africa (over 8 million).

In the US, at least a million people are HIV positive; in New York City AIDS is the commonest cause of death in young males. AIDS first appeared in the UK in 1982 and around 4,000 new cases of male HIV infection are diagnosed every year. There may be 10 times this number who remain undiagnosed and unaware of their status. Seventy per cent of the known cases are in the London area. The Department of Health estimates that, by 1997, HIV- and AIDS-related illnesses will be the third most significant cause of death in the UK in people under 65.

The World Health Organization predict that 40 million people will have been infected with HIV by the year 2000. Worldwide, it is estimated that one new case of infection occurs every 15­20 seconds, and that an AIDS victim dies every 12 minutes.

The Symptoms of HIV infection

The initial stages of infection with HIV are asymptomatic. After two to three months, the body mounts a weak antibody attack against the virus but, in most cases, this is not enough to clear infection. These antibodies are a useful sign that a person has been exposed to HIV infection, however, and can be detected through blood (or saliva) testing. If antibodies are present in the blood, a person is said to be HIV (antibody) positive. The appearance of HIV antibodies in the blood of someone who was previously HIV-negative is known as seroconversion.

Some people develop a non-specific, short-lived illness similar to glandular fever (mononucleosis) as the body seroconverts. This acute illness occurs two to six weeks after infection and consists of fever, sore throat, lethargy and joint pain. Glands (lymph nodes) may be enlarged. Sometimes a non-specific viral rash also occurs on the trunk and upper limbs. This illness is usually dismissed as a community virus ('just something that is going around') and only a high index of suspicion will lead to early diagnosis. For some reason, this early stage is more commonly reported in Australia than in the UK or US.

Some people who are HIV positive remain symptom-free for many years. Others develop vague symptoms such as weight loss, fever, night sweats or unexplained diarrhoea. This is known as AIDS-related complex (ARC).

As HIV becomes increasingly active, it invades and kills increasing numbers of the immune CD4 cells. The number of CD4 cells drop and, eventually, the ability to fight infection is impaired. Sufferers can then no longer fight off infections and become prey to a number of exotic illnesses which do not normally trouble healthy humans. This state is known as full-blown AIDS.

Symptoms that suggest AIDS has developed include recurrent infections (e.g. oral thrush, skin fungi, persistent herpes, atypical pneumonias), hairy leukoplakia (white, hairy-looking plaques on the tongue or inner cheek) and Kaposi's sarcoma ­ a purplish-red form of cancer that forms lesions on the skin or internal organs.

New research suggests that a sizable number of HIV-infected males will experience very little disease progression for many years. Out of 562 men in San Francisco, 31 per cent had not developed AIDS after 10 years of infection and 12 per cent still had normal CD4 counts.

In Milan, a study of 111 infected males led researchers to estimate that 20 per cent would remain symptom free 25 years after initial infection with HIV. Research is ongoing to identify factors in the immune system or lifestyle that might help to prevent the disease's progression.

Transmission of HIV

HIV has been isolated from blood, saliva, breast milk, vaginal secretions and semen. It can be spread in the following ways:

• through infected blood, via:

• sharing dirty needles; sharing razors

• blood transfusions in countries where blood is not screened for HIV, and where sterile equipment is not used

• dental treatment where equipment is not adequately sterilized

• from an infected mother to her child, either during the birth or through breast feeding.

• through sexual transmission, where an infected partner (male or female) has unprotected intercourse (gay or straight).

Sexual Transmission of HIV

The World Health Organization estimates that 80­90 per cent of people who are HIV positive have contracted the virus through heterosexual sex. It seems that the virus is more easily transmitted from a man to a woman than vice versa. Studies show that around 32 per cent of an infected man's hetero-sexual partners contract the virus, compared with 25 per cent of an infected woman's male partners.

During fellatio, those who swallow semen are at high risk of HIV infection. The risk of catching HIV via saliva alone is probably small ­ but significant.

Any bleeding from the gums or vagina (e.g. sores, menstruation) during sexual activity is a high risk factor for transmission of HIV (and hepatitis B infection if present).

Some experts now recommend that oral sex should be avoided unless you definitely know your partner is HIV (and hepatitis B) negative. If you do indulge, condoms or dental dams (bubble-gum flavoured latex squares placed over the female genitalia) provide some protection.

Barrier methods of contraception (male condom, female condom) can protect against HIV during normal sexual activity, and should be used whenever possible. Men who practise anal sex should use extra strong condoms. The spermicide non- oxynol-9 also has some useful anti-HIV properties.