[Question #130] Penis discharge

38 months ago
Recent Sexual History:

Early April - Very brief unprotected sex, after having protected sex, with girl on vacation. She didn't seem promiscuous.
May 2nd -Unprotected sex  with girl I met through friends (condom broke) - nice girl, professional job in hospital setting, again didn't seem promiscuous
May/June Several instances of protected sex, and unprotected receiving oral sex with couple girls
Late July, several instances of unprotected sex with an ex-GF.  She had dated only 1 guy in between us. When we first dated we used condoms until after we both got checked. Responsible girl, no reason to assume she didn't do same with this other guy.

Aug 26th, received vigorous oral sex from girl that had given me same back in May.  Very drunk, and hung over next day. 
Aug 29th , received oral again from same girl. 

Next few days I had a little bit of sensation , maybe even call it irritation in tip of penis. Enough for me to notice/ think about it, but not enough to be concerned with. I dismissed it as it wasn't real persistent or i didn't notice it persistently and I figured maybe result of trauma during oral sex.  However, I did notice lint from my underwear stuck to the side of my urethra twice. This never happened before, I still didn't suspect any std, and chalked it up to poor hygiene or not cleaning up well after masturbation.

However on Sep 2nd I woke up and noticed white discharge poking from my urethra. Almost looked like semen. Upon urinating I felt mild stinging sensation and tickling feeling.  Feel it at times when I wasnt urinating too.  That day I went to non profit aids center that offers anonymous hiv testing and confidential testing for gonorrhea and chlamydia.  The hiv was blood finger prick, instant test. The std test was urine sample.  

The next day ( sep 3) while waiting for results I took 1.5 mg of azithromycin in single dose.  Have physicians in my family and I just happened to have a zpak around my house. Medicine was not expired. 

My symptoms did not abate. Some days I wouldn't have visible discharge unless i milked it out, other days I would.  Cant say for certain if it reduced symptoms or not at any point.  Clear discharge was evident at times throughout the day, only really milky or white in morning.

Never got call with positive results, so I called to confirm on sep 14th. They confirmed negative results. 

On the 15th, 2 days ago, nearly 2 weeks since taking the azithromycin I visited a walk in clinic and was seen by a PA.  The PA didn't seem to be very knowledgeable about STDS, not nearly as knowledgeable as myself from reading a ton of your guys old medhelp forums.  I explained the situation, she brought up Trich.  I didn't think it was likely to cause symptoms in men, she wanted to test for gonorrhea/chlamydia and trich.  I brought up the fact I didn't think testing for trich in men was reliable (the co health dept wont test men), and she told me their test for it was newer. I don't know if she meant new for them or new in general.  She really left more to be desired, as she didn't seem to know the difference between NAAT testing, or culture etc.  Nor could she tell me if there were any health implication of Trich if left untreated. She simply knew there was test, and the medicine to prescribe if positive.

I decided since I was there to get tested for all 3. Should get results back tomorrow.  Also had her do a UA dip to check for leukocytes / wbc , that came back completely normal.

I requested rx for doxy 200mgx7 days. I took 1 pill first day but then stopped.  I figured I would wait on results. The azithromycin should taken out anything to cause NGU besides trich. However, I didnt really experience any normal side effects from the azithromycin, which i normally do. However I was at high altitude during this time, and often I get stopped up when I am, so maybe the altitude kept me "normal" 

 I didnt want to end up taking doxy for 7 days and also take flagyl and have my symptoms resolve to leave me wondering if it was bacteria that cause NGU or trich.

If negative for trich, which i think I will be, I will request the flagyl and if my symptoms resolve shortly, I might conclude I had trich. At which point I will make my ex gf aware and see if she will get wet mount to confirm she has it too. I really dont want to have to do that, as I am trying to get back together with her, and she is pretty emotional fragile right now after sudden death of family member. Also our relationship is pretty fragile as well, hence us not being together.  However their is no guilt, or fault, so will definitely have that conversation if need be. 

If symptoms dont resolve after Flaygl, I will take the course of doxy.

From posts Ive read from Dr Hansfeld, my hunch is NGU caused by mouth flora. Though I am 30 and have received a lot of oral sex and never had 1 issue or discharge in my life.  This same girl has given me oral sex dozens of times, no issue. 

