An overlooked cause of chronic diarrhea in gay men

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Gastrointestinal Spirochestosis in Gay Men: An Underrecognized Cause of Digestive Issues



Introduction

Gastrointestinal spirochestosis (GS) is an underdiagnosed bacterial infection of the intestines caused by spirochetes, specifically Brachyspira aalborgi and Brachyspira pilosicoli. While it has often been associated with immunocompromised individuals, GS has also been found in otherwise healthy gay men, particularly those engaging in receptive anal sex. The infection can cause chronic digestive symptoms, including diarrhea, abdominal pain, and bloating, mimicking conditions such as irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD).

How is Gastrointestinal Spirochestosis Transmitted?

GS is primarily transmitted through the fecal-oral route, meaning bacteria enter the body through contact with contaminated material. In gay and bisexual men, transmission may occur through:

  • Receptive anal sex (including rimming and oral-anal contact)
  • Direct contact with contaminated hands, sex toys, or objects
  • Exposure to fecal bacteria in shared environments
  • Contaminated food or water (though less common)

While GS is often associated with immunocompromised individuals (such as those with HIV), healthy gay men can also develop the infection, particularly if they engage in activities that increase exposure to gut bacteria.

Symptoms of Gastrointestinal Spirochestosis

Many cases of GS go undiagnosed because the symptoms mimic common gastrointestinal conditions. In healthy gay men, the infection may cause:

  • Persistent or intermittent diarrhea (sometimes watery)
  • Abdominal pain and cramping
  • Bloating and excessive gas
  • Urgency to defecate
  • Mucus in the stool
  • Weight loss (in prolonged cases)
  • Mild fatigue

Some people experience only mild symptoms, while others may have chronic discomfort that impacts daily life. The symptoms can persist for weeks or months, leading many to misattribute them to IBS, food intolerances, or other GI disorders.

How is Gastrointestinal Spirochestosis Diagnosed?

Because GS is not a well-known condition, it is often missed in routine testing. Diagnosis requires specific laboratory tests and a high level of clinical suspicion, especially in gay men presenting with unexplained gastrointestinal symptoms.

Common Diagnostic Tests

  1. Colonoscopy with Biopsy – A tissue sample from the colon may show spirochetes adhering to the lining of the intestine, creating a distinctive "false brush border" appearance.
  2. Histological Staining – Special stains like Warthin-Starry silver stain or Giemsa stain can highlight the spirochetes under a microscope.
  3. PCR (Polymerase Chain Reaction) Test – A stool or tissue sample is tested for Brachyspira DNA to confirm infection.
  4. Stool Culture – Culturing Brachyspira species from stool, though not commonly used due to difficulty in growing the bacteria.

Many cases of GS are only diagnosed after a colonoscopy, since standard stool tests may not detect the infection.

Treatment for Gastrointestinal Spirochestosis

GS is treatable with antibiotics, though some cases may resolve on their own in healthy individuals. The most commonly prescribed antibiotics include:

  • Metronidazole (Flagyl) – First-line treatment for spirochetal infections.
  • Doxycycline – A broad-spectrum antibiotic effective against many bacterial infections.
  • Azithromycin or Clarithromycin – Alternative treatments for those allergic to first-line antibiotics.

Supportive treatments include:

  • Probiotics to restore gut flora.
  • Hydration therapy for diarrhea-related dehydration.
  • Dietary modifications to reduce gut irritation.

Most people recover fully with treatment, though symptoms may take a few weeks to completely resolve.

Prevention: How Gay Men Can Reduce Their Risk

Since GS is transmitted via fecal-oral routes, the best way to prevent infection is by practicing good hygiene and safer sex practices. Key preventive measures include:

  • Using protection (such as condoms and dental dams) during anal sex
  • Washing hands and sex toys thoroughly after sexual activity
  • Maintaining good personal hygiene (especially after sex or using the bathroom)
  • Avoiding direct oral-anal contact (rimming) if unsure about a partner’s hygiene or health
  • Staying informed about STIs and GI infections affecting gay men

While GS is sexually transmitted it is not typically though of as a sexually transmitted infection (STI), despite the fact that its transmission is closely linked to sexual activity among men who have sex with men.

Why Awareness Matters

Many doctors are not familiar with GS, leading to delays in diagnosis. Because its symptoms overlap with IBS, food intolerances, and chronic diarrhea syndromes, it may be misdiagnosed or dismissed.

If you are a sexually active gay man experiencing persistent GI symptoms, ask your doctor about gastrointestinal spirochestosis, especially if standard tests for other conditions have come back negative.

Conclusion

Gastrointestinal spirochestosis is a poorly recognized but treatable bacterial infection that affects the digestive tract. While it is more commonly diagnosed in immunocompromised individuals, healthy gay men can also develop GSthrough specific sexual practices. Understanding the symptoms, seeking appropriate testing, and getting timely treatment can help prevent long-term discomfort and complications.

If you have unexplained diarrhea, bloating, or GI issues, consider discussing GS testing with a healthcare provider familiar with LGBTQ+ health.

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