[Question #1173] STD, Trich, Mycoplasma G, or CPPS?

84 months ago

I am writing another question because my last one was over the minimum length and will be deleted. On 7/27 I had unprotected sex with a 47 year old white woman. I immediately worried that I might have caught something. Within the next couple weeks I began developing symptoms: Mild urethral itches and burns that would come and go, tingling sometimes, deep tissue pain in my shaft, pain in my perineum, and feeling abrasions on my tip. Sometimes it feels like there's a burr in the middle of my urethra. I have not had a discharge, frequent urge to urinate, or sores. Moreover, it does not burn or itch when I urinate, only after. Sometimes I get so anxious over this that my penis shrinks and hardens, pulling into me.

I was tested twice (overkill) for chlam, gon, and trach on 8/8 through PP and a private testing company. PP gave me a 1mg zithro, but was skeptical that I had anything. All tests were negative. The symptoms have persisted and I'm filled with guilt and anxiety (married). I am prone to hypochondria and am in therapy twice a week.

1) Could this be CPPS?

2) Can I trust these test results; especially the one for trich? Though my symptoms come and go, I do sometimes get pain after urination and ejaculation that fits trich. I've read the tests aren't reliable for men.

3) Should I be concerned about m. genitalium which isn't/can't(?) be tested for in the US?

Again, the symptoms come and go, with some days (few) being very good. I'm filled with guilt and can't think of anything else. Can CPPS really create that burning and itching? Do I need more testing or more therapy?

H. Hunter Handsfield, MD
84 months ago
Welcome to the forum and thanks for question -- and for your understanding of the policy on overly long questions. The moderators are not inclined to read long essays! OTOH, yours wasn't all that much over the limit and we would have responded. I'm asking the administrators to credit your card for the deleted question. You also can email them directly; their are links on the FAQ page and elsewhere.

My first thought is to provide a bit of education on the epidemiology of STDs in relation to age. (Once in a while I write a blog-like reply to which I can link future answers. So bear with me.) The frequency of virtually all STDs -- i.e. of active, transmissible infections -- peaks in the teens and early twenties, then falls off dramatically. Not all STDs are identical in this regard; gonorrhea and genital herpes have a 5 year later peak age (25-30) and syphilis later still (30-35) than chlamydia or HPV (20-25). But transmissible STDs all become quite uncommon after age 35 or so, and the chance any particular 47 year old woman has a transmissible STD is very low. The reasons are not entirely understood, but the data hold up even in people who seem to be at high risk, such as older sex workers. Part of it undoubtedly is the development of protective immunity after past infections, but that also doesn't cover it entirely. And without being racist, it is a truism that STD rates are a lot lower in whites and those of Asian ancestry than in African Americans and Latinos. Of course there are exceptions to all this, and I'm not guaranteeing your partner wasn't infected. But the available information suggests this probably was a low risk event despite not using a condom. (But of course I would recommend you get into the condom habit for any future exposures!)

As for your symptoms and testing, you certainly can be sure you don't have the STDs for which you were tested. I agree the azithromycin wasn't needed, but it did no significant harm. To your specifc questions:

1) Some of your symptoms certainly are consistent with CPPS, although your symptoms haven't been long enough to be considered chronic. Early versions of CPPS haven't been systematically studied, but all STD experts see lots of men like you. My own terminology is to refer to this as genitally focused anxiety. The physiology probably is the same as CPPS, though:  the symptoms probably are due largely to increased pelvic muscle tension, although urethral itching might not have that particular mechanism. In any case, with no discharge and (presumably) no increased white blood cells in your urethra or first void urine argues strongly against any kind of urethritis.

2) If you had a trichomonas nucleic acid amplification test (NAAT, i.e. DNA test), you can be confident in the result. (Trich NAATs haven't been studied much in men, only women -- but probably work well.) Other tests, especially a simple look at urine under a microscope, are useless. But even then, I wouldn't worry about trich in your case.

3) There are no data on the per-exposure risk of M. genitalium, but undoubtedly it is low. And it isn't known to cause symptoms like yours. Absent urethral discharge, I wouldn't worry about it.

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


84 months ago
Thank you, Doctor Handsfield.  I'm very worried that I might have given my wife something as we've made love 5 times since them.  I just have a very hard time understanding how something like CPPS or genitally focused anxiety could produce this sort of itching and burning.  The context seems to be very specific to circumstance.  The other night I had convinced myself that it was all psychosomatic.  I woke up that morning without symptoms and was symptom free for most of the day.  I then had a panic attack and the itching and burning came back.  That's how it goes.  I've only experienced mildly burning urine on a couple of occasions in these 49 days.  Every other time it's fine and the itching and burning comes on after (which is how trich manifests in men).  My GP seems to think it's psychosomatic, the doctor at PP seemed to think it is, and my psychotherapist seemed to think it is.

Here's my psychosomatic theory of how it works:  After the infidelity I became hyperaware of my penis.  This caused my muscles to contract, pulling my penis in and causing the perineum ache and tissue ache of the penis (like it had been squeezed incredibly hard).  Somehow this then evolves into itching and burning when I begin to relax.  This all usually starts with faint tingling and then progresses.  

