Herpes, Syphyllis, Gonorrhea and 27 Other Bugs

The patient might not have any of those sexually transmitted infections, but the overwhelmed ER isn't great at figuring it out.

Doctor: The triage note says you want tested for sexually transmitted infections?

Patient: That’s right. About two weeks ago, I slept with this woman. It was a one-time thing. I don’t know much about her, and I never do things like this. Anyway, I’ve been worried about it.

The blood-sucking pubic louse, with six legs and claws. From the CDC website.

Doctor: Are you having any symptoms?

Patient: Maybe. It might be a little uncomfortable when I pee, and it might be a little itchy. Itchy down there, I mean.

Doctor: Gotcha. So, pee in this cup, leave it on the counter, and we’ll get you a shot of the antibiotic ceftriaxone, and a prescription for another antibiotic, doxycycline. Tomorrow you can look up your test results on the hospital’s phone app. (Starts to leave).

Patient: Uh, OK, I guess. (Starts downloading the hospital app to his phone.) So, the urine can test for all sexually transmitted infections?

Doctor: Ha ha! No, it tests for two, gonorrhea and chlamydia.

Patient: What about HIV?

Doctor: You don’t have any risk factors for that.

Patient: Sleeping with someone I knew nothing about — that’s not a risk factor? How do you know she didn’t have HIV?

Doctor: Yeah, I hear you. CDC says we can just sort of wing it in deciding whether someone we’ve never seen might have HIV, but it’s weird, I agree. OK, we’ll check a blood test for HIV, and while we’re at it, we’ll check for syphilis.

Patient: Syphilis! Gross. OK, so gonorrhea — that’s “the clap,” right? —

Doctor: Yes.

Patient: — chlamydia, HIV and syphilis. Four things.

Doctor: (Starts to leave). I’ll put in those orders for you.

Patient: Wait, wait. What about the other 26 sexually transmitted infections? (Holds up phone). The World Health Organization says there are at least 30 STIs.

Doctor: There are? (Gets out his own phone). Well, they’re counting things like Ebola, which is absurd.

Patient: I could have Ebola!?

Doctor: What? No! Look, this is the ER, man, we’re not some concierge clinic! We test for two things usually, and at most four things: gonorrhea and chlamydia via urine testing, and HIV and syphilis blood tests. One, two, three, four. “Pee in a cup, blood test if we have to do that, shot in the arm, go home, next patient!”

Patient: But trichomoniasis is super common! A man can have burning when he pees, and it’s treatable. In fact (reading from his phone) it says it’s often asymptomatic, but can still cause “epididymitis, prostatitis, and decreased sperm motility.” So, I could have that — and not feel it — and my sperm could be forgetting how to swim right now! And that needs different antibiotics, metronidazole or tinidazole. This feels like an emergency! Can’t I be tested for that?

Doctor: We don’t have that test. Well, we have a vaginal swab for it.

Patient: So men and women both get this, but you only test women for it?

Doctor: Basically.

Patient: That’s so unfair! You can’t swab my penis with the vaginal thing?

Doctor: I’ve never done that.

Patient: What about crabs? It’s itchy, down there, I’m sure of it now.

Doctor: Which one is crabs again?

Patient: (Reading.) “Pubic lice.” There’s also scabies, and herpes which causes genital sores, and there’s human papilloma virus which causes genital warts, and then different warts caused by molluscum contagiosum which it says here you can get from using someone’s towel — ugh!

Doctor: Gotcha. Well. Do you have any of those things? Sores, or little bugs crawling around?

Patient: It says you have to look with a magnifying glass. Crab lice get treated with a permethrin shampoo. Oooh, this is gross, the nits are little eggs you can’t see, and the adult louse has six legs with pincher claws! They feed on our blood!

Doctor: So, you want me to look at your genitals with a magnifying glass? You’ve never even put on the gown! You’re sitting here in pants and shoes and a dress shirt, reading to me a list of every sexually transmitted infection every identified —

Patient: But there’s a bunch of them here, what about —

Doctor: Don’t you dare say “lymphogranuloma venereum.” Don’t you say it!

Patient: But what is it?

Doctor: No one knows! No one! They make you memorize it for medical school, it’s Latin for “lymph node sex disease thing”, but it literally never comes up again, no one gets it, there’s no test for it —

Patient: It says here it’s caused by chlamydia.

Doctor: I knew that. Right. I knew that. So, in the ER we actually test for five things.

Patient: There’s another one called granuloma inguinale, that’s caused by Klebsiella granulomatis, it causes genital ulcers —

Doctor: Right, like syphilis that one’s also treated by the ceftriaxone. So, we test for, uh, five things (gonorrhea, chlamydia, syphilis, HIV and one of the groin lymph node things), and we treat for, uh, a different five things, including the other groin lymph node thing, but not HIV.

Patient: If I hadn’t complained, you’d have only tested my urine. That’s only, uh, three things.

Doctor: Blood tests are extra hassle.

Patient: Wait. You test for HIV but don’t treat it?

Doctor: Someone else does that.

Patient: This is such a mess. What if I have herpes? I know there’s a treatment for that!

Doctor: If you had genital herpes sores then, yes, we’d start you on an antiviral like acyclovir or valacyclovir.

Patient: But you don’t test for herpes?

Doctor: I mean, do you have sores?

Patient: If I did, would you test them?

Doctor: No, I’d just look at them. Well, there’s a blood test, but we don’t use it, because it only says if you’ve ever in your life had herpes, not whether you have it now.

Patient: I thought herpes was forever.

Doctor: If there’s a sore, we can also scrape it open and swab it with a cotton swab and send it for a viral culture. But that takes forever to come back from the lab, and if you had sores we’d just treat them based on how they look. So, the viral culture test is sort of pointless, and no one does it anymore.

Patient: I feel like you need to take a look, down there, and make sure I don’t have any sores, warts, louses, scabies mites (still reading from phone) — or lichen planus, which are autoimmune purple itchy flat genital bumps — jock itch, that’s tinea cruris, that needs an anti-fungal — genital psoriasis — oh, I knew it, cancer! Genital cancer!

Doctor: You don’t know if you have painful genital sores, or purple bumps, or bugs crawling on your genitals? You need me to tell you that?

Patient: I mean, I can feel a bump or two, down there. What about monkeypox?

Doctor: No way! Forget it! That’s reportable! I am not going to find out you have monkeypox!

Patient: Are you going to check my liver? I could have hepatitis!

Doctor: Argh! This is supposed to be simple! “Pee in cup, shot in arm, go home!”

Patient: The WHO says Zika virus is sexually transmitted! What if I gave her Zika and didn’t know it, and she gets pregnant, and she tracks me down and we fall in love, and we try to raise the baby together, but it gets microcephaly? I’d have to warn her! Is there a Zika test?

An earlier version of this article was published at Emergency Medicine News.