[Question #2351] NSU & Partner Notification

98 months ago

In a long term relationship until October 2013. Unprotected one night stand outside of this relationship in Dec 2011. Tested for standard STIs (NOT M. Genitalium , UU or Trich) 2 weeks and 6 weeks post this encounter and all negative.

- I had never tested for NSU and so 10 months later in Oct 2012 I had swabs done and was diagnosed with non-chlamydial NSU. Me and regular partner treated with 1g of Azithromycin.

- Diagnosed with non-chlamydial NSU again in June 2013 and treated with 7 days of doxycycline (no exposure outside of relationship)

- Two unprotected exposures with different girls (had split with regular partner) in Dec 2013 and diagnosed with non-chlamydial NSU in Jan 2014 and treated

- Met now wife in April 2014 and was diagnosed again with non-chlamydial NSU 12 months later in April 2015. Tested for everything including M. Genitalium privately and all were negative.

Question

1. One of the two unprotected exposures in Dec 2013 was with a married work colleague. I spoke to a private STI Doc in London at the time and given the non-chlamydial diagnosis he confirmed he would be comfortable with me not informing her. I did however inform her of my diagnosis and explained that although this Dr had said it would be ok not to I had also read online from a specialist Doc in the US that all partners should be treated so I said “it’s up to you but you might want to think about seeking advice from a Doctor you trust” – is this ok, or should I have insisted she and her husband were treated?

H. Hunter Handsfield, MD

98 months ago

Welcome to the forum. Thanks for your question.

You've come to the right place. NGU (same as NSU), including partner management, is a particular interest of mine. Just 4 months ago, I published an editorial in the journal Sexually Transmitted Diseases titled "Management of...the Female Partners of Men with Nongonococcal Urethritis (Sex Transm Dis 2017;44:131-2).

My first reaction to this story is that I'm not convinced you had NGU. You don't describe any symptoms to suggest NGU, and there is no reliable test for asymptoamtic NGU in men. Although white blood cells in the urethra can indicate NGU, some men have WBC without symptoms and probably nothing is wrong in most of them. That's why many experts recommend against looking for NGU in men without symptoms, except in particular circumstances. That said, diagnosis by an STD expert, including your private STD provider/clinic (Freedom Health?) likely is reliable. But even here, they might acknowledge that there is a lot of uncertainty about these things, which may explain why they thought it would be OK for your partner not to be treated.

Assuming you have indeed had NGU, it may not have been an infection in the traditional sense. Sometimes it's probably just a nonspecific reaction to exposure to a new mix of bacteria in a partner's genital tract and/or mouth -- harmless and not implying anything abnormal in the partner. There is no good evidence that treating the female partners of men in your situation makes any difference in the partner's health or the risk of reinfection in the man with NGU -- that was the main take-home conclusion in my editorial. However, this is controversial -- I wrote it in response to a paper from Melbourne, Australia that drew the opposite conclusion, that treatment of female partners makes sense. But as this implies, I saw serious flaws in that study and do not consider it a reliable basis to draw any conclusions about partner treatment.

In summary, I do not think it is necessary to suggest your partner and her husband be treated. But as implied by the conflicting opinions in the Melbourne study and my editorial, this isn't a settled issue. However, I would stress that nobody has ever documented any serious health outcomes of any kind from NGU without established cause, either in affected men and their partners. So most likely there is no harm in not treating.

I hope this information has been helpful. If you want to pursue all this further, e.g. with your private clinic provider, you might consider printing out these comments as a framework for discussion.

Best wishes-- HHH, MD

PS: Final comment: If you get into the habit of consistent condom use for your non-monogamous exposures, none of this should be an issue in the future.

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98 months ago

Thanks Doctor. With regard to symptoms, I didn’t have any noticeable symptoms the first time I was diagnosed in Oct 2012 but on the other three occasions the symptom was a feeling of irritation/tingling/ the feeling of something moving in my urethra (these sensations weren’t constant from memory).

I never noticed any discharge but I am not circumsized, don’t look at the tip of my penis in the shower/when urinating and don’t wear fitted underwear (so wouldn’t feel it) and simply wasn’t looking for it.

In Aug 2013 I had another unprotected one night stand (multiple times on one night with same girl). On this occasion I did notice some abnormal discharge (looked like semen but I hadn’t been aroused hence i found it abnormal), tested 11 days post exposure for NSU and only one puss cell found so told not to worry . However, the Dr taking the swab was junior (to the point she needed to check what one pus cell meant) so my concern was that she didn’t take swab properly. I then felt some irritation a few days later but ignored it as I wanted to trust my Dr’s advice.

1. 1. Should I tell the girl I had this unprotected encounter and my ex-long term partner at the time to be treated as a precaution? (I had tested negative for ghonnoreah and Chalmydia)

2. 2. You mention that no harm has ever been shown to come as a result of NSU without a specific cause but surely M. Genitalium is a serious concern as a cause of NSU?

3. 3. If you were me, based on what I’ve said in my initial questions and in this follow up would you agree that the risk to any of my ex-partners is miniscule/negligible, doesn’t warrant me telling any of them to be treated and that I should just move on without worry?

4. 4. You mention that whether to treat partners is still up for debate, does this mean that I need to keep an eye on the research and tell my partners if things change, or again, can I just put it behind me?

H. Hunter Handsfield, MD

98 months ago

See my comment in your other thread, hoping to put NGU/NSU into context for you.

1. As best I can tell, you may never have had NGU at all. Even if you did, in absence of gonorrhea and chlamydia, there likely is little potential harm for partners. Finally, this apparently was 4-5 years ago. Any infection your partner might have had at that time probably would have been cleared by her immune system long ago. For example, chlamydia is cleared within a year, and it's likely the same for other potential causes.

2. M genitalium in men has never been associated with complications, e.g. no epididymitis (like chlamydia or gonorrhea) and no known urethral stricture (as can occur with gonorrhea). M gen is a potential cause of PID in women, but the frequency with which PID develops in any particular woman probably is low. And M genitalium PID has not (yet?) been known to be associated with infertility or other long term complications. Although new information about M gen and its dangers may evolve over time, so far it doesn't appear to be as serious or fearful as chlamydia or gonorrhea.

3. Yes. If it were me or a close friend or family member, I would advise exactly as I have done here (and in your other thread).

4. I wouldn't worry about monitoring research on this. Useful information likely will trickle out over several years. In the meantime, your partners probably are sexuallly active with other men. Whatever risk there was from you probably is just as high or higher in their ongoing exposures. You don't have responsibility for the heatlh of everyone you ever slept with. Let it go.

That completes the two follow-up comments and replies included with each thread, and so concludes this one. Best wishes -- and do try to stop worrying so much about what is generally a rather minor health issue!

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