So my question is what do you guys think? Could it be trich? I know it doesn't usually cause symptoms in either women or men,  especially men. If it was trich, is it likely symptoms wouldn't present themselves until month later? I know there probably isn't any empirical studies or data on that, but in your experience what is typical? Anecdotally , having symptoms develop in the days immediately after receiving the oral sex leads me to believe that exposure was the source of symptoms. I had not had any sexual encounters since the unprotected sex with my gf before receiving the oral sex in question.  Looking forward to hear your opinions.

Thanks

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
38 months ago
Welcome to the Ask the Expert forum. Sorry for the longerthtan usual delay in responding -- all three moderators are traveling for an international STD research conference.

You clearly have nongonococcal urethritis (NGU), probably related to the recent oral sex events, although that's by no means certain. Probably you could have been infected a few weeks earlier. This assumes your gonorrhea test returns negative, which it probably will -- although the quick onset of symptoms after the last oral exposure is consistent with gonorrhea, which sometimes doesn't respond to azithromycin. The standard approach when NGU doesn't respond to either azithromycin or doxycycline is to switch the the other. So the main treatment priority is for you to go ahead with doxycycline for 7 days.

You are correct that trichomonas rarely causes symptoms in men, although occasionally it causes NGU and your symptoms are consistent. However, trich is not carried orally and if your NGU was from the recent oral sex exposure(s) -- which I think it probable -- then trich isn't the cause. So I'm definitely betting on a negative trich test -- since it's "new", probably a DNA test. That said, the test isn't certified for use in men and non-response of NGU to azithromycin is consistent with trich as the cause, and some experts would say to treat, since it's so simple, with just a single dose of metronidazole or tinidazole (Tindamax®). (I would recommend the latter, seems more effective in men.) There's no reason why it can't be taken simultaneously with doxycycline. Or you could wait and give it a try if symptoms persist after finishing doxycycline. But I think you'll find they clear up.

I hope this has been helpful. I'll be interested in hearing how it goes. In the meantime, this isn't something very worrisome. There have never been documented complications (such as urethral stricture, epididymitis, fertility issues, etc) or known health problems in partners from nonchlamydial NGU acquired by oral sex. In fact, one theory is that orally acquired NGU may not even be an infection in the usual sense -- just the urethra's adjustment to a new mix of bacteria.

Best wishes--  HHH, MD


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38 months ago
Just to clarify my last sexual encounter prior to the Aug 26 and 29th oral sex, was roughly July 25-26th.  But had probably slept with my ex gf several times in preceding 2 weeks unprotected. Probably didnt develop symptoms until Aug 31/Sep 1. 

That would mean if she did pass trich on to me, it would have taken 6-7 weeks to develop symptoms. Based on that would you think it is pretty unlikely that my NGU is caused by trich?

The 2nd round of tests came back again negative for Chlamydia/GC as expected.  The Trich test I should hear on today. The test was: IADNA Trichomonas Vaginalis Amplied Probe Tech.  I called the Drs office yesterday to try to get a rx for trich, and they refused.  This clinic was literally the worst medical experience Ive had, and upon looking them up, they have dozens and dozens of negative reviews online.

They said they wouldn't give me rx unless test came back positive for trich, even though they would have when I was there initially, and they wanted to give me shot of Rocephin too even though I already had one negative test for GC.

When speaking to them over phone I told them as far as I knew the test for trich was unreliable in men, and a negative result didnt mean much. They made it seem like they would only give me RX on positive test.

If I do have NGU from bacterial source, would you not expect the UA dip to reflect high WBC or infection of some sort? Does that help point to Trich? Or that the azithromycin I took cleared everything up and symptoms are just slow to go away.

 Ive read you say in the past, it can take a while 2-3+ weeks for symptoms to dissipate after taking medicine for NGU. Today would be day 15 for me.  I am thinking my symptoms are lessening , but I cant tell if I am just more use to them.  I didn't have hardly any discharge this morning, but I did have some if a try to squeeze it out, more clear than white tho.  And it still is irritated (slight sting )inside my urethra after peeing, and sometimes slightly without peeing. I cant tell anymore. It is not red or irritated looking tho.

