[Question #1257] Female NGU

49 months ago
Hi, I’m very worried I may have HSV urethritis. I was in a monogomous marriage for 12 years. Recently, we separated, and I have had protected sex with 4 men in the last couple months. Terrible decision on my part. Over a week ago, I had protected sex with one of the men. Within a couple of days I began to have what I thought were UTI symptoms. After two negative urine dip stick tests at my PCP and negative gonorrhea and chlamydia testing, I was diagnosed with nongonococcal urethritis. I have no other symptoms other than painful burning during urination and constant, painful burning with slight swelling around my urethra. There are no lesions present, no discharge (vaginal or urethral), no fever or malaise, and no swollen lymphnodes. I just began a course of antibiotics, though I have not been on them long enough for them to become effective. I’m seriously freaking out because I slept with my soon to be exhusband in the midst of all of this (when I thought this was just a UTI and now he is having painful urination. How common is HSV urethritis with no other symptoms present? I am incredibly worried. Any advice or opinions would be most appreciated.
49 months ago
New development, as of this morning I noticed a yellowish discharge in my underwear.  I have been on moxifloxacin for 24 hours and there has been no improvement in the burning symptoms. It is incredibly uncomfortable. Please help!
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
49 months ago
Hi Heather,
I'm sorry you are having this problem.  I think it would be highly unlikely to have only urethral symptoms and no external lesions at all AND that your husband would not have any lesions either - only UTI symptoms.  It seems very likely to me if you have new herpes and you think you gave it to him, one or the other of you, more likely both, would have some lesions externally.  Is your husband having any discharge?
Nongonoccal urethritis is generally a term used for men - cervicitis is more often used for women  - I'm assuming that's what you have?   Did they do an internal exam?  Are you certain that they discharge is new?

Terri

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49 months ago
Thank you for your response. My pcp referred to this as NGU and prescribed moxifloxacin.  Today is day three on a/b's and I am absolutely miserable. The pain is not cervical. It's urethral. I believe the whole area around my urethra is inflamed and swollen.  There is no odor or inflation around my vaginal opening. Could this be a chalymidia infection that was misdiagnosed?
49 months ago
Sorry for the typos in my above response. I had an internal exam today. No lesions were found and he is sending out cultures. I do not believe my husband is having any discharge. 
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
49 months ago
Were you tested for gonorrhea and chlamydia?  Is that what the cultures sent out were about?  Or were the cultures from urine?  Was another urine dip done, do you know?  If you've not been tested for gonorrhea and chlamydia, you should be, just to be certain that's not what is going on. 
I'm so glad you were evaluated again today.  And I'm glad no lesions were found, that's a good sign for sure, in terms of herpes. 
If you have a true typical UTI which may well be the case, another antibiotics specifically for UTI might be a lot more helpful.  Did your Dr. talk at all about changing antibiotics? 
We do use moxifloxacin for certain  genital infections, like mycoplasma, but it surely is not a first line drug either for chlamydia or gonorrhea or UTI.  I would certainly not want to undermine your relationship with your doctor or question their judgement but I think it's worth knowing. 
so is your primary symptoms burning with urination?  Do you have the need to urinate more often?  Do you feel some urgency about peeing, like you have to pee right now?  Do you have pain at the end of urination or all during urination? 
So with herpetic urethritis, the main symptoms are pain with all of urination, as acidic urine is passing over open lesions but again, so often when patients present with this, we can see lesions at the urethra when we do an exam.  And sometimes, we see small numbers of white cells on the urine dip, but nothing grows in the urine culture. 

Terri
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49 months ago
My chalymidia and gonorrhea urine tests were both negative. There were no traces of WBC/RBC or bacteria on urine dip. I have constant pain and burning around my urethra with swelling of the urethra. All I can say is it feels like the worst UTI of my life. I have increased frequency of urination as well. I have tried taking cranberry supplements and AZO, to no avail. There are no other symptoms. No fever or malaise.  The yellowosh discharge has been present for the last couple days. Symptoms began 10 days ago and have progressively become worse. The burning, frequent urination and urgency  began a few days after a protected encounter. Today my Dr. did a full pelvic exam (no lesions were found). He did find that my urethra was swollen and inflamed and there was a slight yellow discharge. I was give  rocephin IM and a Z-pack. He sent cultures off and a blood test for HIV and HSV 1&2.  He also started me on an antiviral.  He believes it could be herpes related, and I am very stressed.  As a side note,  my husband tested negative across the board for HSV 1/2 via blood tests and negative for gonorrhea and chlamydia. 
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
49 months ago
Well, it's good that you know you are negative for gonorrhea and chlamydia.  I suspect the reason you were given moxi was because your doctor was trying to cover for other things that can cause a cervicitis, although your symptoms, other than the discharge, are more urethral, correct?  And on the off chance that the testing missed either gonorrhea or chlamydia, you are now covered with antibiotics that will treat those infections.  The frequency and urgency are more bladder symptoms than urethral symptoms, which again suggests a more bacterial origin of the issues than a viral one.  Those are bladder symptoms.  But with a completely negative urine dip, I'm  a bit stumped about what might be going on here - I suppose herpes cannot be totally ruled out given we don't know the herpes status of the partners with whom you had sex.  But again, I feel that with new herpes, you would be more likely to have some lesions that are visible.  Do you know if your doctor did a viral culture or PCR from the urethra?  Sometimes that can be helpful as well. 

