Category Archives: Blog

Gay Men Misdiagnosed

Gay Men Misdiagnosed

By Dr. Tom McQuaid.

If you are a man that has sex with men (MSM) and think you have Lactose Intolerance, Gluten Sensitivity/Gluten Allergy, or Irritable Bowel Syndrome, You may want to read this.

What is the point of this article?

Many gay men with intestinal parasitic infections are misdiagnosed and can live for years thinking they have one of the above when in reality what they have is an infection that could easily be treated if known about.

Why does this happen? Well, straight people living in developed countries are at very low risk for parasitic infections, so medical providers who don’t specialize in the care of MSM frequently aren’t that familiar with them, don’t know how to test for them properly, and tend not to expect them. Lastly, some of the testing for intestinal parasites isn’t very sensitive, meaning one test for parasites coming back negative may not be enough to ensure you aren’t infected. Yet, many times only one test is done.

If you are an MSM and have ongoing GI symptoms, you should discuss the possibility of a need for parasite testing with your provider.

If you aren’t a hypochondriac and want more details read on, on the other hand, If reading about diseases makes you feel like you have them probably best to stop here as we’ve covered the basics and discuss your risks with your health care provider who specializes in caring for MSMs.

One of the biggest frustrations I’ve had in the 17 years I’ve been providing primary care to gay men is the lack of research done into basic illnesses that gay men are likely to have but that aren’t significant in the non-MSM population. That is, of course, unless there is the potential for a big blockbuster drug related to such research.

This is particularly evident in the case of intestinal parasitic infections and the lack of reliable testing, lack of recognition of the frequency with which gay men acquire these, and the failure to recognize that some of the parasites that are considered non-pathogenic (meaning they don’t cause symptoms or harm) are actually very pathogenic for some people.

The four common intestinal parasites for gay men and MSM are Blastocystis Hominis, Endolimax Nana, Giardia Lamblia, and Entamoeba histolytica. With a few others like Cryptosporidium, Microsporidium, and Strongyloides also being possible but somewhat less common.

These can cause an array of symptoms varying from gas and diarrhea to a swollen prostate and colitis. More importantly, in some people, these can cause no problems at all. Allowing these people to go on for years spreading the parasites to others. For example, In 2009 in Barcelona 8 men were hospitalized within a 2 week period with E. histolytica that was causing proctocolitis. Of the 8 men only 2 tested positive for E histo when a traditional screening test was used. The other 6 were only identified as positive by specific antigen testing done on their stool. When their partners received testing, many were shown to have the infection but had no symptoms. How common is this? Well, studies done in the ’80s showed that MSM had a rate of parasitic infection varying in developed countries from 1-22%, with New York City consistently showing prevalence near 20%. That means that nearly one in 5 MSM in NYC had intestinal parasites.

I have found that about half the time when an MSM thinks he has lactose intolerance, gas/bloating problems, irritable bowel or gluten sensitivity the diagnosis is either completely wrong and being caused by a parasite or the condition, if present, is actually milder and being exacerbated by a parasitic infection. Many patients tortured themselves thinking they had food sensitivities or irritable bowel disease. They developed elaborate diets and dealt with constant anxiety related to their bowel movements. Since avoiding lactose can often help alleviate symptoms of parasitic infections, lactose intolerance often gets blamed as the culprit. What’s more, the traditional testing for some of these parasites is not very sensitive, and it’s a shitty test for patients to have to do (see what I did there?). What is traditional testing you ask? Well, you have to bring one or two little bottles of liquid home, shit onto a piece of Saran Wrap or a special poop collector pan, scoop said shit into the little vials being careful not to spill the liquid and yet also to add just the right amount of shit (oh did I mention the liquid is poisonous). Then you bring the little vials with your poop in them back to the lab and usually have to hand them to someone who knows you are handing them a little jar with your poop in it and that you probably have bowel problems. After all that, this test, if done just one time is not very sensitive. For it to be sensitive in determining if a parasitic infection is present, it needs to be done 3 times in a row preferably on three different days. (yes you can collect all three specimens usually over a few days and then bring them all at once to the lab).

