[Question #1124] NGU confused

48 months ago
I recieved brief unprotected oral sex (30 sec max) from new partner. 

21 days after suddenly frequent need to urinate, slight itchy feeling on tip. Went for swap test (very painful, 4 times deeply inserted), negative for Chlamydia and Gonorrhea, Epitel 8-10 LPB, Leukosit 1-2 LPB, Gram negative +2, Coccus Gram positive +2. No medications given. 
After test occasional burn (not really pain),  but not during urination. No discharge but urin drops a few minutes after urination (more than usual). Slight redness of tip twice. 
30 days after exposure went to std clinic for another swap and also urine test. Swap negative for PMN and Diplococcus. Leukosit +1 in chemical analysis urin, leukosit 2-5 and bacteria +1 in mikros. urine (no crystals). Docter told me this is normal and to drink lots of water. 
39 days after exposure (yesterday) went to another doctor who couldn't find discharge or unusual symptoms. Didn't do new tests but looked at old test said possible nonchlamydial NGU but not sure, prescribed Azithromyicn 1g & 3g fosfomycin trometamol. 

Do I have a non-chlamydial NGU based on the facts in your opinion ? I am surprised the std doctor with same results didn't give medication. Is my longterm partner at any risk (unprotected sex 3 & 20 days after exposure, no symptoms)? 
Is the combined therapy of Azithr. and Fosf. common & safe?
Is it possible that this is another infection or symptoms combination of swap test damage and anxiety? 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
48 months ago
Welcome to the forum. Thanks for your question.

The bottom line is that I agree with the STD doctor and, unlike the second physician you saw, would not have treated you with azithromycin and certainly not fosfomycin. You do not meet standard diagnostic criteria for NGU and your symptoms are not typical for it; both the timing and nature of the symptoms are wrong. From your description, the second physician doesn't really believe you have NGU, but decided to give the antibiotics a try, i.e. benefit of the doubt in case of NGU or possibly a non-sexually transmitted urinary tract infection. (Fosfomycin has not been studied and likely would not be effective against NGU nor any other STD that might cause lower genital tract infection.)

To your specific questions:

1) As just discussed, this probably is not NGU. Even if it were, your partner probably would not be at risk:  NGU acquired by oral sex has never been associated with anything likely to harm partners, i.e. chlamydia, Mycoplasma genitalium, trichomonas, etc. Many cases are suspected to result from reaction of the urethra to new but harmless oral bacteria. In any case, you probably don't have even this, so probably no need for partner treatment.

2) Fosfomycin is an uncommonly used antibiotic and I have never prescribed it. But I know of no interactions between it and azithromycin and I'm sure it is safe.

3) I think the anxiety explanation is a good bet. Whenever someone suspects his or her own symptoms have a psychological or emotional origin, s/he usually is correct, especially when no other medical explanation can be found. Certainly genitally focused anxiety is common following a regretted sexual decision or exposure, and I suppose irritation from a urethral swab could contribute, but would not last more than a day or two. However, some of your symptoms also are consistent with prostatitis. If they continue, perhaps evaluation by a urologist might be considered. In any case, I am confident this problem is not due to any infection from the oral sex event.

I hope this has been helpful. Let me know if anything isn't clear.

HHH, MD


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48 months ago
Thank you very much for your fast reply, Doktor Hunter. I am relieved to hear that a NGU is unlikely and accept that anxiety and guilt were a huge factor.

A short follow up question about the prostatitis: How long if symptoms should continue would you suggest to wait before such a follow up? Meaning could this in your opinion be an urgent matter or would it be reasonable to calm down, wait one or two weeks and then if symptoms still accure to visit an urologist? 

Thank you once again. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
48 months ago
To clarify, I doubt you have prostatitis -- just raising a theoretical possibility. However, this is partly terminology:  I am suspicious you have the chronic pelvic pain syndrome (CPPS), which is sometimes called "nonspecific" prostatitis, and is easily confused with prostatitis even by experienced physicians. Google the term (spell it out); there is a very good Wikipedia article. I'm guessing you'll see a lot of parallels with your symptoms. In any case, neither of these possibilities is at all serious. I think you can very safely wait at least 2-3 weeks, then consider further evaluation if your symptoms persist.

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48 months ago
Dear Dr. Hunter, 
This will be my last follow up question:
Is it possible that my symptoms (itching & problems urinating) are not due to anxiety / CPPS but due to a syphilis ulcer inside the urethra? 
I had a negative test 25 days past exposure (rapid and rpr test) took 1g Azith 36 days (threw up after 30 minutes) and another 1g two days later.
I will go tmrw (49 days) for follow up blood test. Would syphilis still show up in a test despite the Azith.? And is there a risk that despite two negative tests my partner could have been infected ? Meaning that I passed on the syphilis 3 and 20 days after exposure, but there are no detectable antibodies in my blood because of fast antibiotic treatment? 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
48 months ago
I have never heard of chancre occurring inside the urethra. If it did, the likely symptoms would be an obvious tender lump you would feel along your penis, at the site of the chancre; probably marked pain on urination; and possibly partial urine blockage at the site. (Chancres are quite large.) Your negative blood test is good evidence against syphllis, and I'm sure the follow-up syphilis blood test will remain negative. The azithromycin won't make much difference either way:  if it makes your test negative, it is because you never had it or the drug cured you. Either way, you don't have it now. All things considered, I am 100% confident syphilis isn't the problem here and never was. 

Do your best to move on without worry. Whatever the cause of your symptoms (CPPS, non-bacterial prostatitis, etc), it is harmless to you and your sex partners. Do your best to go on with your life without worry.

Best wishes and stay safe.

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