Were any of these partners the giver of oral sex to you?  Have you ever in your life had a cold sore on your lip or in your nose?

If you by any chance do you have new herpes, your IgG will  be negative at this point - either that or a very low positive, given the timing you suggest for symptoms of about 10 days.  It can weeks or even months for a positive IgG to show up after new infection.  But if a swab test was done for herpes, it could be positive now.

My hope is that you are going to start getting some relief of your symptoms soon with the treatments that have been started.  The problem is, you are taking both an antiviral and an antibiotic so it's going to be tough to know exactly what's working, right? 

Please keep me informed of your results - I'll leave this up for one more post from you and then you will need to renew to ask more questions.
The good news is that it sounds like your doctor is all over this and really being thorough in your evaluation and treatment.  

Terri
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H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
49 months ago
Greetings, Heather. Terri and I have exchanged a couple of emails about your questions. I agree with all Terri has said.

Althugh herpes did not seem like the best bet from the initial information provided, at this point I think it is a reasonable possibility. While most new genital herpes has obvious sores or lesions, there's no particular reason that urethral irritation and pain couldn't occur as the main symptom. Initial herpes also can cause colored vaginal discharge due to herpetic cervicitis. I strongly reocmmend you return to your doctor ASAP. If you have overt cervicitis, that could go along with herpes, and it's also possible that a professional would better be able see if there is an ulceration in your urethra, which also would be consistent. Whether or not these are seen on exam, insist on testing of both your urethra and cervix for HSV (preferably a PCR test). Do it ASAP; the HSV tests are more reliable the sooner the better.

If your doctor agrees herpes is possible, you should be promptly started on valacyclovir or other HSV treatment. Better safe than sorry, and these drugs have virtually no side effects, so no harm in having a low threshold for treatment.

By way of background, up to 5% of men with NGU have herpes. Most have obvious herpes sores, but many have only urethritis. The main differences vs other NGU are greater pain on urination and increased redness and swelling. So although women have not been studied, your situation seems similar.

Finally, speak with your last couple of sex partners. Depending on timing, if you have herpes or any STD, it isn't necessarily from the most recent one. If there is a history of genital or oral herpes (if cunnilingus occurred), that might help sort this out.

Best wishes to you --   HHH, MD

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49 months ago
Thank you for your input, Dr Hansfield. I am afraid my worst fears are being realized. I've noticed stinging pain elsewhere than the urethra in the last few hours and the urethral pain is absolutely unbearable. My Dr has started me on acyclovir, and I took my first dose this afternoon. I feel like I'm a sitting duck waiting for the lesions to occur. There was oral sex with one partner a few months ago, yes. I can't believe I have put myself in this situation. I am feeling worthless and overwhelmed. I believe the antibiotics I received almost 12 hours ago should be offering some relief by now. I am in excruciating pain. I am so incredibly alone and terrified because I cannot take this pain anymore  and the idea of going through life never knowing when this will recur is too much to handle. It's reassuring to know from Terri that my doctor seems to be on top of this. Thank you again for your input. I am not sure how I will ever feel better or normal again. 
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
49 months ago
A partner giving you oral sex a few months ago is not likely to manifest as new infection this late. 
So Heather, take a deep breath and then another.  This may be herpes, as I and Dr. Handsfield have said, but maybe not.  It would be very useful for recent partners to be tested, though that might be tricky, I don't know.  Did your doctor do any urethral swabbing for herpes?  If not, you might want to consider asking about that.  If you develop new sores in other places, outside of the urethral pain, please go and have them swab tested immediately.  We want to know if they really are herpes and if so, what type. 
It isn't necessarily true that 12 hours would be long enough for the antibiotics to work - give it another day. 
You are not worthless and you need to try to stop that thinking right now.  Whatever is going on with you, you are the same person you were before.  I'm sure you had worth then and you still do. We don't even know what on earth is going on here for certain.  Please try to just wait a bit and see.  Things will reveal themselves, I believe, so you can sort this out, one way or another.  And if it is herpes, you will deal with that too  and we will help you.  there are lots of really good resources for education, counseling and companionship.  Try to wait and see what's really going on here.  More deep breaths.  We are here for you.
For now, I need to ask you to renew if you need to talk a bit more.

Terri

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H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
49 months ago
I think Terri won't mind if I add an additional word of reassruance. If you are (sort of) lucky and it's HSV1, you are likely to have few if any recurrent outbreaks and might be unlikely to transmit it sexually to partners. And if HSV2, outbreaks can be controlled and transmission prevented. So do your best to not overreat. This may not be herpes, but if it is, your romatic life isn't over. All in all, this won't turn out to be as big a deal as it seems now.

Very best wishes to you.

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