Needless to say, patients who are already anxiety ridden about their bowel habits aren’t often excited to go through the diagnostic process and end up only tested once with a single specimen. When the test is negative it often confirms in everyone’s mind that a parasitic infection isn’t to blame. When in fact, that may not be the case. For Entamoeba, Giardia, and Cryptospiridium there are some excellent and highly specific tests however the provider needs to know to order them. Entamoeba, in particular, can be a severe infection for some people. Yet, for Blastocystis and Endolimax the testing is not as good, and patients often go undiagnosed and symptomatic suffering for years.

Why write all this? Well many MSM are embarrassed to talk about their bowel habits with their provider. Many providers know patients are unlikely to submit all three stool samples and order only one. Many patients google their issues and end up misdiagnosing themselves with things that are more common for non-MSM and don’t even find out about or are aware of parasitic infections. So if you have a history of GI symptoms or have sex with a partner who does (any type of sex) think about discussing the possibility of parasitic infection with your provider. It may change your whole life.

Do condoms protect from parasites? No, not at all. Handling a condom after insertive sex without adequate hand washing, in fact, can be a perfect way for the disease to spread.

What kind of sex transmits parasites? Well, rimming (analingus) is the most common way you can transmit parasites but you can transmit them without having sex at all, in fact just failing to wash your hands thoroughly means you can transmit parasites to someone by handling their food, drinks, etc.

If it were up to me, it would be a recommendation that all gay men are screened annually for intestinal parasites. Unfortunately, it’s not. As a patient however you can ask to be screened if you think you may be infected, but bear with the not so fun and annoying process of the testing!

If you have experienced a misdiagnosis with intestinal parasites, please share your story on my page.

The Good, The Bad, and The Poopy

The Good, The Bad, and The Poopy

By Dr. Tom McQuaid.

The Rectum is the Jan Brady of the sexual organs (for those of you that are too young to know who that is, think Khloe Kardashian) – by this I mean it doesn’t get a lot of attention. In fact up until recently even though you can get gonorrhea, chlamydia, HPV, and syphilis in your rectum, people were rarely if ever checked for any of these. Additionally, there has been very little research done on the rectum as a sexual organ and what health-related consequences exist for those that do use it sexually. It is known, that up to 60% of MSM (men who have sex with men) that have receptive anal intercourse (“take it in the ass”) douche to, “clean out.” Yeah, of course. they do because the majority of people find having feces make an appearance during sex to be a boner kill. If you aren’t one of those people and have a partner who also doesn’t care, this post isn’t for you… you can read my upcoming post on poop-exposure.

Douching how, why, and what if?

Let’s start with an evolutionary perspective, while anal sex is without question natural; bonobos (a type of chimpanzee) have anal sex. They don’t however douche. Regular anal douching is something that hasn’t been a part of our evolution, and so we don’t know how well our bodies are set up to adapt to our doing it frequently. Thus, we don’t know very much about what, if any, health impact may come from excessive or prolonged anal douching. So before getting to the “how to”, let’s be clear – since we aren’t sure about potential negative consequences don’t get carried away and do it more than is necessary to have an enjoyable and rewarding sex life.

Now let’s talk about the known and theoretical risks of douching – It’s known that anal douching seems to increase the risk of acquiring anal gonorrhea and chlamydia. This is likely to be because it cleans out not only the unwanted boner-killing poop-butt also some of the good bacteria that line your rectum and large intestine leaving them lonely for bacteria of any kind including some of those unsavory sorts you’ll hit up, on Grindr at 2:00AM. So if you are douching often, you should also be getting tested for anal GC/Chlamydia regularly. This is especially important as anal GC/Chlamydia can often be asymptomatic (meaning you have no idea that shit is there). (see what I did there? )

Additional possible risks come from using regular tap water for douching. This could be a problem for two reasons. Firstly, your intestine acts like a dialysis membrane. When we put fresh water in our colon, it leaches the electrolytes (salts) from our body’s water. For the most part, the volume of water used for douching and the amounts of electrolytes in your system make this loss negligible, and there are not any health consequences. Yet, for some people that douche with vast amounts of tap water or that have health conditions where they have low levels of electrolytes (like sodium/potassium) this presents a potentially dangerous health risk. How much is too much for a healthy person? We don’t know for sure, so err on the side of caution and make sure your health care provider knows if you are douching very frequently and especially if you have a known electrolyte imbalance. Douche with the smallest amount of fluid possible and if you can, use gallon bottled saline from the drug store. Doing this will help maintain your electrolyte balance and reduce the risk of any problems.

