What STI testing is recommended for a male who has been sexually active with both males and females, with a history of oral sex but no anal sex?

STI Testing for a Male with Oral Sex Exposure (Both Male and Female Partners)

For a male who has been sexually active with both males and females through oral sex (no anal), you should order: first-void urine NAAT for chlamydia and gonorrhea, pharyngeal swab NAAT for chlamydia and gonorrhea, and blood tests for syphilis and HIV. 1, 2, 3

Core Testing Components

Urethral Testing (Urine-Based)

• First-void urine using nucleic acid amplification tests (NAATs) is the optimal specimen type for detecting urethral chlamydia and gonorrhea in males, regardless of symptoms 2
• This non-invasive collection method is patient-friendly and can be self-collected, enhancing screening participation 2
• NAATs offer superior sensitivity and specificity compared to older culture methods 2

Pharyngeal Testing (Throat Swab)

• Pharyngeal swab NAAT is essential for anyone engaging in receptive oral sex, as standard urethral testing will miss oropharyngeal infections 3
• The American Academy of Pediatrics recommends routine annual screening for pharyngeal gonorrhea in sexually active males who engage in receptive oral intercourse 3, 4
• Pharyngeal chlamydia should also be tested, though gonorrhea is more commonly detected at this site 4, 3
• Critical pitfall: Gram stain of pharyngeal specimens is insufficient and not recommended due to low sensitivity 3

Blood-Based Testing

• Syphilis serology should be included based on sexual activity with both male and female partners 1, 2
• HIV testing should be offered as part of comprehensive STI screening for sexually active individuals 2
• For men who have sex with men, annual syphilis screening is specifically recommended, with more frequent testing (every 3-6 months) for higher-risk behaviors 4, 1

Risk-Stratified Screening Frequency

Standard Annual Screening

• Annual screening is appropriate for sexually active males with ongoing sexual activity 1, 3
• This includes pharyngeal, urethral, and serologic testing based on exposure sites 1

Intensified Screening (Every 3-6 Months)

Consider more frequent screening if the patient has: 4, 1

• Multiple or anonymous sexual partners
• Sex in conjunction with illicit drug use
• Partners who engage in high-risk behaviors
• History of recent STIs
• Sex work or exchanging sex for money/drugs

Important Clinical Considerations

Site-Specific Collection Based on Sexual Practices

• Specimens must be collected based on anatomical sites of exposure 1, 3
• Since this patient reports oral sex only (no anal), pharyngeal and urethral sites are the priority
• If sexual practices change to include receptive anal intercourse, rectal swabs would become necessary 4, 1

Post-Treatment Rescreening

• Rescreen at 3 months after any positive test for chlamydia or gonorrhea, regardless of whether partners were treated 4, 1
• If 3-month rescreening is not possible, retest at the next healthcare visit within 12 months 4, 1
• High reinfection rates justify this approach 2

Window Periods for Serologic Testing

• Immediate testing can detect bacterial STIs (chlamydia, gonorrhea) even shortly after exposure 2
• Follow-up testing at 3 months is essential for HIV and syphilis due to window periods where antibodies may not yet be detectable 2

Common Pitfalls to Avoid

Failing to test pharyngeal sites: Many clinicians only order urethral testing, missing oropharyngeal infections that are asymptomatic in the majority of cases [3,