Syphilis: Symptoms, Testing and Treatment for Gay and Bi Men

Syphilis is a sexually transmitted infection that is easy to treat and still does damage when nobody notices it. In Germany it affects mainly men who have sex with men. This text explains how it shows up, how testing works and what happens after a positive result. It does not replace medical advice. It is based on the Robert Koch Institute's guidance on syphilis (RKI-Ratgeber), last updated November 2020, so the figures in it are older than this article.

What syphilis is

It is caused by the bacterium Treponema pallidum. Humans are its only reservoir. It spreads mostly during sex: the germ enters through tiny breaks in skin or mucous membrane. According to the RKI, about 30 percent of contacts with an infected person lead to infection. Transmission through shared needles is less common.

From infection to the first signs, 14 to 24 days pass on average, and anything from 10 to 90 days is possible.

The stages and how to recognise them

First stage. A painless, firm sore appears where the germ entered. In men it is often on the head of the penis. It can also sit in the throat or the rectum, where it is easy to miss. After four to six weeks it heals by itself. That is misleading: the infection is not over.

Second stage. Four to ten weeks after infection, fever, tiredness, joint and muscle pain and swollen lymph nodes can follow. A typical sign is a rash that does not itch, often on the palms and soles. Hair loss and changes to the mucous membranes are also possible. In stages one and two syphilis is highly infectious.

Latent phase. After that comes a phase without symptoms that only shows up in a blood test.

Late effects. Without treatment, the heart, blood vessels and nervous system can be damaged after years or decades. In 15 to 40 percent of untreated people, the RKI says, germs can be found in the spinal fluid after a long course. Thanks to penicillin, such courses are rare today.

Testing

The screening test is a blood test, usually TPHA or TPPA. It generally turns positive two to three weeks after infection. A recent syphilis infection counts as reliably ruled out only after 8 to 10 weeks. If you have a suspicion and the result is negative, the test should be repeated after one to two weeks. An abnormal screening test is confirmed with a second method. A further value shows how active the infection is.

How often you should test depends on your life. According to the guideline the RKI text points to, people on PrEP should be tested every three months. If you have several partners, regular tests also make sense. Places to go are GP practices, public health offices and the counselling centres of your local AIDS service organisation (Aidshilfe). Ask there which tests they offer and what they cost.

Treatment

First choice at every stage is penicillin. No resistance is known so far. What matters is that the drug level stays high for at least ten days; how long and in what form is up to your doctor. After treatment starts, fever, chills and headache can occur, known as the Jarisch-Herxheimer reaction. It is a known effect and can be treated.

A follow-up blood test shows whether treatment worked. The value should fall clearly after therapy, within months to a year in early syphilis. If it rises again, that points to a new infection or a relapse. After treatment you can be infected again.

Telling partners

Until treatment success is confirmed, there should be no unprotected sex. The RKI also recommends a full screening for other infections, including HIV. Partners should be informed: for primary syphilis those of the last three months, for secondary or early latent syphilis those of the last twelve months. Notification is voluntary. Public health offices and AIDS service organisations help if the call is hard for you.

Protection

There is no vaccine. Condoms, used correctly, protect well. Early detection and fast treatment matter just as much. Even a painless sore is a reason to see a doctor, even if it goes away.

Numbers in context

In 2019 almost 8,000 cases were reported in Germany. More than 90 percent of diagnoses are in men, and among men it is mostly sex between men. Numbers rose from 2010 up to the date of the guidance. The RKI links this mainly to changed sexual practices as part of HIV risk reduction and to online partner search. Rates are clearly higher in big cities than in the countryside. Detection is reportable without names, so your name does not go to the RKI.

Current yearly figures are available from the Robert Koch Institute.

When to see a doctor quickly

If you have a sore on the genitals, anus or mouth, an unexplained rash, especially on hands and feet, or contact with someone who has been diagnosed with syphilis. A sore can have other causes, such as herpes. Only a test settles that.