[Question #10620] Follow up [Question #10590] Stupid actions.. Very scared.

21 months ago

Hello Dr's.Just a followup from a few days ago. Dr.Handsfield provided great information.

Summary. Low risk partner, unprotected sex. Both mid 40s, central Canada. Not a stranger, both with only a couple partners past 10 yrs.

Meds summary :1g z-Pak day after exposure, 500mg 2 days later. 8 days later 2g z-pak at one time. Metrinidozole 2g a few days after that..500mg cipro.

I took the 2g Az after noticing discharge sometimes after squeezing tip. Have never seen without squeezing & not every time. Notice it more after holding urine & sitting for a long time. Occasionally see trails in dark underwear, not every day. Clear to slightly white, no pain urinating.

For peace of mind went sti clinic, 1 wk after 2g z-pak. Nurse said meds would ONLY cover Chlam. I thought 2g z-pak would likely work for Gono though not ideal. She insisted it would do nothing. They refused to anonymous test (complicated situation)so I could not get urine test. They offered to swab, look at it. Nurse said it would not tell them type of infection. Nurse told me there were signs of infection, implied it wasn't a strong result, I am unsure. She treated me just in case. I got 2 pills (cefixime?) & 1g az. She said it could be chlam, gono, "other", or even from checking penis.

I contacted partner, told me she tested neg a couple months ago, no partners since.D

oes this sound like NGU? Chlam/Gono unlikely with meds/symptoms? I'm very confused & stressed.

H. Hunter Handsfield, MD

21 months ago

THIS IS AN EDITED REPLY, WITH A FEW SIGNIFICANT CHANGES FROM MY FIRST COMMENTS 40 MINUTES AGO.

Welcome back. Sorry you found it necessary. Yes you may have NGU: unusual to occur after azithromycin, but not rare. But some NGU probably is inflammation not caused by infection and doesn't necessarily need antibiotic treatment. More on this below.

Sorry you found an STI clinic nurse who needs more training. She probably is confusing two facts: CDC no longer advises single dose azithromycin in any dose for treatment of gonorrhea; and the fact that it works only ~90% of the time. That's not good enough to advise it, but obviously it's not the same as saying it doesn't work at all.

Second, gonorrhea does not typically cause the trivial symptoms you report; indeed they are much more typical for NGU. My guess is that "signs of infection" but "wasn't a strong result" means she found a few white blood cells and nothing else. That's additional strong evidence against gonorrhea, despite what she might think. If gonorrhea is present, almost always gonorrhea bacteria are easily identified by microscopic examination. The treatment she gave you will make absolutely no difference: you don't have gonorrhea, cefixime is is completely ineffective against NGU, and you've already had azithromycin without success. Why would she think it would help this time?

This "just in case" treatment suggests the nurse is following guidelines that do not apply in your situation. Cefixime + azithro is advised only for initial treatment, not for patients with persistent urethritis after preceding treatment. The standard approach when NGU fails initial treatment with azithromycin is a 7 day course of doxycycline. But as noted above, even this may not be necessary. Given all the antibiotics you've already had, at this time it might be reasonable to not be treated at all at this point and see what happens: no harm would come with a further delay in eventual treatment, if treatment is needed at all. Trust me on this: you clearly have nothing that will ever harm you or any future sex partner(s) If there still is objective evidence of urethritis after another week or two (i.e. both visible discharge that contains WBC) doxycycline could be tried at that time.

Even with apparent NGU, I would have expected your new partner to test negative for all STDs. NGU from oral sex is believed to usually result from entirely normal oral bacteria -- it's just the urethra getting used to new kinds of harmless bacteria. Your partner doesn't need treatment.

You might not want to get into a potentially contentious discussion with the nurse. However, if you want to help educate her, you might consider showing her these comments. (You also could tell her that I'm a consultant to the Public Health Agency of Canada (PHAC) for their gonorrhea treatment guidelines, which currently are under review for potential changes in the near future.

