[Question #318] Multiple STD concerns and hopeful response to Dr. HHH article?

35 months ago
I appreciate the opportunity to discuss my sexual medical concerns on this forum with such top experts.  I have done a lot of homework on the subject, as I had an ex girlfriend with HSV 2 and HPV.  I posted on this forum and not Herpes because I am concerned about multiple STDs and most of my herpes questions are actually related to info I have read from Dr.HHH specifically, if he is willing to comment on them... Much of what I have read is thanks to this site and your work on medhelp.  In any case, I appreciate your time and will try to brief but thorough, however I do have many questions...

Sexual History: 
-straight 32yo male 
-celibate for the last 3 years 
-4.5 years ago had female partner with genital HSV2 and HPV (LEEP performed 6months before I knew her). We had mostly oral sex (both ways)  and masturbated eachother for the year we were together and had condom protected intercourse 3-5 times.  She was not on suppressive therapy, although hopefully we avoided obvious outbreaks. Certain factors may have increased my susceptibility, including her being older than me by 2-3 years and her being possibly treated with corticosteroids for her eczema.  Her infection was also likely around a year old so her shedding was probably higher.
Out of the blue, after no sexual contact of any kind in the last couple years and zero contact with my ex, 10 months ago I had what seemed like a UTI or prostatitis. Severe semen like discharge (slightly yellow when wiped onto toilet paper) that didnt stop, urethral and some pelvic pain, and after a day or less even had a relatively constant watery anal leakage/discharge.  I had no problems with defecating, but I certainly had significant urinary voiding problems.  Urgency, incomplete voiding, some pain with stream.  Notice no external lesions at the time.  1-2 weeks prior I did hold my urine for a long time during a very hot and sweaty road trip.  I wonder if hygiene or the long hold time played a role in my infection?

I saw my GP and a urologist.The GP did a urinalysis: 
Blood:  +++ 50 
Ketone:  50 
Protein:  100 
Nitrites:  Positive 
Ph: 5 
SGravi: 1.025 
Leuko: 500 
Found  Greater than 100,000 FU/ml of Ecoli 
Everything else negative including Gono PCR on discharge.  STD PCR urine test for chlamydia, trich, mycop, neisseria gono, ureaplas all neg.  No tests done for HSV at the time 

GP suggested UTI from E coli or perhaps Prostatitis. I took Cipro and the discharge stopped and pain went away with 48 hours.  I still had some fear it could be herpes related. 

I had lingering pain in the tip of my penis for several months and still to this day have a sense of incompletion after voiding.  Some very very minor discomfort urinating.  I had varying levels of pain in tip of penis, urethral and prostatic? ache but have mostly gone away. Urine tests since and cyscoptomy were normal. HPV or HSV the cause? Urologist seems to think it is just sensitive prostate issues, although sudden onset of E. Coli out of no where with no sexual activity was highly unusual in a younger man.
HPV, herpes, or any other STD a possible cause?  Recently had a negative Western Blot for HSV 2 (positive for type 1 probably from childhood) and of course no test for HPV are available.  I had Quest Labs test done for HSV as well (igg I believe) with the same result.

Other symptoms to note:
A few weeks ago I had what I thought was just a pimple in my the crease of my groin at/on the scrotum. There is some hair there but not a lot and I couldnt be sure if the ‘pimple’ was on a hair follicle or not. I didnt get the ‘pimple’ tested… maybe I should have… what do you think?  My lesion ‘popped’ pretty readily. I did not see any white waxy stuff like with a cyst (which worries me), but it definitely felt like it needed to be popped (and it took little effort to do so) with the type of under-the-skin welling up you would feel from a pimple. And the fluid was reddish, sanguineous (big word) blood like… not clear or straw colored like I read herpes lesions are? It also had a lot of force behind it when it popped because it shot out.  Gross description, I know, but as I understand it, herpes lesion or anything related to hpv for that matter is not associated with such pressurized lesions while something like this is typical for a cyst or infected hair follicle, yes?

