[Question #2782] Possible NGU?

41 months ago
I am a physician who is super anxious about a problem that seems to be lingering.  Sexual encounter on day X and started noticing symptoms on day X +5.  The encounter consistent of protected vaginal sex and unprotected oral sex.  Symptoms of increased urinary frequency with scant clear and watery discharge.  No pain, burning or cutaneous lesions.  Went to the MD, urinalysis showed negative leukocyte esterase, negative nitrites, but >30 WBC per HPF with negative culture.  Treated with 250 mg of ceftriaxone and 2 G of azithromycin.  Gonorrhea/chlamydia NAAT negative, negative culture including mycoplasma hominis and ureaplasma.  Symptoms of discharge and urinary frequency have improved but still linger so took 7 days of doxycycline after the azithromycin.  Discharge still present after so  now currently on day 9/10 of taking moxifloxacin 400 mg incase of mycoplasma genitalia.  In a panic also took 2g x 1 tinidazole two weeks ago incase of trichomonas infection.  Currently day X+28 and still scant clear discharge, mostly when examining/milking head of penis.  Repeat urinalysis day X+18 (mid way through course of doxy) showed no WBC on microscopy.  Question: was this NGU and if so is there any other treatment that was missed?  If NGU could I still be infectious given persistent clear scant discharge even after abx and negative follow up urinalysis?  If NGU how long can discharge persist because?  What is the next step (is there a next step)?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
41 months ago
Welcome to the forum. Thanks for your confidence in our services, especially considering your profession. It's an occasional pleasure to be able to respond using clinical and professional terminology!.

There's a lot that isn't understood about NGU. As it happens, I recently wrote an editorial about some of the uncertainties. The focus is on partner management, but that issue is directly related to the unknowns about etiology and significance:  Handsfield H. Sex Transm Dis 2016;43:712-3 (https://www.ncbi.nlm.nih.gov/pubmed/28079750).

By definition, you had NGU:  you met criteria for urethritis (symptomatic discharge, urethral leukocytosis) and didn't have gonorrhea. Clearly it was nonchlamydial, as expected:  condoms work and chlamydia uncommonly infects the oral cavity and hence is rarely transmitted by oral sex. Your negative M. hominis and U. urealyticum were expected, indeed testing really wasn't indicated:  MH isn't known to cause urethritis, and although UU can do so, most UU reflects colonization with nonpathogenic strains; and neither is known to be carried in the oral cavity or transmitted by oral sex. Ditto for M. genitalium:  rarely if ever in the oral cavity and not known to be transmitted by fellatio (the latest report, from Japan, found no oral MG among 92 men with gonorrhea or NGU). Trichomonas vaginalis also is rarely if ever carried orally. I'll mention HSV for completeness, but herpetic urethritis usually is much more painful and usually accompanied by typical cutaneous lesions; it's not a serious consideration in your case.

You have been treated with all the right drugs and, as you apparently know, in the right sequence for NGU that doesn't initially respond to standard regimens:  if despite the above (e.g. oral transmission after all? condom failure?) you nonetheless had any of these, they should have responded to the treatments you had. M. genitalium may not always respond to moxifloxacin, but for the reasons above we can be confident you didn't and do not have it.

So what's going on? As discussed in my recent editorial, it seems likely that some NGU represents urethral inflammation in response to a new but not necessarily abnormal bacterial flora, i.e. the microbiome hypothesis. Some investigators believe this is especially likely after oral as opposed to vaginal or rectal exposure. It is also possible that some urethritis isn't infectious at all, but some sort of primary immunological phenomenon. In any case, except for gonorrhea, chlamydia, and M genitalium, there is no evidence that urethritis is harmful either to affected men or their sex partners. Admittedly, this is somewhat speculative:  as they say, absence of evidence is not evidence of absence, and there are legitimate worries about a relationship to non-infective prostatitis. But the weight of evidence is that there is no serious problem:  certainly in my 40+ years in the STD business I've never had a patient like you who later showed up with any important genitourinary problem in either themselves or a partner.

Finally, from your description, your symptoms seem to be gradually improving. My inclination is for you to just sit tight (not trying to be cute!) and wait out your current symptoms. I'll bet they fade. I also see no reason you cannot resume sexual activity, with no need to raise any issues with your partner(s). Of course I would recommend condoms for new or other non-monogamous vaginal sex events, but that should be routine regardless of this recent episode.

Sorry the answers aren't clearer, but that's how I see things at this time. Let me know if anything isn't clear.