I am trying to rule out Trich so I don't have to have my ex gf go get tested.  Her dad just died suddenly and I don't think she could handle it. But doesnt sound like there is really any way to do so in Men? Besides being treated, but you never know if you did have it or not.

Thanks! 

38 months ago
Also, I get the NGU from normal mouth flora theroy, but wouldn't you think I would have dealt with this before. The girl who gave me oral sex had done so at least a couple dozen times in past. And Ive received oral sex from dozens of girls since I was probably 14, with no issues.

Or is that just what happens sometimes? 1 in 100 type of event?

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
38 months ago
Try to get trichomonas out of your mind. That's a very long shot and harmless anyway, so not worth much worry. I can't and won't challenge the judgment of a provider who would decline to prescribe treatment if your test is negative. The time to symptoms of trich in men -- if symptoms occur at all -- aren't known. It hasn't been studied and never will be.

That your symptoms are gradually improving would suggest the problem is clearing up on its own, not because of the antibotics you have had. However, standard medical practice would be to treat you now with doxycycline, as discussed above, and that is what I recommend.

Sorry if I misunderstood the timing of your exposures, sex with your ex girlfriend, etc. But if I now understand correctly, you and she had unprotected sex after the exposure(s) when you acquired NGU. Therefore, your ex gf should be examined for STDs and treated. You can't get around that just because you don't have trich. As discussed above, the chance of a serious outcome in your ex gf is low, assuming your NGU was acquired by oral sex. But it may not be zero, and standard recommendations are for all exposed partners to be treated. In my opinion, you are ethically obligated to inform her and recommend she be evaluated and treated. (Given your non-response to azithromcyin, doxycycline is preferred for her.)

What you say about NGU from oral flora makes sense. However, we really don't know. That normal oral bacteria are responsible for some cases is a theory about the cause, nothing more. There has been no research to prove the point, or to know and why it might occur from one exposure but not from others.

As a reminder, your posting fee covers two follow-up comments with replies. One more coming -- but perhaps best to wait until you have your trichomonas test result or, even better, until you have been treated with doxycycline can judge how your symptoms respond.
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38 months ago
No you were correct first time. The oral sex exposure was probably 6 weeks after the first time I had unprotected sex with my ex. So if I got ngu from the oral sex, I would not have exposed her. 

Trich test came back negative. Confused what that means really, as you said it wasn't cleared in men. It was DNA probe urine test. 

I'm not 100% certain my symptoms are getting better. They were mild to begin with. I'm thinking the discharge might have improved but I definitely still have times where I have this weird sensation (almost like the inside of my urethra is being slightly pinched) right below glass on underside of shift. 

I began taking the doxy today and hoping it works.  Just don't know what caused this and why the 1.5 grams of azithromycin didn't work. Or maybe it did and symptoms persisted? Does discharge usually clear up quickly? 

This whole ordeal is just so weird. At this point do you think it's safe to conclude the ngu isn't caused by Trich? You said it was long shot, but also my symptoms were consistent with ngu caused by trich because non response to azithromycin. So confused how to take that. And am I under any obligation to have my ex treated with doxy too? She isn't having any symptoms of anything. 

If doxy doesn't resolve symptoms do you suggest rx for trich? If that doesn't work too, then what? Hopefully doesn't get that far :-) 

Thanks
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
38 months ago
Although not formally approved for diagnosis of trichomonas in men, your negative DNA test (the only possible test in males) can be considered highly reliable. And the chance you had trich was near zero anyway.

The most likely scenario is that your urethritis is (or was) caused by some bacteria resistant to azithromycin. Most likely the doxy will work. With successful treatment, symptoms of NGU usually resolve gradually over 3-5 days. If symptoms persist after doxy, I sugtest no other treatment until and unless you have been examined by a physician or clinic with substantial experience in evaluating STDs and urethritis. If symptoms only, without visible discharge or documented inflammation (increased WBC in your urethra or initially voided urine), such an expert probably would conclude that no treatment will be indicated.

Whatever happens, don't make this out to be more important than it is. You are dealing with what most experts would consider a bothersome inconvenience, not an important health risk for you or your current or future sex partner(s).

That winds up this thread. Best wishes.
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