There are a number of sexually transmitted diseases but in men, the most commonly seen infections include chlamydia, gonorrhea, genital herpes, HPV (human papilloma virus), syphilis and HIV (human immunodeficiency virus).
Men who are at a greater risk are those who :
- Have multiple sexual partners
- Practice unprotected sex (whether oral, anal or vaginal)
- Have a previous history of sexually transmitted infections
These infections may present with various signs and symptoms in the groin area that may be indistinguishable from other medical conditions. To the untrained eye, it is often difficult to identify the causative organism simply by the physical signs and symptoms. However, the following clinical features should raise the concern about a sexually transmitted disease (STD).
HIV infection rarely presents with the signs and symptoms discussed below, except for short term lymph node swelling. Refer to Early Signs of HIV Infection.
Urethritis is inflammation of the urethra, whether due to infectious or non-infectious causes, and pain is a common feature. It is often associated with an infection, especially if it is accompanied by urethral discharge (typically thick, foul smelling).
The pain may be persistent or only present upon urination, during an erection or ejaculation. With the latter, blood in the semen (hematospermia) may be noticed although this could be indicative of pathology within other areas, like the epididymis, which may not be related to an infection.
While urethral pain may be present with sexually transmitted infections like gonorrhea and chlamydia in men, it can also be caused by a number of other micororganisms, especially bacteria, that are responsible for UTIs (urinary tract infections) and prostatitis.
Other Pain with STI’s
Pain in the groin region or of the genitals, with or without skin rashes, sores, ulcers or enlarged lymph nodes, may be experienced in many STI’s. Pain in the groin region is a non-specific symptom and without any other features, genital herpes should first be considered although it can be attributed to other infections as well. Other causes of pain include :
- Testicular pain – gonorrhea, chlamydia (rare)
- Prostate pain (prostatitis) in young men may be due to an STI.
- Painful urination – gonorrhea, chlamydia
- PainLESS sore – possibly syphilis or if genital wart(s) then consider HPV infection
Urethral discharge is a common sign of sexually transmitted infections (STI’s). It may be accompanied by urethral pain and other signs and symptoms of STI’s or may occur on its own. It is important to differentiate discharge from seminal fluid. Discharge due to an infection is usually purulent – appearing white to yellow, rarely green, with a typically offensive smell, which may be described as a fishy odor.
Urethral discharge is often seen with gonorrhea or chlamydia, but like with urethral pain, it may also be a result of a urinary tract infection or prostatitis which is not associated with an STI.
Skin Rash and Itching
Itching is prominent in genital herpes and may occur on its own with no skin rash initially. The itching in genital herpes may extend to the buttock region. Itching may also be seen in gonorrhea when it affects the rectum. Less frequently, itching is reported with syphilis and genital warts.
Many STI’s with cutaneous features will initially present as a flat or slightly raised red skin rash (erythema). This will develop into sores, ulcers or warts over time. A general red skin rash on the groin or genitals may be due to a number of causes that may not be related to an STI. This includes fungal infections like jock itch, other skin diseases like eczema or psoriasis, allergic reactions to latex condoms and lubricants, or chaffing from poorly fitting underwear. In men, the concern about prolonged use of laptops resting on the thighs or over the genitals needs to be investigated if the skin has a red to brown mottled appearance (erythema ab igne).
Sores, Ulcers and Warts
The typical syphilis sore is known as a chancre and appears like a tiny lump, sometime decribed by patients as a large pimple. In genital herpes, small red bumps and/or water-filled pimples may be early skin features. Both genital herpes and syphilis skin lesions may progress into ulcers (open sores) over time. In genital herpes, pain and itching is severe while in syphilis, sores are usually painless.
Genital warts are typical of HPV infection. It is skin-colored and multiple warts lying close to each other are sometimes described as cauliflower-shaped eruptions. Wart-like sores on the genitals may be seen in secondary syphilis.
Enlarged lymph nodes may be seen with any sexually transmitted disease. It is a prominent feature in syphilis and HIV (human immunodeficiency virus). Refer to Swollen Groin Lymph Nodes.
Swelling of the testis (orchitis) may be an indication of gonorrhea and very rarely of chlamydia. At times, the swelling may be isolated to the periphery of the testis and this may be a result of inflammation of the epididymis (epididymitis). When both the testis and epididymis are affected, it is known as epididymo-orchitis.
Gastrointestinal symptoms are rarely considered as a part of a sexually transmitted infection as signs and symptoms related to the skin and/or genitourinary tract is often thought as the only sites affected by these infections. However, sexually transmitted infections can cause a range of gastrointestinal symptoms often related to the route of entry i.e. oral or rectal. It is more often seen in men who have sex with men (MSM).
Proctitis is the inflammation of the rectum. The most common infectious cause of proctitis in men is a sexually transmitted disease. Among the more common diseases are gonorrhea, chlamydia, herpes and syphilis.
Signs and symptoms of proctitis include :
- Discharge from the anus (white, yellow or sometimes green offensive smelling discharge)
- Fresh blood in the stool (hematochezia)
- Rectal pain
- Urging to pass stool (tenesmus)
Outbreaks of severe proctitis among men who have sex with men is sometimes seen with certain strains of Chlamydia trachomatis and could lead to lymphogranuloma venereum (LGV).
It is rare for these sexually transmitted diseases to cause any symptoms higher up the gut. However, if other gastrointestinal symptoms are present and sexual transmission is suspected, it could be associated with :
- Entamoeba histolytica (amebiasis)
- Shigella spp
- Campylobacter spp
- Cryptosporidium spp
The signs and symptoms may present shortly after sexual contact, often within 24 to 72 hours, and may include :
- Nausea and/or vomiting
- Abdominal pain
The sexual mode of transmission in infectious gastroenteritis is often missed. However, it should highlight the possibility of risky sexual behavior and an increased risk of STD’s.