[Question #13] NGU?

100 months ago
Good Afternoon,

This question is directed towards Dr Hunter Handsfield.

I am a 30 year old male, I have been suffering from an irritation of the urethra for about 10 months.  I have seen multiple urologists and none have been able to help.  I have tested negative for every STD under the sun.  The symptoms started a few days after oral sex was performed on me by a new partner and I can't help but assume this is the cause of my symptoms.  Because doctors have been unable to diagnose anything, I have had ZERO treatment for this.

Primary Symtoms (these are constant and severe)
-inflamed, red meatus
-pain and tingling at tip of penis, any contact with boxers or clothing causes pain

Secondary (these are occasional and less severe)
-tingling and discomfort in scrotum and perineum

I have read some articles indicating that oral sex can be a cause of Urethritis in men (one was penned by you i believe).  When dealing with my urologist is there any specific tests I should request?  Do you have any advice on treatment options? The pain is absolutely horrible and my quality of life has plummeted.  I am MORE than willing to fly out to see you at your clinic or participate in any research studies.  Let me know.  Thanks
H. Hunter Handsfield, MD
100 months ago

Welcome to the forum. I'll try to help.


Symptoms alone do not define urethritis. There needs to be visible discharge or evidence of it, like staining of underwear, as well as  objective evidence of urethral inflammation like white blood cells in the urethra or the initial ounce or so of voided urine. Your impression of redness is not necessarily abnormal, and pain and tingling, without discharge or elevated urethral WBC, is not usually a symptom of urethritis. Rather, you likely have some variation of the chronic pelvic pain syndrome (CPPS), which overlaps with chronic prostatitis. Pain, tingling, etc from the prostate area is often referred to and felt primarily at the tip of the penis, the scrotum, etc. CPPS is non-infectious, often (usually?) related to psychological factors, including anxiety over regretted sexual exposures. (The pain is believed to be from pelvic muscle tension, just as psychological factors can cause tension headaches through the same mechanism involving muscles of the head and neck.) While oral sex can cause nongonococcal urethritis (NGU), perhaps related to normal oral bacteria, for the reasons above I doubt NGU is the problem. For more information on CPPS, google it (spell it out). A very good wikipedia article should be near the top of the hit list, and also look for excellent info from the Stanford University Dept of Urology. I'm guessing you'll see a lot of parallels with your symptoms.


Having said all that, I'm a bit surprised you haven’t had a trial of antibiotic. In a way, that's good news, since it implies your urologists are well versed in these problems. Still, many would have given treatment for NGU in the hope it would help. I doubt it would help, but it would not be unreasonable to give it a try, e.g. doxycycline for 7-10 days.


So my advice is to keep working with one of your urologists; you could print out this reply as a framework for discussion. It wouldn't help to see me in person. In our own clinic, we refer patients like you to urologists for diagnosis and management In the meantime, try not to worry. You have symptoms only, i.e. nothing harmful either to you or current or future sex partners. In fact, some experts believe sexual activity helps symptoms of CPPS.


I hope this has helped. Best wishes and good luck.

100 months ago
Hi Dr,

Appreciate the quick response.  I have read alot about CPPS and CP and  I am seeing a prostatitis specialist (Dr. Curtis Nickel) next week so the wheels are in motion when its comes to that.  I agree that CP is a likley cause, however, I don't want to pigeon hole this as there seem to be many men who suffer from similar symptoms where unprotected oral sex is the common denominator:


As a follow up to your comments regarding NGU.  I do not have persistent discharge of any sort, but often times my urethral opening appears puffy, swollen and stuck together.  

Two quick questions 

1.)  If "normal" oral bacteria is the culprit, what tests need to be performed and what treatment course is appropriate?
2.)  Is there a way to test if the irritation is caused by a fungal infection of some sort?

H. Hunter Handsfield, MD
100 months ago
"Opening stuck together" could mean abnormal discharge or inflammation -- or just the residual effect of a little normal mucus, leftover semen after ejaculation, or pre-ejaculate fluid after arousal or nocturnal erections. It would be easy to check for urethral WBC and I'd be surprised if your urologist(s) didn't do that.  What exactly were your urologists opinions on all this?

"Oral sex is the common denominator":  I don't agree with your reasoning. People with unknown, unexplained problems are obviously overrepresented in online forums. People with unexplained urethral symptoms may recall a past oral sex episode and post their stories. But for all we know, there are a hundred or a thousand times as many men with the same symptoms but who don't have or aren't concerned about past oral sex events. Maybe it's true, and maybe someday research will show something along these lines. But this is the absolutely least reliable kind of data on which to base any conclusions.

The oral bacteria business is only a theory which has never been the subject of scientific research. It's not much more than an educated guess to explain some cases of NGU after oral sex, in which typically no known STD bacteria or viruses can be found. A related possibility is that it isn't an infection at all, in the usual sense, just the urethra's adjustment to new bacteria or other oral factors. There are no standard tests to check out any of these possibilities. In any case, I stress that you still have given no clear evidence that you NGU (or urethritis of any kind). As discussed, your symptoms really don't fit with urethritis.

Fungal infections are not known to be acquired in this manner.  If you had any infection at all, I would expect both discharge and WBC, as discussed above.

Note ASHA's rule on this forum:  a maximum of 2 follow-up comments/questions, after which a new thread must be started, with the fee. Just a heads-up so you carefully consider any further comments to be sure you don't miss anything. I suggest you wait until you have seen Dr. Nickel. It will be interesting to hear the outcome of that evaluation. But for now I still think CPPS is the best bet.
99 months ago
Hi Dr,

I had my appointment with Dr. Nickel at his clinic in Kingston and he agreed that I have symptoms of CPPS/Chronic prostatitis.  He took first, mid and post DRE urine samples, performed a bladder ultrasound and asked some questions about my symptoms.  He prescribed Elavil and an alpha-blocker to try out and said he would be in contact if anything came up in my urine.

He also found it interesting that my symptoms occurred after oral sex as he had seen 4 other men with similar symptoms who thought the cause was oral sex in the same week.  Its very hard to convince me that this is a coincidence but i guess there isn't much anyone can do if they can't find a pathogen or evidence that oral sex was the definitive cause.

If you have any other thoughts or suggestions, let me know.  If you are aware of any clinical trials or studies, I am more than happy to participate.

H. Hunter Handsfield, MD
99 months ago
Sorry, I'm not aware of any studies. I'm not surprised (of course) by Dr. Nickel's diagnosis.

My final comment is that I don't think your problem is a coincidence in regard to the oral sex event. Only that i'm confident no infection from that event is the cause. If a connection to it is real, it is likely psychological in nature, since CPPS may be mostly psychogenic. The important thing, though, is that you only have symptoms, not disease. Nobody ever gets significant complications from CPPS or chronic nonbacterial prostatitis, and it will never harm a sex partner. You may have to live with the discomfort, but many people find that easy once they are confident it's not serious and no harm will come.

That will wind up this thread. Best of luck with it.