[Question #1383] slightly painful urination, whitish discharge

46 months ago
I had unprotected sex 3 nights ago. High risk prostitute, though I know her and she is tested for HIV. The very next morning, my urethra was irritated and it burned when I peed, I figured this was from sex. Now 3 days later, I can produce a slightly milky discharge if I squeeze it out of my penis like you would a toothpaste tube ( LOL). No increase in pain, still burns a slight bit when I pee but less than before. I have an appointment at GUM clinic, but nothing for a week. They said I can call to see availability each day which I will. I am leaning towards the clap or chlamydia...my question is how serious is this? Can I wait for the GUM clinic appointment, or should I go to urgent care in the next day or two? 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
46 months ago
Welcome to the forum. Thanks for your question.

I think you're exactly right about clap (gonorrhea), not chlamydia. Nongonococcal urethritis (NGU) -- usually called nonspecific urethritis (NSU) in the UK -- is often caused by chlamydia, but regardless of the specific cause, typically doesn't cause symptoms until 1-2 weeks after exposure, whereas gonorrhea typically shows up in 2-5 days. (The initial irritation the next morning probably was just physical irritation, as you suspected.) If it's gonorrhea, over the next few days the discharge probably will become more purulent (pus-like, i.e. thicker, creamy) and painful urination could become quite severe quite rapidly.

Accordingly, I wouldn't wait. Try calling the GUM clinic, tell them that you suspect gonorrhea based on rapid onset of symptoms (and, if you like, my opinion) -- my guess is they'll try to find a way to see you quickly. But if they cannot, for sure see someone in the next day or two.

I hope this is helpful. Please return with a follow up comment and let me know how this turns out. In the meantime, get in touch with your partner, who also should be tested and treated.

Best wishes--  HHH, MD

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46 months ago
I did call the clinic. While they were able to move my appointment to later today, I ended up just going to an urgent care center this morning. They said it was gonorrhea though they still sent the urine test out. I was given a shot of Rocephin in the butt, plus a large single dose of Zithromax and then doxycycline for several days. They said it was standard procedure for this, and that's what I also see when I looked up treatment online.   

Thank you for the reply Doctor, it got me there that much faster. I'll be contacting my partner today so she can get herself treated.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
46 months ago
Thanks for the follow-up. I'm glad to have helped. Did they do a quick diagnostic test, like microscopic examination of urethral discharge by Gram or methylene blue stain? That's over 90% accurate in diagnosing gonorrhea in men -- while awaiting the result of the formal lab based gonorrhea/chlamydia test. (The GUM clinic almost certainly would have done the microscopic exam, but that's probably less consistent in UK urgent care clinics.)

You were overtreated. Both CDC in the US (www.cdc.gov/std) and the British Association for Sexual Health and HIV (BASHH) (https://www.bashh.org/guidelines) recommend ceftriaxone (Rocephin) plus single dose oral azithromycin (Zithromax), as you were given. The US guidelines suggest doxycycline as an alternative to azithromycin, but neither agency (and no experts) recommend giving both drugs. It is unnecessary overkill. You might contact the urgent care clinic and confirm you really need to continue the doxy. My guess is the clinic just isn't up to speed on standard recommendations. It probably won't hurt anything to continue doxy, but overuse of antibiotics is a major problem in all societies and ought to be limited whenever possible.

Anyway, glad it's under control and your partner will be treated soon as well.

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46 months ago
They took a urine sample, and confirmed a UTI. They said that they would be sending it over for testing for Gonorrhea and that they would get back to me with any abnormal test( if it were positive) within a day. 

I am from the USA :). I used the term "GUM" because I see it often, but I'm gathering that is the term only in the UK. But when I searched for GUM in my local area it came up with sex health clinics so I assumed that was a world wide term. I am in RI if that matters. I did text my partner, though she is not the fastest to respond. But I will have contact with her by tomorrow if not tonight. 

The Doctor said he was confident it was Gonorrhea, and that they treat cases quite often(several times a week). Nonetheless, I will contact them tomorrow and verify that the doxy is necessary. Of the 3, it is one I have experience with in the past, and does give me a good amount of digestive distress. I agree as well that antibiotics are way overused, and its sending us for an interesting future. 

Already the discharge seems to be down to almost nothing and most of the discomfort that had been growing over the last 24 hours has subsided. 

Again, thanks :)
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
46 months ago
Thanks for the follow-up. Indeed I assumed the UK (or commonweakth country) from your use of GUM, not the norm in North America.

Probably your clinic thinks you have gonorrhea for the same reason I did, i.e. quick onset of symptoms. In itself, WBC in the urine says only there is inflammation in the urinary tract, without any implications of the cause. Even though they used the term UTI, their treatment doesn't indicate they believe that's what you have. (*UTI" is used almost exclusively to mean non-STD infections.) Presumably they alo examined you to observe urethral discharge, right?

The urine should have been tested for chlamydia as well as gonorrhea. Probably it was:  the standard test by almost all labs includes both, i.e. the allternate being automatic regardless of which test(s) the doctor or clinic orders. But it will make no difference in treatment either way.

In the past few years, many STD experts have come to prefer doxy over azithromycin when rectal chlamydia is suspected or diagnosed, e.g. in gay men and some women. For urethral chlamydia, and to maximize gonorrhea cure, azithro and doxy are equally effective. But see what the clinic says; if they still prefer you take it, I would enjoy hearing their reason.

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46 months ago
Yes, they did state that the on site testing they did only confirmed an infection. They were sending the sample out for any tests that can be performed by urine(that is my wording). I declined blood testing, as I just had full testing done last week with a physical I had(prior to this encounter). 

I explained when and what happened. He did check me out pants off, and he saw discharge. He did the ol' cough test with each testicle as well, checking for any pain which there was none. 

He only said that it was "standard operating protocol" for the meds he gave me. I am not sure what info he is going off there, if it is from the CDC or local health department. Maybe its just a "cover all bases" approach that blankets all types of infection(ie urethra and rectal)? FWIW, I have gone to this urgent care several times, I've never had reason to doubt them. But this is also the first time I have presented a likely STI to them as well...usually its been for strep, ear infections, etc. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
46 months ago
The drugs you got definitely are not SOP -- for sure not from CDC, and I would be extremely surprised if both doxy and azithro are recommended by the local or state health department. Trust me on this:  there is absolutely no need to be taking doxycycline. There are no "bases" not covered by the other drugs.

You should have a blood test HIV in a few weeks. The occurrence of gonorrhea is a strong indicator of increased HIV risk. The odds still are strongly in your favor, but better safe than sorry! Or if you're in touch with your partner and she is tested now and negative, then feel free to forego it. (A case also could be made for syphilis testing, except that ceftriaxone etc would abort incubating syphilis if you were exposed.)

That completes the two follow-up comments and replies included with each question, and so will end this thread. I hope the discussion has been helpful. Best wishes and stay safe.
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