[Question #3119] chronic urethritis

40 months ago
45 y/o m ; unprotected penis massage only by sex worker after sex worker masturbated herself (she used hand sanitizer after masturbation)4 weeks later dysuria one day after doing triathlon in open fresh water; NAATs for GC/CT/ (-) ; Herpes Select IgM/G (-) ;urologist noted distal urethral meatitis ; Rx for nonspecific urethritis: mult antbx...10 days Levo; 10 days Cipro; 3 weeks Doxy; no improvement; 10 days Valtrex no improvement; some mild rectal discomfort did ensue; diagnosis chronic urethritis with prostatitis; off antx x 2 weeks prostate massage w urethral culture:  4+ enterococcus; given amoxicillin 875 bid x 6 weeks; 1st 3 weeks felt dramatic improvement then developed relapsed symptoms now with prominent groin/suprapubic pain. NSAIDs seem to help the best. Another urethral culture showed 1+ enterococcus and Klebsiella Oxytoca. ID curbside for Urologist felt that enterococcus and Klebsiella ‘commensal’ organisms rather than pathogens. Off antbx 1 month. Still w groin/suprapubic pain and mild rectal pain; dysuria improved; NSAIDs still help; Still see some distal urethral meatitis Monthly Herpes Select (-) x 6 mo since original encounter. Urine NAAT? for Trich and Mycoplasma (-); HIV, VDRL, PSA, urinalysis, semen culture, ESR, CRP, Hemoccult, HSV/CMV urine PCR, CT abd pelvis all (-). Uro confused concludes not infection and could be immunologic…reactive urethritis? Recommended against cysto. Any input? Could this be HPV? Have we ruled out HSV?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
40 months ago
Welcome to the forum and thanks for your confidence in our services. Unfortunately, however, I cannot come up with the answers you hope for, i.e. a clear diagnosis or a particular treatment to suggest. I can, however, assure you with substantial confidence that nothing important is wrong, i.e. that no serious consequences are likely for you or for any current or future sex partners.

First, I am not at all confident you have urethritis at all. Although there is no true gold standard for its diagnosis, the main way we document urethritis is with increased white blood cells in the urethra, either by urethral swab or in the first part of the urine stream. You don't describe that any such test has been done, but if and when it might be accomplished, I am pretty confident it will be negative. Second, you don't really describe typical urethritis symptoms, i.e. urethral discharge. Third, you were not at risk for any known STD. You cannot catch urethritis or any other STD from hand-gential contact.

However, you almost certainly did have prostatitis due to enerococcus and may still have it; or perhaps persisting non-bacterial prostatitis. But these are not STDs.

On top of the impossibility of any STD based on the exposure described, as your multiple negative tests document you have none of the infections for which you were tested, including HSV. HPV is not known to cause utrehthris or symptoms like yours. Finally, I agree with your urologist about the possibility of "reactive" urethritis, i.e. an immunologic reaction not caused by any infection. This is not an established medica entity, but non-infectious inflammation probably can affect almost any organ system, and I cannot say this is impossible. Indeed, it sounds like your urologist is quite insightful to raise the possibility.

Perhaps the most important bottom line is the one noted above: whatever is going on, nothing dangerous is going to come from it. This is an issue of comfort, probalby nothing more. All humans live with various aches and pains at one time or another. They generally tolerate them well once they become convinced no harm will come. Not all symptoms mean disease.

Sorry I can't come up with any better answers, but hope these comments have been helpful. I recommend continuing to work with your urologist if your symptom continue or you remain concerned. But for now I agree with him that further evaluation probably will not be fruitful.

Best wishes and Merry Christmas--  HHH, MD

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40 months ago

Thanks for the information Doctor.  I think you are right about the fact that this may not represent true urethritis. I never had discharge and never had WBCs seen on urinalysis (though did not have urethral smears). The urologist felt that the urethral abnormalities represented ‘meatitis’. I can assure you that I do have inguinal and suprapubic pain…strangely enough, worse at times of stress. In addition, I have rectal discomfort that was originally thought to be prostatitis but I am not so sure … I think it could represent mild proctitis. From my research, normal PSA value would argue against prostatitis.

I just had another urethral culture finalized…no further enterococcus growth and just grew coagulase negative staph (contaminant or skin flora, I understand).

To some extent I cannot stop obsessing about the possibility of some type of ‘chronic HSV’. My follow up question would be is it possible that for some reason my immune system has not made IgG to HSV 1 or 2 at this point? How likely is it that the serial negative Herpes Select IgG and HSV urine PCR represent ‘false negatives (type II error)?’ Finally could HSV or a viral infection lead to some type of inguinal or suprapubic ‘neuralgia?’ Thanks again for your input. 

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
40 months ago
There is no such thing as "chronic HSV", at least not persistent symptoms from herpes. All HSV is chronic in that all infections are lifelong, but any symptoms are always intermittent, not lasting more than 1-2 weeks for any single outbreak and never recurring more often than once a month, and usually no more than every 2-3 months. Your negative HSV blood tests and PCRs are undoubtedly true:  you don't have it. (Even if the blood test had been positive for HSV of either type, my conclusion would be that you have asymptomatic HSV that would not explain your symptoms.)

Also, be clear that I am not saying you don't have real pain. You do. But I'm not convinced it is caused by any sort of ongoing inflammatory or infectious problem. Tension headaches cause very real pain, but the origin is nonetheless psychogenic, with stress, anxiety, etc causing increased tension in scalp and neck muscles. Much the same can occur in the genital area. In other words, even though the pain is real, I suspect your concern about the overall situation is magnifying your perception of trivial symptoms or normal body sensations that otherwise would not be bothersome and perhaps not even noticed.
 
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