Sadly, carting huge bottles of saline around isn’t a feasible solution for many, but without question douching with physiological saline from the drug store is the safest way to go! Using bottled saline also protects you from the second and more insidious risk of tap water douching. Which is related to what’s in that tap water? If you are on a well water system, it’s possible the water could be contaminated with parasites or bacteria that could cause infection. Water contamination is unlikely in most places but if you’re camping in Yosemite, think twice before douching with stream water. Lastly, you could also be exposing yourself to toxic contaminants in the tap water. When we drink with our mouths, our livers are given a chance to eliminate a lot of pollutants from the water before it gets dispersed in our bloodstream and throughout our body. When you stick things directly in your ass (think booty bump), it goes straight into your blood with no filtering. This puts you at risk for exposure to toxins and contaminants. So you may not want to douche with tap water on your vacation trip to Flynt, Michigan, for example.

Doing this will help maintain your electrolyte balance and reduce the risk of any problems. Sadly, carting huge bottles of saline around isn’t a feasible solution for many, but without question douching with physiological saline from the drug store is the safest way to go! Using bottled saline also protects you from the second and more insidious risk of tap water douching. Which is related to what’s in that tap water? If you are on a well water system, it’s possible the water could be contaminated with parasites or bacteria that could cause infection. Water contamination is unlikely in most places but if you’re camping in Yosemite, think twice before douching with stream water. Lastly, you could also be exposing yourself to toxic contaminants in the tap water. When we drink with our mouths, our livers are given a chance to eliminate a lot of pollutants from the water before it gets dispersed in our bloodstream and throughout our body. When you stick things directly in your ass (think booty bump), it goes straight into your blood with no filtering. This puts you at risk for exposure to toxins and contaminants. So you may not want to douche with tap water on your vacation trip to Flynt, Michigan, for example.

If you often douche at home and have the option of using filtered water there, go for it, or consider getting your water tested. At least look at water quality reports in your area if there is any doubt about the safety of your water. Think about this when you travel as well. Lastly, think about what and how you’re using your douche. There is no question, it is possible to damage your rectal tissue if you are jamming a fire hose in your ass and blasting it, so don’t. It’s also possible to transmit infection via an anal douche. I have had multiple patients who without question acquired Hep C via sharing a douchenozzle. Soak your douchenozzle in a 10% bleach/water solution for 30 minutes and rinse it thoroughly or better yet never share it with anyone else.

Ok, so if I haven’t scared you out of douching with all the what if’s? (cause let’s face it you’re likely going to do it anyway) – Here’s a reader’s digest “how to” guide….

Firstly, douching when you have loose or runny stool can feel like trying to bail a sinking ship with a teaspoon (this can also lead to using a lot of water and all the risks described above). If your stool is very loose and you have no medical contraindications, you can consider taking a single, loperamide (OTC antidiarrheal) a few hours before. This will help slow down the movement of the crap through your colon and make it so you don’t accidentally stimulate your colon into pushing everything towards the exit, setting you up for a considerable investment in time. Taking loperamide also makes what’s there a little more solid and dry so that it comes out in a nice lump instead of like a lot of chocolate milk. Use small volumes of preferably saline but alternatively clean water, preferably at body temperature and administer it with a slow flow rate, using a lubricated nozzle that you either never share or that has been sterilized with bleach. Hold the water in there for about 30 seconds before letting it expel into the toilet. Keep doing this until the water runs clear or has only yellowish mucus present. Once done, give yourself about 30-60 minutes for your body to reabsorb any remaining water and to make sure there aren’t any late comers to the party. If someone does arrive late, you may be back to the drawing board for a few more rinses but take heart the end is probably in sight. If the process is taking you a considerable amount of water or an exorbitantly long time be careful. If you start to feel dizzy, or lightheaded, stop, the anal sex gods are telling you it’s all not in the cards for you that day.

HPV? What does it mean?

HPV? What does it mean?

By Dr. Tom McQuaid.

Human Papilloma Viruses know collectively by the title HPV are responsible for a large percentage of rectal, penile, and head/neck cancers. Men who have Sex with Men (MSM’s), especially those that are HIV positive are at increased risk for becoming infected with strains of HPV and therefore have increased risk for these types of cancers. The Nanovalent HPV vaccine is a safe and effective way of preventing the likelihood of acquiring 9 strains of HPV including some of the types most likely to cause cancer in addition to some of those that cause visible genital warts.

