[Question #29] NGU fears

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108 months ago
Hello Dr.,
I'm at a breaking point and am looking for some objective, expert advice. I'm afraid my OCD and guilt have gotten the best of me so I need an outside opinion. Everything started three years ago (6/4/2012) after I had unprotected oral and protected vaginal sex with a prostitute on a business trip (NYC if that matters). I don't remember the condom breaking but I cannot be sure anymore. My wife and I use condoms as protection and always have (with the lone exception of one encounter where the condom broke, noted below). I have not received oral sex from my wife in four years.  

The following is a timeline of events:

6/11/2012: Strong urge to urinate, clear discharge, diagnosed with NGU (clear for Gon, Chl, HSV, HIV) at an STD clinic based on high WBC's from urethral swab. Treated with 1g azithromycin and 1 week cipro. 

6/22/2012: Still feeling discomfort so return to STD clinic. No evidence of WBC. Just to be safe, given 2 weeks doxycline. Return to clinic after abx finished and given clean bill of health but some irritation around urethral opening persists. 

1/5/2013: Still feel tenderness around urethral opening so I go to a urologist. Prescribes flagyl for one week and difulcan. No immediate relief but symptoms fade over the next 8 months. 

2/1/2013: Wife has gyno exam and nothing is noted (but I'm unsure what tests were done). 

5/20/2013: Out of nowhere, I develop discharge again and strong urge to urinate. I immediately get tested for gon and chly and pay for an expensive trichomoniasis and m gen NAAT test through urethral swab. Both come back negative and symptoms end after a few days.

12/30/2013: Once again, out of nowhere I develop discharge and a strong urge to urinate. Urologist sees "unusual looking" WBC's in microscope analysis of urine and prescribes one week of clindamycin (negative tests for gon. and chlamydia). Symptoms pass after a few days. 

11/24/2014: Condom breaks during sex with my wife. One week later, I develop clear discharge and strong urge to urinate. Discharge stops after 24 hours. One week after discharge stops, I test again for standard STDs and for trichomoniasis (NAAT urine) and m gen (NAAT urine). Everything is negative. 

My wife will be going to the ob/gyn two months from now in preparation for having a child. She has had long and irregular periods for the last few years along with occasional discharge. She will also bleed during sex from time to time (only about 1/4 of the time we have sex). Broadly, I need to know whether I need to get a divorce attorney after the ob/gyn appointment. More directly, I need to know:

1. What the chances are that I contracted an STD that failed treatment, was transmitted to my wife through a condom, missed by her ob/gyn appointment in Feb. 2013 and reinfected me at some point despite condom use? 

2. I'm especially worried about trich for some reason. I feel that I have been adequately treated and tested for gon., chly., and m gen. Do trich infections in men persist for weeks and months (I read that they may not but others say yes)? Would the NAAT tests I took miss it or are they reliable? 

3. Do my wife's symptoms (long, irregular periods, occasional bleeding during sex, occasional discharge) indicate an STD...in particular, trich? Would her gyno exam miss an STD if I gave it to her between June 2012 and February 2013? 

4. What might explain my short bouts with discharge and frequent urination (sometimes with evidence of WBCs)? Two have no possible explanation (no condom failures and no unprotected sex of any kind) and one occurred a week after a condom break. Whenever a urologist has looked at the discharge, he has said it is "crystal clear" so I had nothing to worry about. Is there an STD cause? 

I realize I may sound a little crazy doctor. I apologize. I just cannot explain my recurring symptoms and my wife's problems. Please help ease my mind. Thank you doctor. 
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H. Hunter Handsfield, MD
108 months ago
Welcome to the forum. Thanks for our question.

I won't comment on all the dated events and tests. But a few comments on them before I get to your questions.

First, I am not convinced you ever had NGU. Your symptoms have never been typical (the main symptom is discharge), and urinary urgency is usually not a symptom. There may be discomfort or itching in the urethra with voiding, but not urgency. That symptom is, however, typical for genitally focused anxiety after a sexual exposure that may be regretted or anxiety producing. Second, a single observation of WBC in the urethra is not necessarily abnormal. In my clinic, many patients with that finding are treated for possible NGU, but with full knowledge that the diagnosis isn't confirmed. In at least half of men with increased WBC on a single sample (without visible discharge), repeat testing shows no WBC. In other words, it probably is entirely normal for men to have a few WBC in the urethra from time to time.

Second, even if NGU was present, it had to be from the oral exposure. And NGU from oral sex is not known to cause any significant health problem for either affected men or their partners. Even with NGU, you had nothing that was likely to cause symptoms or any health problem in your wife. This problem was not a valid reason for you and your wife to be using condoms the past few years.

