Sex. Many claim they can't live without it. Some say they can't live with it. As a species which is motivated to continue its kind, it is as important a drive to most human beings as breathing and eating. And contrary to what the fashion and lifestyle industries try to make us believe, it is as pleasurable and necessary a part of life for large people as it is for anyone. As a doctor in whom people have confided some interesting secrets, I have come to the conclusion that humans are by nature not necessarily monogamous, despite the societal norms of the time. This applies, in my experience, to both men and women. Unfortunately, many organisms have evolved over millions of years to take advantage of the intimacy between humans in order to propagate their own kind. I wont deal with every sexually transmitted disease (STD) in this article (HIV, vaginosis and viruses like Herpes will be discussed In a future column) nor will I go into the depth that may be necessary for your particular circumstance. As always, consult a health care professional.

Dose, Drip, Gonorrhea
The tiny Gonococcus (from the Greek Gone pertaining to semen or sperm, and Kokkos meaning berry shaped, referring to the appearance of the organism under the microscope) is a member of the same family of bugs that causes one dangerous form of Meningitis. They thrive in a moist, oxygenated environment, such as the mouth, anus, penis. and vagina, but can even infect the eyes and lungs under certain circumstances. Contrary to popular belief, it is unlikely that this infection (or most of the others I will deal with below) can be transmitted on toilet seats or by towels unless there is virtual immediate contact. In fact, most STD organisms are killed by heat, sunlight, and most disinfectants.

Two to five days after contact of an infected partner, the Gonorrhea organisms which inhabit the lining of the inside of the penis multiply enough to produce a low level inflammation. The male may only notice a problem because of a drop or two of pus at the tip of the penis or on the underwear. This would be most obvious first thing in the morning because urination washes out much of the evidence during the day. Some men notice a burning sensation when urinating and have the urge to go more often. Frequent urination may occur as the body tries to flush offending organisms out. Unfortunately, many men don't notice the symptoms or signs or may choose to ignore them which in any even, usually disappear a few days later. But the organisms do not depart. In fact they can travel back into the body to damage the prostate, cause strictures of the urethra, or even sterility.

Sadly, Gonorrhea is even more cryptic in women. There are often no symptoms at all. After intercourse with a partner, the organisms move from the urethra and vagina into the cervix (the entrance to the womb). Because for many women a white or slightly yellowish discharge of fluid in the vagina is normal, they often notice nothing unusual. However, in about one in four infections, the organism works its way back into the womb causing menstrual irregularities, or even as far as the Fallopian tubes and ovaries producing pain, fever, and other very serious problems. If left untreated, the end result may be scarring and infertility.

In both males and females, the organism can even travel around the body via the bloodstream causing arthritis, eye, heart, skin, and even lethal brain infections (Meningitis). Babies can get gonorrhea in their eyes by passing through an infected mother's birth canal. This may lead to blindness. Oral sexual transmission can cause sore throats. Rectal infection is more severe with repeated sex and may present with pus-mixed stool, burning and straining, mimicking hemorrhoid problems.

Discharge, with or without vaginal, oral, or rectal pain in a child often indicates sexual abuse.

Chlamydia
Chlamydia (from the Greek chlamys meaning cloak, perhaps referring to the thick fatty coat around the organism) is responsible for one of the most communicable diseases in the world, with one of its species causing more blindness in third world countries than any other antecedent. The sexually transmitted variety often goes along with gonorrhea, or acts as a separate culprit. In males the symptoms are very similar to gonorrhea. There might be some urgency and frequency of urination, burning, itching, and discharge one to four weeks after exposure. Most infected women have no symptoms until the serious sequelae begin. Others may notice a yellowish discharge from the vagina, pain with sex, or, if the urethra is infected, urgency, burning pain, and frequency of voiding. Infections of the throat, rectum and eyes (especially in newborns) resemble the aforementioned patterns with gonorrhea.The consequences of the infection going unnoticed are also similar to those with cryptic gonorrhea.

Another Dose; The Clap
I am not sure where the nicknames for these STDs came from...any ideas? Syphilis (interestingly from the Greek syn="together" and philein="to love" and possibly the word Siphlos meaning crippled or maimed because of the damage done to those infected prior to modern times) is a very complex disease caused by a squiggly little corkscrew shaped organism called a spirochete, named for obvious reasons). After exposure, the organisms get into the body through tiny breaks in the skin or mucous membranes. Within hours the link spirals work their way through the lymphatics and blood stream and are often spread literally throughout the body. The human immune system responds quickly with soldier cells (see previous issues' discussion on the lymph system) to try to destroy or wall off the organisms. After several weeks of latency, when victims often would not know anything was a problem, a small lump or papule appears, usually at the initial site of infection. This turns into an ulcer called a chancre because its appearance resembles the erosions when cancer deforms the skin. The chancre is notably a painless erosion with a firm base. Even if untreated and ignored, this first lesion will usually gradually heal over the next four to six weeks. A number of months often go by and some people may get an achy flu-like illness associated with a red spotty rash. Most would assume this is some kind of viral infection. I remember seeing such a patient. The clue in his case was that the spots covered most of the body including the palms and soles (rare with most exanthems) and was not itchy. He didn't realize that there were millions of tiny corkscrew-shaped organisms multiplying in each spot. Eventually the spots disappear. In virtually all untreated victims the disease becomes hidden for months or even years, only to reemerge with a vengeance. Ulcers or swellings may appear in virtually any organ system. One such area is the brain causing in some the personality changes/madness allegedly associated with people like Al Capone, Henry VIII and Ugandan tyrant Idi Amin. The disease can even be transmitted to a fetus causing devastating defects.