So where do I go from here?  I assume I have a High Risk Type HPV from my ex, and I am learning to cope with that, however herpes is still a bit of a question and I wonder if any of this played into my E. Coli infection.  I think the key to knowing at least my herpes status is the WB testing, but the only published statistics I could get for the UW WB was actually from you, Dr. HHH, and I had hoped you could weigh in on that specifically along with my HPV infection concerns.
You commented on medhelp that 2-3% false negatives show up here:
http://www.medhelp.org/posts/STDs/Final-word-on-Herpes-test-Accuracy/show/2130911
But on CDC article back in 1998 you give a much more confident quote of ~1%.
http://www.cdc.gov/std/herpes/prev1998/herpes1998.pdf
I suppose it is asking too much to split hairs on figures like that, but I thought I'd ask in any case.  Of course, a person is going to prefer 99% accuracy over 97-98% when you are talking about STDs, but I know no test is perfect.  I had hoped you might know University of Washington's official stance on the matter?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
35 months ago
Welcome to the forum and thanks for your question; and thanks as well for researching your questions ahead of time. However, there is a limit of 2500 charcters including spaces (about 500 words); yours is twice that long. You must have written it offline and then pasted it, which bypasses the software that otherwise prevents >2500 characters. (If you entered directly, please let me know and I'll alert the adminstrators about an apparent software glitch.) In any case, the moederators can't be expected to read long essays. I will reply after you edit down to <2500 characters, including spaces. Thanks for your understanding.

HHH, MD


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35 months ago

Sorry Dr. HHH, I definitely did copy and paste.  I hope this is better, I couldnt find a word count tool to verify:

celibate since 2010

2008 -female partner w/genital HSV2 & HPV (LEEP performed 6months before I met her)Mostly oral sex (both ways) &masturbated eachother for the year we were together &had condom sex 3-5 times.  No suprsve therapy, avoided outbreaks, but likely Fingered her 1-2 days before one. Other susceptibility factors: she is older by2-3 years & her being possibly treated w/corticos for her eczema.  Her HSV/HPV was also around only a year old so her shedding was higher.

Recently had a neg Western Blot for HSV2 (pos for HSV1)

After no sexual contact of any kind for years &zero contact w/ex, in Feb-I had what seemed like NGU. Severe semen like discharge (yellowish on toliet paper) nonstop, urethral/pelvic pain,&after a day or less even had a relatively constant watery ANAL leakage/discharge. Urgency, incomplete voiding, some pain w/stream. Notice no lesions at time.1-2 weeks prior I held my urine for hours on very hot&sweaty roadtrip. Hygiene/long hold time play a role?

Blood: +++ 50

>100,000 FU/ml Ecoli

Everything else neg incldng Gono PCR on discharge.No tests done for HSV at the time

GP suggest UTI/Urethritis via E coli or perhaps Prostatitis. Cipro stopped discharge by48 hours.

Lingering pain penis tip for months but now improved, but still now have sense of incompletion after voiding w/minor discomfort. Urine tests since &cyscoptomy normal.  Urologist says sensitive prostate, although sudden onset of E.Coli w/no sexual activity unusual in 32yo man

A month ago I had what I thought was a pimple in the crease of groin at/on scrotum. There is some hair there but not alot & I couldnt be sure if the ‘pimple’ was on a hair follicle or not. I didnt get the ‘pimple’ tested, mistake?  My lesion ‘popped’ readily. I did not see any white waxy stuff like w/a cyst (which worries me), but it def felt like it needed to be popped w/the type of under-skin welling up you would feel from a pimple. Fluid was reddish, sanguineous blood-like; not clear/straw colored like HSV is? It also had alot of force behind it when it popped because it shot out. Gross sorry but I read herpes/hpv is not associated w/such pressurized lesions but is typical of infected follicle?

What now?I assume I have High RiskHPV from ex, but HSV2 is still a bit of a question &I wonder if any of this played into E. Coli issue or maybe NGU? The links in my first post (last paragraph) were your comments on WB testing.  I had hoped you knew UW's official stance on false neg rate since that is my only concrete evidence; it is a concern

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
35 months ago
Thanks very much for the compressed version.

