[Question #1568] Worried about possible exposure

44 months ago
Hello and thank you in advance for what you do here.  I am male 38 y/o.10 days ago i had an encounter of unprotected cunnaligus and condoms were used for vaginal sex. She was a 25 to 30 y/o white female who i just met. I have no contact info on her because it was a one night thing. She did not look like an IV drug user either. She had condoms at her house  and they were used. At first she was on top and when she got up to switch positions the condom was halfway on the base of my penis. We then used a new condom which i know was intact after i was on top. 6 days post exposure i noticed a tingling sensation after urinating. I went to the std clinic ran by the city yesterday and got swabbed for bacterial infections. The result was NGU and the chlamydia results will be in next week.  Now about 12 hrs. After the swab it is very painful during and after urination.

My ?s are:
1. Is this pain normal after 12hrs of getting the swab test?
2. I know condoms were used, didnt see any breakage. how would i have contracted NGU from this?
3. IF chlamydia is negative any ideas on what caused this?
4. How concerned should I be about HIV?
Thank you for your help.
44 months ago
Addition to question #1568. I fogot to mention i was treated with 1g of azithromycin at the clinic. 

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
44 months ago
Welcome to the forum. Thanks for your question.

I'm a bit puzzled by some aspects of this exposure, your symptoms, and the diagnosis of NGU. First, it sounds like your penis wasn't exposed except via condom protected sex. If there was no exposure of the opening of your urethra by either vaginal or oral sex, you couldn't have acquired NGU. Second, 6 days is on the short side for onset of NGU symptoms. It might happen, but 7-14 days is more typical. Third, the main NGU symptom is discharge; tingling with urination, by itself, usually doesn't indicate urethritis. So it would be interesting to know exactly what was found at the STD clinic. Did they tell you they saw white blood cells in your urethral swab? If so, NGU is possible. OTOH, even that isn't definite:  entirely healthy men may have a few WBC in their urethras from time to time, without indicating any infection at all. And did the clinic say definite NGU? Or perhaps that they were going to treat you for it as a precaution only?

To your specific questions:

1) Unfortunately, yes, urethral swabs can be painful and the discomfort can persist for a day or two. Nothing dangerous, though; it should clear up quickly. (FYI, in my experience, such pain is most common in men without NGU, not with it. The increased urethral fluids that occur in NGU may provide some lubrication and reduce the discomfort of swabbing. However this has never been studied -- just my impression in swabbing hundreds of men over the years.)

2) See above. I agree it would be unlikely for you to acquire NGU based on your exposure history, and I am somewhat skeptical you in fact have NGU. However, I could be convinced of it depending on details of what they found at the clinic. 

3) For the reasons implied above, I expect your chlamydia test to be negative. Chlamydia causes about 25-35% of NGU. About 10% of cases are due to Mycoplasma genitalium, and very small percentages to herpes, adenovirus, and perhaps a bacteria called Ureaplasma urealyticum. The cause is entirely unknown in about 50% of cases.

4) I see no realistic chance you acquired HIV. It is statistically unlikely such a partner has HIV, and the exposures described carry no risk of it. The only slight wrinkle remains the possibility of NGU:  if you really have it, then there must have been a lapse in sexual safety, in which case there might be a very small chance. Anybody with any new STD should be tested for HIV -- better safe than sorry. But for sure I would expect negative results.

I look forward to hearing more about exactly what the STD clinic found. In the meantime, you really need not be seriously worried. Nonchlamydial NGU is rarely if ever a serious health problem. Whether or not you actually havfe it, nothing dangerous is going to come of it.

Best wishes--   HHH, MD

---
44 months ago
Hello Dr. and thanks for your response. The clinician said they saw white blood cells under the microscope. That is how he came up with the NGU diagnosis. That is why im worried about possible condom failure. I do not understand how i would get this otherwise from the exposure i had. I was treated with 1g of azithromycin as a precaution while waiting for the chlamydia results. He did do an exam on me before the swab and said he saw no discharge from the penis. If it is not chlamydia should i put this behind me? Do you recommend hiv testing because of my condom failure worries?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
44 months ago
With apology, I need to get into the weeds of how NGU is or should be diagnosed. The bottom line is that I remain very suspicious you do not have NGU.

Research 30+ years ago studied men without symptoms coming to STD clinics, and did urethral swabs looking for WBC. If the men had no definite urethritis other than WBC (no symptoms, no visible discharge), they were not treated but instead advised to return to the clinic a week later. At the return visit, the urethral WBC were gone in half the men. In those in whom WBC still were present, 40% had chlamydia -- exactly the same proportion as in men with definite NGU at the first visit, i.e. both discharge and WBC. In those with no WBC on the return visit, none had chllamydia, gonorrhea, or any other problem. Most STD experts and STD clinics still would treat such men for NGU:  it's easier all around to treat everyone, even knowing that about half have nothing actually wrong, just a few WBC that come and go.

I suspect this is what is going on with you. In other words, despite the diagnosis of NGU, and the policy of treating uncertain cases with azithromycin, it is likely that nothing at all was wrong. So at this point, I remain confident you chlamydia test indeed will be negative. In that case, and if your symptoms clear up and do not return in the next couple of weeks, I indeed recommend you move on with your life -- that is, yes:  you should "put this behind [you]".