Chancroid
This bacterium that is usually associated with warm climates and endemic where prostitution or sexual promiscuity are prevalent, has an interesting name. It used to be seen quite a bit during the Vietnam war era, when it was believed to have been spread in North America to some degree bv returning war veterans. Chancroid means "like a chancre" referring to the lesions that initially look like many of the other ulcerative STDs. It usually begins as a small pimple on the external genitalia which quickly turns into multiple painful yellow ulcers. The lesions often coalesce into small lakes of pus if left untreated. There might be painful lumps in the groin (lymph nodes) as the body's soldier cells try to fight off the infection. Once again, women are at somewhat of a disadvantage as lesions may be minimal or hidden in the vagina or on the cervix.

Dilemma For Large People
Many large people get pimples, erosions, and ulcers in the groin and around the genitals because of difficulty with hygiene, blood sugar levels, and a variety of other problems I have discussed in previous columns. Unfortunately, many of the aforementioned sexually transmitted disease may therefore be mistaken for more benign problems. The solution is evident: Seek medical advice as soon as suspicion of STD occurs in the form of odd odor, discharge, lesions, or pain.

A doctor or nurse visit should include a thorough history. Don't be offended if the health care professional gets very personal with questions and asks a sex partner to leave the room for the initial interview. Absolute honesty about sexual partners and practices may not only save you pain and sorrow, it may preserve several lives in a chain of contacts.

Female Examination; "Whiff" Testing
Ensure by phone or early visit if necessary, that the examining tables are large and sturdy enough since a pelvic exam is a necessity for a female. Do not douche, take previously prescribed antibiotics, or ap- ply any over-the-counter remedies as these will affect test results. Blood and urine tests will help diagnose exposure to syphilis, hepatitis, and other infections.

Once in the stirrups the doctor will examine the outside vulva and groin for swelling, pain, and obvious lesions. Specula, the devices inserted into the vagina come in a wide variety·of sizes and materials. The disposable plastic variety do not require warming and are sterile, but tend to pinch the skin and make a loud snapping noise which alarms some patients. I prefer the sturdy stainless steel variety. They should be prewarmed and rinsed momentarily with water as the only lubricant prior to insertion. Most large women or those who have had a number of pregnancies will need a large size speculum. A cotton tip will obtain a sample from the cervix for gonorrhea, chlamydia, and possibly herpes if appropriate. If you are due for a pap smear (for cervical cancer), a wooden spatula and a small brush will gently scrape the area for a sample. If there is a discharge in the vagina a sample can be examined under the microscope for yeast, trichomonas, or other causes of non-STD vaginal infections. Don't be upset if the doctor sniffs the speculum or if you suddenly smell a strong odor. When secretions are mixed with a special chemical and produce a distinctive odor, diagnosis of a non-gonorrhea vaginal infection is likely.

With the aid of lubricant the examiner will feel inside the vagina for abnormalities. Normally, the human cervix does not perceive pain. If there is tenderness there or in the area of the womb, the Fallopian tubes, or ovaries, this may be a sign that an STD has progressed to a more serious pelvic inflammatory disease. Hospital admission, intravenous antibiotics, and/or surgical intervention may be required.

Male Examination; No Umbrellas Please
Virtually all males fear old fashioned tales of "umbrellas" being inserted in delicate spots producing excruciating pain. This is, of course, nonsense. Be sure not to urinate for at least one half hour prior to visiting the doctor (an early morning appointment is best) as this might wash out the organisms that will prove valuable in an early diagnosis. The doctor may ask you to stand, naked to your knees. After checking the groin, penis, and testicles for problems, two small cotton-tipped swabs will be placed gently just in the distal tip of the penis for a few seconds. Men are more fortunate than women when being investigated for STDs.

If there is frank pus on the cotton swab, the laboratory can tell right away if gonorrhea is a culprit. Be cognizant that infections with different STDs at the same time is not uncommon. Unfortunately, many women normally carry bacteria in their vaginas which look very similar to gonorrhea under the microscope, so a diagnosis may take a few days while the organism grows on a culture medium. New tests are available for a more rapid diagnosis but they may not be available everywhere.

If ulcers are present in any part of the body, a swab or a scraping may be required to distinguish syphilis from chancroid or herpes. Some of these tests will take several days to analyze.

Treatment
In the bad old days, injections in the bottom might have cured some STDs. Today it is possible to take a few pills right in the doctor's office and this is often all that may be required to cure gonorrhea and chlamydial infections. Other infections might need a week or two of oral medications. If a patient is allergic to first line medication, pregnant, or is taking treatment for other conditions such as asthma or epilepsy, medications may have to be carefully chosen and adjusted. Abstinence from alcohol and sex until a cure is confirmed at a follow-up visit, is advisable. So called "Ping-Pong" reinfections by improperly treated partners are commonplace.

The Best Policy
Most people are familiar with preventative measures. If you have any concerns or questions in this regard pick up the phone or visit a local public health office and learn how to practice safe sex. Although some new contraceptive vaginal sponges claim to also prevent disease, I suggest you use common sense and condoms.

Over the years many people have begged me to treat them in isolation without notifying a loved one in order to "save the marriage or partnership". Epidemiologic science has traced the human immune Virus (HIV) back to a so-called patient "zero". Imagine all the misery that could have been avoided if proper reporting had been followed early when the HIV epidemic started. Public health authorities, trained in discrete investigation and follow-up, must be told about each and every sex partner to avoid untold heartache and danger. In most jurisdictions the contact is never told who named him or her. Treatment and prevention of spread of disease are the only goal. It is amazing how time and an understanding of human nature cure broken hearts. In future columns I will discuss other communicable diseases. I trust this has dealt with a sensitive issue many of you have asked me about over the years without turning you off to the joys of intimacy.

Enjoy life and keep in touch. ß

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Heretic Physician