First, you can dismiss herpes. Based on your sexual history, your risk was very low despite your partner's HSV2 infection. In HSV2 discordant heterosexual couples, the average transmission risk per episode of unprotected vaginal sex is around 1 in a thousand; and you had only a few vaginal exposure, apparently all condom protected as well. Sure, the risk could have been higher since your partner's HSV2 infection apparently was relatively recent, but what if the real risk were twice as high as otherwise? One in 500 still is a very low risk per sexual exposure. And regardless of the risk at the time, your blood test results prove you weren't infected. It is a mistake to focus only on blood test performance -- whether they miss 1%, 2-3%, or some other proportion of HSV2 infection. The calculation of your chance of having HSV2 is also based not only on the blood test(s), but on the low chance of infection based on your exposure history, plus lack of symptoms to suggest genital herpes. There is simply no realistic chance you have HSV2.

Second, you could be infected with HPV, and could even have been the source of your partner's infection. But not necessarily. As you likely know from your own research, we all get genital HPV, which is a normal, expected, and essentially unavoidable consequence of human sexuality. And pap smear abnormalities that require LEEP as often as not are the consequence of HPV acquired years earlier. If you acquired HPV from your partner, and even if you were the source of her infection, you can expect your immune system to clear it up and to never have any health problem from it.

Although non sexually acquired UTIs are uncommon in men, and most don't start out with overt urethritis, it happens. E. coli is the most common cause, so that apsect is typical. The tests for gonorrhe aand chlamydia are highly reliable, and herpes doesn't cause this sort of syndrome. When herpes causes urethritis, it's generally limited to painful urination with scant discharge, and as already discussed, your blood test proved herpes would not be possible unless it was newly acquired -- but you weren't exposed. And HPV never causes problems anything like these.

Your urologist is correct to be concerned about possible underlying prostatitis or perhaps other urinary tract problems. It is universally understood that spontaneous UTI in all males, unlike UTI in females, requires evaluation for underlying problems that explain it. Prostatitis is the single most common underlying factor, but others must also be excluded, such as kidney stones, stricture somewhere along the flow system (ureters, urethra, etc), or congenital anomalies like bladder diverticulum. These are aspects to discuss in further detail with the urologist. But the lingering discomfort at the penile tip and sense of discomfort and incomplete bladder emptying are typical for prostate problems. It is often difficult, requiring several weeks of antibiotic treatment, to clear bacterial prostatitis.

As for the pimple in the groin, I'm sure this is entirely unrelated to herpes, HPV, the UTI, or your sexual history. Sounds like you had a garden variety pimple or sebaceous cyst that became infected.

"What now?" First, don't worry about HPV. If you have it, you can expect your immune system to clear it up and it will never cause you problems. You need not mention your partner's infection to future sex partners. Your chance of having it, or future partners' risk of catching it, is no higher for you than for any sexually active male your age. Second, forget herpes; it should no longer be on your mind at all. Third and most important, follow your urologist's advice about your UTI, likely prostatitis, and so on. But you can be absolutely confident this has nothing to do with your previous sexual relationship or any STD.

I hope this has helped. Thanks again for your patience with the forum's standards about question length. Best wishes and stay safe--

HHH, MD




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34 months ago
Hello Dr. HHH, I apologize for the long time since my last post to now.  I just wanted to take a lot of time to absorb and digest the advice you offered me.  I have a few thoughts that remain in my conscious I had hoped you could address before my thread is closed (I know this is my last reply).  I am very appreciative for the help you have offered already.  I am still thinking about my moral obligations with HPV, but your words have eased them a bit.  I wont bother you further with that now, but I had couple last thoughts about herpes...

Remaining herpes concerns:
I had one other event (similar to my pimple you already addressed) well over a couple years ago:
I had one small scare in 2012 (4 years post herpes exposure, when I wasnt dating anyone) when I had one (and perhaps a second next to it) pea sized lesion in the fold of my leg (pubic hair area) right inside the crease. A smaller red bump this time (there was actually a second very small bump next to it near hair follicle). To me, it behaved like a pimple again, like the one we discussed.  I did not have a white head (pustule?) but it was red (papule?), felt solid in the skin, and a bit tender. I did ‘pop’ it and with some force the way a tense pimple would. I am not certain but I think I saw a very small bit of white fluid (pus?) that maybe was the plug in the hair follicle? It was accompanied by clear fluid. Squeezing a second time expressed blood. I have read clear fluid is more suggestive of herpes, but it seems to me I’ve had pimples on other parts of my body express clear fluid. I can recall yet another similar bump on the opposite leg crease ‘pop’ with a significant amount of white pus. 
The more worrisome part is that I went to my urgent care over it, and I had a 100.4 temp (I dont remember how they took it) but I was anxious and probably had my heart racing from nerves. Anyway, the doctor seemed confident it was just infected hair follicles and if my memory is right went as far as to touch the lesion with his bare hands. I wasnt exposed or anything, as I was able raise the leg of my shorts enough for him to see the lesion without actually taking my shorts off. I know this sounds similar to my previous pimple/lesion question, but I wanted to be thorough, especially given the unexplained elevated temp.  perhaps I should have mentioned this event initially.