I hope these comments help. If you remain concerned, my only other advice would be to see a STI expert physician, i.e. taking it to the next step beyond a nurse just following standard procedures. Good luck with it all.

HHH, MD

---
---
---
---

21 months ago

Thanks for the quick response Dr.

I made an assumption if she thought I had gono after looking at the swab that she would have told me. At least I hope she would have. She basically said it could be anything including me checking for discharge, and that sometimes they find no cause of these symptoms.

1). The swab test is confusing. If not for a culture, is it to see if there is a gram neg bacteria? Or looking for WBCs? When she took the swab she told me she would only take 10 minutes and she wouldn't be able to tell me what kind of infection.

I've read enough of your writing to know 2g AZ isn't perfect or recommended but isn't completely ineffective. I tried to explain that a little bit but she cut me off & said zero effect, and she has never seen it work. I just went with her statements. I also understand they don't want to recommend. I also know it wasn't smart to take.

As for treatment, maybe being cautious, or maybe to give me piece of mind. Maybe she wanted to verify that I took treatment. I saw more than one nurse, one was certainly more understanding than the others.

Thank you doctor for your straightforward replies.

H. Hunter Handsfield, MD

21 months ago

I don't understand what's confusing about the swab test. Undoubtedly for gonorrhea/chlamydia testing (by NAAT, not culture) and probably WBC evaluation.

Be clear on an important issue, important to recall in event of similar exposures in the future: It is likely that everything going on now is the direct result of your overreaction. You should not have sought antibiotic treatment. Probably nothing was ever wrong at all. Your trivial NGU symptoms may well be due to alterered normal bacteria in your urethra as a result of the unnecessary treatment at the outset. You were at no significant risk for anything. That's water under the bridge, nothing to be done now. But had you done nothing, it is likely you would never have had any symptoms and there would be none of the current dilemmas. I can't prove any of this, but that's my best judgment.

---
---

20 months ago

Hi doctor,

I want to say thank you for all the info. It has helped, I rarely check for anything, have mostly moved on.

First, to answer you last post. The swab confused me bc I wasn't sure if it shows what you have. I guess it just shows if there are any signs of infection?

Some things have happened since my post. I have noticed discharge occasionally, but nothing regularly & I'm not constantly checking.

My urine stream & ejaculation became weak/slow for a week. Sometimes slow stream, sometimes normal then slow then normal (in same stream). During this time I noticed a burning/cramping feeling in my bladder or maybe prostate, only AFTER urinating, no pain during.

Last, I have noticed swollen inguinal nodes the past week. They are not sore but I can feel them at all times & have checked just once to see if I can feel them with my hands, I can, they feel firm.

1). I assume nodes would swell up closer to time of infection & be tender, for most infections,(It's been almost 2 months, no pain).

2). For syphilis, my treatments would likely make this non issue correct? (1g azith day after, 2g azith a week later, & again at clinic a week after that (azith & cefix).

The nodes have really got into my head.

Thank you for all great info you provide.

H. Hunter Handsfield, MD

20 months ago

1) Any infection can cause lymph node inflammation. I can't tell whether you have node inflammation, however. Self assessment of enlarged lymph nodes is notoriously inaccurate. That you can "feel" a nontender node from time to time doesn't sound abnormal, and In my clinical experience, most people who have complained of it had nothing abnormal when I examined them. Given your "into my head" comment, I suggest you stop feeling for nodes entirely. If you don't have pain, or visibly obvious swelling, then almost certainly nothing is wrong.

2) Yes, syphilis is impossible after the treatments you have had.

Your urinary symptoms are very typical for prostate gland enlargement and/or over active bladder (and those two problems often occur together).

Bottom line: Keep working with your urologist. Disregard STDs; unequivocally this isn't the problem.

That concludes this thread. Since it is clear no STD is a concern here, and that's the only domain for this forum, let's make this your last forum question about these issues. Thanks for your understanding. I do hope the discussions have been helpful. Best wishes and stay safe.

---