Third, a comment about failure of various antibiotics to improve symptoms. It did not mean you were infected with bacteria (or viruses or anything else) resistant to those antibiotics. What it meant is that no infection was causing the symptoms. 

Most likely the only problem you have ever had is the chronic pelvic pain syndrome (CPPS) or chronic, non-infectious prostatitis (these two conditions may be one in the same). These are inconvenient and often uncomfortable syndromes, but harmless for both affected men and their partners. Google CPPS (spell it out) for lots of information. The Wikipedia article is good; also look for information from the Stanford University Dept of Urology.

Those comments pretty well cover some of your questions. To be explicit:

1) I believe you never had any STD.

2) Trichomonas isn't known to cause symptoms like yours, and you can't get it from oral sex -- and the vaginal was protected. And you have been treated for it. This is not a valid concern.

3) There is nothing in your wife's symptoms that make me suspicious she has any STD. (I don't follow your comment about a divorce attorney. Unless you're driving your own wedge into the relationship because of the concerns you've been having for the past three years.)

4) Some men have clear urethral mucus from time to time. From all you say, I tend to agree with your urologist that nothing is wrong. For sure you have nothing that will ever harm you, your wife, or any other future sex partner. Not all symptoms mean disease.

I hope this has helped. Best wishes--  HHH, MD
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108 months ago
Hi Dr. Handsfield,
Thank you very much for your reply. Perhaps I've been misunderstanding NGU or did a bad job describing my situation. Each of the times I have been worried about my symptoms, discharge has been the main cause of my concern. The first instance of NGU was diagnosed (one week after my oral exposure with the prostitute) at an STD clinic where the clear discharge was noted and the WBC's were confirmed through a urethral swab. Is it possible that this was a misdiagnosis? The three subsequent instances over the last couple of years had very clear discharge that cleared up over the course of two days. I feel that I've taken every antibiotic under the sun and have received multiple expensive tests for gon, chly, m gen, and trich. Was this all for nothing?

My anxieties all stem from a concern that my encounter with the prostitute infected me with something that was never resolved and somehow infected my wife at some point over the last three years despite our use of condoms. Her symptoms (which as far as I can tell are horrible menstrual cramps during periods, long periods, irregular periods, occasional bleeding during sex and occasional discharge) make me very, very, very worried that when she attends her obgyn appointment, she will be diagnosed with a cervicitis or PID from an STD. The only STD that would make sense given my testing, treatment and her symptoms is trich (I hear it is hard to diagnose in men and may be missed in a standard gyno exam like the one my wife had a few years ago). If this happened, I would have to confess my slip up and would almost certainly end up divorced. Of course, I am completely ignorant about female STD symptoms and diagnosis. 

So I guess my few clarification questions (if you don't mind addressing them) are:
1. Eight months after my diagnosis with NGU, my wife had a gyno appointment. At that point, I had been treated with flagyl, doxy, zithromycin and cipro and received negative tests. We used condoms every time. Is it possible the gyno missed something with her because she is married and therefore a low STD risk? 

2. How plausible is it for a bacterial STD to persist this long in me or my wife (or pinging back and forth)? It has been more than three years.

3. What is the quality of the NAAT tests for Trich in men? I hear conflicting things. I paid for it twice and both times it was within two weeks after the onset of symptoms. 

4. Based on everything, is there really any chance that my wife has an STD (resulting in cervicitis  or PID) that she received from me that will be diagnosed at her obgyn appointment or are my mental health issues sprialling out of control? I'm really, really worried about her symptoms as they sound like something that could be caused by an STD. 

Thanks again doctor for your kindness and your patience and your expertise. It is a high stress time for me and I realize that my questions may seem repetitive and without a basis in reality but your thoughts help me tremendously (in fact, my therapist encouraged me to reach out to this service). I hope your answers will help me move on with my life and put this one stupid night behind me at last. 
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H. Hunter Handsfield, MD
108 months ago
This information doesn't change my opinions or advice. If anything physiologic was ever wrong, almost certainly it was prostatitis -- which is not caused by STDs, will not harm you, and cannot harm your wife.

1) Please get this straight:  you were not at risk for anything that could ever harm your wife! I cannot imagine her doctor missed an STD problem.

2) Good point. Even if I'm wrong and you had a bacterial STD, it would have been cleared by the immune system long before 3 years.

3) As I said, you could not have caught trich from the exposure described. The NAAT for trich is not approved for use in men -- not because it doesn't work, but because it hasn't been systematically studied and the manufacturer hasn't applied to FDA for approval to use it in men. But it probably is highly accurate.

4) "Based on everything, is there really any chance... etc":  Absolutely not.

You seem to be trying very hard to have verification that you really have something wrong. Please do your best to accept the science based reassurance I have tried to give -- as have your own doctors, I am sure. If you cannot, see my previous comment about counseling. Your fears really are far beyond normal.