Up until this past year it was thought that it probably wasn’t worth vaccinating older MSM’s as they probably would already have acquired HPV and the ability of the vaccine to eliminate a strain of HPV once it has already been acquired is not known. Now it is known that it is unlikely that anyone has acquired all 9 strains of HPV the vaccine protects against, that even if you have a strain of HPV infecting at one site (for example your rectum) the vaccine my protect you from acquiring that strain at a second site (for example your penis). In addition it is possible although not proven that having the vaccine may help your immune system try to eliminate the virus from an already infected site.

What does all this mean?

If you are a man that has sex with men, you are at increased risk for rectal, penile and head/neck cancers from HPV infection

It means if you are an MSM and under the age of 45 you should consider getting the HPV nanovalent vaccine if you haven’t gotten it already (even if you’ve already gotten the quadrivalent HPV vaccine) as it will likely decrease your risk of penile, rectal, and head/neck cancers.

The vaccine may not eliminate strains of HPV you already have but you are unlikely to have all the strains the vaccine protects against.

The sooner you get the vaccine the more likely you will have an effective response and the less likely you will be to have new strains of HPV that the vaccine might protect you from.

Insurance may or may not cover the vaccine for you ask you healthcare provider for more information.

Check For Ticks

Check For Ticks

By Layne Gianakos.

Warm weather is here and as we all spend more time outside, so do ticks! Here’s some tips on avoiding the diseases they carry:

Ticks are most active after rain and prefer warm, damp conditions and places. These are also the places they’ll prefer on your body! Make sure you check your hairline, underarms, groin, ankles, and behind the knees.

Check for ticks OFTEN even if you haven’t been in an area where they are common. They can attach to other people and animals and be carried indoors. According to the Lyme Disease Organization, Lyme can be transmitted in the first 24 hours after a tick bite. There are not definite guidelines on how soon Lyme can be transmitted and it may be as little as 6 hours, although 36 hours is the normal window.

Removing a tick on your body is a delicate process. You can buy tick removal tools to help. If you remove a tick with your fingernails or tweezers, be careful not to squeeze as this can force the tick to vomit inside the bite, spreading infection.

The CDC recommends pulling straight out since twisting can cause the head to break off. Do not compress the tick’s body, do not irritate or injure it, and make sure the mouth parts are cleanly removed from your skin.

Once removed, call your medical provider for advice. If you receive a single dose of doxycycline within 72 hours after removing a tick, you can prevent infection. Do not attempt to treat yourself with antibiotics you may have at home, since these may not be appropriate and can have side effects.

If possible, save the tick and bring this into the office. You can place it in a Ziploc bag and put it in the freezer.

The only way to stay safe is to check regularly for ticks, there are some prevention methods you can use when venturing outdoors:

Know where you’re likely to find ticks (coastal areas, grassy fields, right after it rains)

– Tuck your socks in and wear long pants and sleeves

– Wear darker clothing (studies have shown ticks are more attracted to lighter clothing. Keep in mind it will be harder to identify ticks on your clothing with darker colors).

– Check your whole body with special attention paid to your hairline (including behind your ears), underarms, groin, ankles, and behind the knees. Have someone else check for you, if possible.


References:

Centers for Disease Control and Prevention. (2019). Tick Removal. Retrieved from https://www.cdc.gov/ticks/removing_a_tick.html

Cook M. J. (2014). Lyme borreliosis: a review of data on transmission time after tick attachment. International journal of general medicine, 8, 1–8. doi:10.2147/IJGM.S73791

Keystone, J. (2016). What’s bugging you? Part three: Ticks. Retrieved from https://www.uhn.ca/corporate/News/Pages/what_is_bugging_you_part_three_ticks.aspx

Louise Stjernberg & Johan Berglund (2005) Detecting ticks on light versus dark clothing, Scandinavian Journal of Infectious Diseases, 37:5, 361-364, DOI: 10.1080/00365540410021216

Mervine, P. (2013). Hard science on lyme: Ticks can transmit infection the first day. Retrieved from https://www.lymedisease.org/hard-science-on-lyme-ticks-can-transmit-infection-the-first-day/

Süss J, Klaus C, Gerstengarbe FW, Werner PC (2008). What makes ticks tick? Climate change, ticks, and tick-borne diseases. J Travel Med. 15 (1): 39–45. doi:10.1111/j.1708-8305.2007.00176.x. PMID 18217868