As for HIV, I already answered. HIV testing is routine whenever anybody is suspected to have (or just at risk of) any STD. On that basis, you should be tested. Do I think you could safely skip it? Yes. But that's the policy. It's up to you whether to have an HIV test in a few weeks.

Forum policy is that each question is accompanied by up to two follow-up coments/questions and replies. So you have one more coming. I suggest you hold off on that until you have the chlamydia test result. Let me know that result and how your symptoms are doing. But I won't have anything more to say until then. In the meantime, stay mellow. Even if you have NGU, if it's likely harmless and won't ever cause you any important health problem.

---
44 months ago
Dr. H i know you suggested i wait until my chlamydia test came back until I posted again but i had some complications since my last post. The pain was not going away so i sought help at another STD clinic in my city. I told them my symptoms and they tested for chlamydia and gonorrhea (again) and trichonomas with a urine sample saturday (results in a week) I was prescribed 2g metrodonazole for preventive treatment saturday morning to be taken all at once. By this morning (sunday) the pain was unbearable so i went to an urgent care facility.  I explained my symptoms and situation and urine was taken there. They have their own lab and urine came back with white blood cells again. I was prescribed moxifloxacin for 7 days and was given  a shot. I also had the doc examine a rash i had around the outside of my anus. He said that it was a fungal imfection and i was prescribed chlotrimazole.  This got me thinking of condon failure because i saw some things on medical sites that fungal infections can be a sign of acute HIV infection. Could you please give me your expertise on what you think is going on now with my situation. Should i be concerned about HIV? The quickest i can test is the 17th of Jan. with an ab/ag combo. Thank you again for your help and having this forum.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
44 months ago
This is obviously not only painful for you, but frustrating as well.

With these developments, I wonder if you have viral NGU. Studies of men with NGU consistently show that about 5-6% of cases are due to viruses, usually herpes or adenovirus. Common characteristics of both these conditions is prominent dysuria (painful urination, sometimes excrutiating) and scant if any discharge. Often there is also "meatitits", i.e. overt redness, swelling, etc of the urethral opening. Do you have anything like that? Adenovirus is one of many common cold viruses, but some strains infect the urethra. If you also have cold symptoms (nasal congestion, sore throat, etc) or especially conjunctivitis (pink eye), it would favor adenovirus. Herpes would be favored by external genital blisters/sores, which you would have mentioned so I assume are not present; or tenderness along the penis, at the site(s) of urethral ulcers. Both of these also are consistent with the short time from exposure to your first symptoms, unlike the usual causes of NGU. The problem with both these explanations, however, is lack of oral contact with your penis, which is by far the main source of NGU due to either herpes (HSV1) or adenovirus. However, if there was a condom failure, the vaginal sex could have been a source of HSV, especially HSV2.

The good news about both herpes and adenovirus is that the problem will clear up on its own, probably within 1-2 weeks. Healing of herpes would be faster with anti-HSV treatment, but there is no treatment for adenovirus. There is no readily available test for adeno, but you could have a urethral swab test for HSV, which the STD clinic probably offers or can arrange. If they agree herpes is at least a possibility, they might add treatment with an anti-HSV drug like valacyclovir or acyclovir. It's a long shot, but so are moxifloxacin and metronidazole (I doubt you have either trichomonas or Mycoplasma genitalium). I recommend you discuss these possibilities with your current STD clinic ASAP (presumably tomorrow, since today is a holiday).

Beyond those possibilities, I wonder about a bacterial urinary tract infeciton or bacterial prostatitis. These probably would respond to moxifloxacin, however.

In the meantime, you could consider adding treatment with phenazopryridine, a urinary tract anesthetic drug. The main trade name by prescription is Pyridium, but it's available over the counter under many names (look for "Azo" products or ask the pharmacist). It should help reduce pain on urination, and won't interfere with your current treatment or other diagnostic tests.

Also, in regard to your last question:  Definitely still no worries about HIV, which for sure would not cause these symptoms, and was virtually zero risk for the exposures described.

I'll keep this thread open -- looking forward to the reaction of the STD clinic to these ideas. Good luck.

---
---
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
44 months ago
I should have commented about the anal area rash. If it looked like a fungal infection by an experienced STD clinician, that's probably what it is. However, combined with your other symptoms, I would have a slight concern about herpes -- something to also ask your current STD providers about.

---
44 months ago
Thank you doctor for keeping the thread open! I am going to get results back at different dates so I will post them all when i get the last ones if that is ok.I also have a dr. Appt with my PCP later this month.  I can tell you that i do not have any sores or lesions on my penis. Also, the pain has been reduced somewhat from last night after the second dose of moxi. Thank you again for all you do on this forum.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
44 months ago
Glad to hear your urinary pain is improving. However, it could be coincidental, i.e. was going to improve anyway regardless of moxifloxacin. I suggest you still discuss the possibilities of herpes or adenovirus with your STD clinician. I still look forward to hearing how it all shakes out.

Thanks for the thanks about our services.

---
44 months ago
Hello Dr. 
     I was able to see my doctor today and based upon my symptoms and examination he didnt think herpes was the cause of my NGU.   I just want to thank you for the great help you have been to myself and im sure many other people on this site.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
44 months ago
OK, glad things are working out and hope this discussion was helpful.---