Do STD symptoms fluctuate as I've described?  When I'm occupied with something they go away, when I think about having an STD they come back.  A handful of days I have little to nothing at all, then the rest of the days its on again and off again.  I love my wife deeply and don't want to tell her what happened and bring about a divorce.  My doctor referred me to a urologist to ease my mind, but I'm worried he'll diagnose with MG without an objective test and I'll then have to tell my wife.  I just have such a hard time believing my mind can do this.
H. Hunter Handsfield, MD
84 months ago
Last question first:  no, STD symptoms (or those of any infection) definitely do not fluctuate. Intermittent symptoms like this almost have to be psychological, and your own "psychosomatic theory" sounds pretty good to me. I don't know where you read that "itching and burning is how trich manifests in men". The vast majority of trichomonas infections in men are entirely asymptomatic; and when symptoms occur, they are just like typical nongonococcal urethritis, with discharge as the main symptom. 

While I cannot challenge your doctor's advice, I would not have recommended seeing a urologist. Based on this expanded description, there is simply no chance your symptoms are due to any STD. That said, I doubt most urologists are cognizant of M. genitalium; it probably won't enter his mind unless you raise it yourself. (Without demeaning an entire specialty, in my experience the large majority of urologists are not up to speed on STDs; they really don't deal with them very much. There are exceptions of course, and this doesn't apply in all countries, e.g. Japan where most STD expertise overlaps with urology. But not here.)

So now you have four professional opinions that agree with one another:  your GP, the Planned Parenthood doc, your psychotherapist, and I all agree your problem is psychological and emotional, not infectious. And I have given you solid information from the STD perspective both about the low risk of your sexual encounter a few weeks ago and the inconsistency of your symptoms with any STD, plus the reliability of the tests you had. Adding a urologist to this list isn't likely to do anything except perhaps lead down a new path of unecessary testing and/or treatment.

84 months ago
Thank you, Dr. Handsfield,

It's VERY reassuring to know that STD symptoms don't fluctuate or come and go.  I'm working very hard to get over my health anxiety with regard to this incident and this helps.

I hope you'll pardon me a couple more questions:

1)  In your first response, you mention that I should be fine so long as there are not increased white blood cells in my urine or first void.  Are white blood cells in urine something visible to the naked eye and if so, what should I look for?  I have noticed that there are occasionally 1 - 4 small snowflake like particles in my urine since this started (I never bothered to check before).  That said, my urine has consistently been clear and the appropriate color.

2) You say that the mechanism for itching and burning might be different than increased muscle tension in CPPS or genitally focused anxiety.  Any idea what that mechanism might be?

3) Once or twice for the last couple weeks I've been getting a sensation in my urethra that feels like a piece of glass or a bur is lodged there.  This happened again last night.  When I voided I noticed two very small black particles in my urine.  This happened again the second time I voided.  Do you think this is something I should be worried about?  I haven't seen symptoms like this mentioned for any STDs.  If it were a HSV-2 sore inside my urethra I would think that would last more than a few hours like this does and that it wouldn't go away.  I suspect that it might be very tiny kidney stones, but I haven't had any abdominal pain, back pain, fever or nausea; just that occasional feeling of something like glass lodged in my urethra.

Thank you so much for your time.

84 months ago
Honestly it's difficult to localize the pain under 3.  It could be at the base of my urethra where it meets my body or could be back towards my testicles or perineum.  It's a very sharp pain when it happens, but very hard to describe.
H. Hunter Handsfield, MD
84 months ago
1) WBC in urine are detected by urinalysis; it's not a symptom you would see.

2) I can't say a physiologic mechanism for it. Sorry. Most likely it's just anxiety magnifying trivial symptoms or normal body sensations  you otherwise would ignore or not even notice (e.g. like the universal human experience of urine feeling "hotter" after certain foods or varying fluid intake).

3) A herpetic sore in the urethra would a lot more painful than what you have experienced; and would last a minimum of 7-10 days each time. And as discussed above, symptom fluctuation over a few hours argues against any infection at all. So does your description of the vagueness, i.e. your difficulty describing it. That itself supports a psychogenic mechanism.

The only thing I can think to suggest at this point is to reverse my previous advice, see a urologist, and discuss the symptoms. Perhaps s/he would advise urethroscopy, i.e. a look inside your urethra. I'm not actually suggesting this, because I truly believe the best thing is for you to ignore and do your best to live with your symptoms. For sure you have nothing that will ever harm you or a sex partner. Once you come to believe and understand that, I would expect your symptoms to fade away or at least become tolerable.

Also, I would advise another discussion with your mental health provider about your probable psychologic tendency to conflate your guilt and anxiety over a sexual decision you regret with potential medical consequences of that decision. Continue to deal with the former as you need to. But the latter is simply not an issue here.

That completes the two follow-ups that come with each new question, ending this thread. Please do not post another with these same questions. Repeatative qustions about the same issues are against forum policy, and another would be deleted without reply and without refund of the posting fee.

Best wishes--  HHH, MD