I know it is ultimately a game of statistics.  I am trying to cut through the likelihoods. I know transmission rate is roughly 4% but I also know that is in couples who have been together for a while, so they are sort of 'survivors' to start with, but still 4% is low.  I know my blood tests are (hopefully) around 99% accurate, but I am also weirdly in the <1% of guys to randomly get a UTI/prostate issue with acute discharge.  I know garden variety infected hair follicles make sense, but then what are the odds they were once accompanied by a slight fever?  My mind struggles to justify it all.  OK, I will stop absorbing this forum's time now.  I appreciate you greatly.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
34 months ago
Thanks for the thanks about our services. I'm glad to have helped.

Thanks also for the clarifications. The additional symptoms still are not typical of genital herpes; the previous events were much more consistent with folliculitis with secondary cellulitis; and fever goes along with that diagnosis even more than with herpes. And herpes rarely occurs in the skin fold; most lesions are on the penis, especially the initial infeciton. I remain confident herpes has nothing to do with your recent UTI. Moreover, your Western blot result is definitive:  you do not have HSV2. Given that, it is pointless to play probability/statistics games about the likelihood you have HSV2. You do not, period.

Finally, it isn't "weird" to have an uncommon condition like a bacterial UTI without an obvious predisposing cause. Rare things happen.

Happy new year!

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31 months ago
Hello Dr. Handsfield,

It has been a few months since you offered me all the great advice and help.  I largely moved on with my concerns, however there has been a new development... I am not certain if I am allowed another post, but if not, I will happily puchase a follow up.

The problem is that my initial acute prostatitis/UTI symptoms have re-emerged.  I have significant discharge (which appears to me to be prostatic fluid) that is on going and some discomfort when voiding.  I still have no herpes lesions externally at least.  Like my initial acute issue, my symptoms are paired with watery bowels and slight discharge from rectum as well.  What the heck is wrong with me?  STDs, worms, painless hidden fistula?  Of course my Urologist is on vacation.  I will likely see one of his partners tomorrow.  What tests should I ask for?   I have had zero sexual partners of any fashion for a few years, so if this is an STD it is years old.  Naturally herpes is still a worry since it was my only know exposure.  To save you time in re-scanning our previous interaction, my acute UTI previously found e coli in my urinalysis but no reliable direct herpes testing was done at the time.  
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
31 months ago
Welcome back. As we discussed earlier, prostatitis often is a chronic, recurrent problem, not related to STD. However, it isn't usually simultaneous with the sort of rectal symptoms you have, and they make me think of an inflammatory condition in your rectum, such as ulcerative proctitis (rectal inflammation) or colitis; or if you were a gay man who had had receptive anal sex, an STD. Something that could connect all this would be if you have a fistula. A fistula is an abnormal connection between hollow organs, or from such an organ to the skin. I wonder if you have a fistula between your bladder or urethra and your rectum. Fistulas in this part of the body can complicate any lower pelvic infection or inflammatory bowel disease, like ulcerative proctocolitis. If the problem started in the intestinal tract and fistulized to your urinary tract, that would explain the E. coli UTI. Also, a rectal problem could fistulize to nearby skin, perhaps showing up as pimple-like lesions. (This is pretty speculative. Fistulas to the outside usually are peri-anal i.e. show up near the anus, not the groin. But I wouldn't rule it out.)

I didn't remember or focus on the simultanous rectal symptoms in my replies above. Sorry I didn't think of it then. But at this point, if I had to take a stab at a unifying diagnosis to explain it all, I would be suspicious of a primary rectal problem that resulted in a internal peri-rectal abscess that then drained (i.e. fistulized) into your urinary tract, causing the UTI. In any case, there continues to be no realistic chance that an STD is responsible for any of it, or that it has anything at all to do with any sexual exposures at any time in the past.

