[Question #13121] Follow up to earlier post

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2 months ago
About a month ago I had a posted a question about symptoms that I assumed were caused by gonorrhea or by chlamydia. I had a large amount of antibiotics that had been prescribed for ureaplasma (like 21 days of doxycycline and 14 days of azithromycin). I knew I couldn’t get tested for several days, so I decided to just take the prescription I had (since it would at least treat the chlamydia if I had that) and then get tested after completing it for gonorrhea. Well, more or less as soon as I completed the doxycycline, I noticed symptoms again (more prominent than they had been before) so I decided to finish the azithromycin then get tested for gonorrhea. 

I got a “comprehensive panel” done and everything (including both gonorrhea and chlamydia) came back negative. Since my symptoms are now worse than before, am I correct in assuming that the likeliest explanation is mycoplasma genitalium? 

I’m feeling really bummed because I didn’t even realize this infection existed, so I feel like if I had waited to get tested, I would have turned up negative for everything anyway, but now I’ve put myself through all this treatment with nothing to show for it. I’m not even sure how to get tested for M Gen, or what the recommended treatment would be. I also had informed a female partner about my symptoms and she was treated for chlamydia and gonorrhea to be safe, and now I’m concerned I need to go back to her with bad news again. I assume that if I have a strain of M Gen that doxycycline and azithromycin didn’t treat, it wouldn’t have treated hers either. 

Can you offer any guidance?
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Edward W. Hook M.D.
2 months ago
I’m sorry to hear that your symptoms continue. From the sounds of things, while you were taking doxycycline, they may have been better. Is that correct?

Mycoplasma genitalium is the most readily treated cause of persistent or recurrent nongonococcal urethritis in men. The test for M. Genitalium, like tests for gonorrhea and chlamydia can be performed on a voided urine specimen. At this point rather than guessing what might be going on, I would strongly recommend testing. I would test for gonorrhea, chlamydia, and mycoplasma genitalia. In addition, I would suggest a urinalysis looking for white blood cells in the urine.  For all of these tests, a specimen collected as you begin to void after not urinating for several hours is the preferred test.

EWH
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2 months ago
Dr. Hook,

You are correct that my symptoms seemed to improve while I was on doxy, then they seemed to return afterwards. The primary complaint for me right now is discharge, which is mostly painless (maybe some tingling / burning but not much?), but the discharge appears to be thicker and just more prevalent than it was even before I started the antibiotics. 

I’m wondering why you suggest I should retest for gonorrhea and chlamydia. I just got test results back today for both of them, and they both came back negative. Is there a reason you think I might have gotten a false negative? The fact that my symptoms seemed to come back and/or get worse, along with negative tests for gonorrhea and chlamydia, led me to think that M Gen was the most likely explanation. Do you think I really need to be tested for all three?

I also wanted to ask about the possibility of increased discharge just being the result of some kind of lingering symptoms but not a sign of infection? I’ve read that some men who clear M Gen (if that was what I had) will actually continue to show symptoms for a few weeks even if treatment was successful, but I don’t know if that’s a real possibility. 

I would have thought that if my symptoms got better, then returned after completing doxy but while still taking azithromycin, and then I tested negative for chlamydia and gonorrhea, that pretty much leaves M Gen as the likeliest case. (I figured it might also explain why the person I contracted it from ghosted me, if he was also getting mixed/confusing signals about ongoing symptoms but not getting tested for or treated for M Gen, and unsure how to explain what was going on to me.) 

I’m just trying to make sense of what negative tests on the STIs I’m familiar with but still having symptoms might mean. 
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2 months ago
For what it’s worth, as an addendum to my previous comment, I woke up this morning with the most obvious symptom yet that I still have an infection. It was clearly a viscous, white discharge from my urethra, but I received negative test results for gonorrhea and chlamydia just yesterday, so I don’t understand what’s going on. 
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Edward W. Hook M.D.
2 months ago
I suggested re-testing for gonorrhea and chlamydia to be thorough and they are often included as a "package".  I see no real need for repeat testing for gonorrhea or chlamydia.  

Most men do have a certain and variable amount of normal urethral discharge which, one looks as you are, can be detected.  What you describe could certainly ne normal.   I suggested the urinalysis to help determine if inflammation is present which would help oto sort this out.  

The possible benefits of of doxycycline include that this antibiotic has a modest anti-inflammatory effect in the absence of infection. 

Regarding the likelihood of M. genitalium, only testing will tell.  Many persons with persistent/recurrent urethral discharge are not found to have a pathogen present and are encouraged to not worry unless things change.  No partner therapy is suggested if tests are negative unless.   I should also point out that recommended M. genitalium therapy currently starts with doxycycline but then is followed by moxifloxacin, again emphasizing the important of testing and using the results of testing to guide therapy and decision making.  

One follow-up remaining.  EWH
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2 months ago
I just have a few follow up questions.
1) You would recommend that I test for M Gen, but you do NOT think I need to retest for chlamydia or gonorrhea, correct? Is there any other pathogen that you would recommend I ask to be tested for?
2) The STI clinic close to me doesn’t mention anything about offering M Gen testing on their site, and I’m not familiar with a doctor really recommending testing for it before. I think it may have been tested for in a panel when I got the ureaplasma result. Will I have trouble getting a test for M Gen?
3) I’m surprised to hear you say that a viscous, visible white discharge could be a normal discharge.  Before I took the antibiotics, the discharge felt “normal” - slightly watery and more quantity than usual - but after I completed the antibiotics and was off for a few days, the discharge is now a thick white discharge that I can “express” from my urethra particularly after sleeping all night. I feel like that wouldn’t be a “normal” discharge? 
4) You mention the urinalysis can look for inflammation and white blood cells. Do white blood cells point to an infection even if chlamydia, M Gen, and gonorrhea all turn out negative? Does a result for inflammation point towards something different than having white blood cells? 
5) If it’s some kind of infection that isn’t readily tested for, should it just eventually resolve? Would a doctor likely prescribe some other round of antibiotics to address the issue?
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2 months ago
Thanks for helping me understand better. When I have sought answers for these types of questions in medical clinics before, I feel like the providers don’t often have good understanding of the issues, so I get overwhelmed with trying to seek guidance or treatment options. It’s helpful for me to have the information upfront so I can prepare myself for the conversations I need to have with a provider when I go to test and/or seek treatment for M Gen. 
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Edward W. Hook M.D.
2 months ago
Final response:

1.  Testing for gonorrhea and chlamydia is not crucial but if you are seeing someone who you’ve not seen before, they may want the test to be thorough.  I think testing for M. Gent. Will be helpful.

2.  Tests for M. Gent are widely available.  They just need to ask.  

3. Nothing to add.  That’s part of why I suggested testing for inflammation with a urinalysis ( or smear of the discharge).  Getting too far down the “…but if… rabbit hole doesn’t help).  Nocturnal discharges can be thick.

4.  White blood cells indicate inflammation but not what is causing it.

5.  If there is no demonstrable pathogen, as is sometimes the case, many would observe in anticipation of it resolving.  Others might investigate your prostate.

This completes this thread.  EWH
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