You definitely need expert evaluation by a urologist, proctologist, or gastroenterologist or some combination of them. You may require internal examination (e.g. protosigmoidoscopy and/or cystoscopy) and sophisiticated imaging of your pelvic area, like ultrasound, MRI, etc. Don't let anybody start antibiotics or any other treatment until the evaluation is well underway, assuming you're not seriously ill (fever, severe pain, etc).

I'm not going to be able to speculate further on this until and unless you have been examined by an expert. Nevertheless, I'm going to leave this thread open in the hope you will return to report the findings after you have had specialty care, i.e. if and when a final diagnosis has been made. I'm very interested in learning how this shakes out, even though it's not an STD problem.

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30 months ago
Hello Dr HHH,

I want to start by thanking you for how kind you have been through all of this, this site has been a blessing.  

Here is my latest status.  My urine test came back positive for 80k e coli, same cause as my initial symptoms.  Discharge was negative by PCR for herpes.  Anal discharge and penile discharge cleared quickly on cipro.  I wanted to delay treatment to see a gastro as you advised, but the symptoms were pretty significant and I couldnt see anyone soon.  My urologist dismissed the anal discharge as coincidence but I think he is wrong.  I am relieved it is only bacterial and not some viral cause however... I feel much better after treatment.  Should I go ahead and follow up with a gastroenterologist?  What do you advise?

One final word on herpes...  Concerns about it have weighed on me.  I appreciate your words of comfidence that I dont have it, but a few worries linger.  Anytime I have anything worrisome appear down there (I do occasionally get pimples) I often have them swabbed.  I learned recently that PCR can produce false negatives when the swabs are bloodied, which has been the case in at least a couple of my swabs.  This lowers my confidence that every bump ive had was indeed just a pimple, though I think it is more likely to be benign than it is to be herpes at this point.  I am about to start a sexual relationship with a girl I hope to marry, she knows my history.  I explained to her that there is a lot of evidence that I dont have herpes.  The biggest evidence being a negative WB after well over a year after exposure.  I have told her the opinions on the test varies.  My best understanding is that you put the false negative hsv 2 rate to be around 2-3%, Dr. Hook around over 5%, and Terri Warren and Dr. Corey less than 1%.  (This is what I have gathered from this site and medhelp) unfortunately there appears to be zero info in black and white documentation on the true number.  The only studies I have found seem to show that prior hsv 1 may make false negatives more common for hsv2 which puts me in the less confident category.  I dont know if you are aware of this, but there are massive forums going back and forth on herpes WB testing reliability on the web.  It has been exhausting to read through.  I had hoped you could offer some final words on this, and what info I should share with my gf about my status in general as well.  Thank you infinitely
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
30 months ago
If you asked your urologist about my speculation about a fistula and he still feels confident that the anal discharge and genital problems are unrelated, he's probably right. But you definitely should ask about it or get a second opinion, e.g. from either a gastroenterologist or a colon and rectal surgeon.

The urine culture indeed supports the notion of chronic bacterial prostatitis that occasionally flares up. There remains nothing in your story that suggest any STD is responsible.

As for herpes, you are overly focused on the lab test results, and it true they are not perfect. HSV PCR misses the vast majority of infections except when a herpes lesion or sore are sampled. And the HSV2 blood test misses 1-2% of cases. (The data on this are not precise, hence slightly different estimates from equally qualified experts.) But the conclusion you don't have genital herpes rests on a lot more than your test results. Absence of symptoms that suggest herpes (despite your past genital pimples), and the impossibiliy that herpes would cause the symptoms you do have, also is important. I don't recall what potential HSV exposures you might have had, but if you have never had a regular partner with known HSV2 infection, that also lowers the odds. Considering all factors, I am 100% confident you don't have HSV2, need not mention it to current or future sex partners, and should have no more testing for it. And stop searching the web about it.

From a medical or risk standpoint, there is no need to discuss any of this with your girlfriend. As a sign of commitment and caring, many new couples discuss their past sexual exposures, STD history, STD concerns, and other medical problems with each other, so you may choose to have a conversation with your partner. But this is strictly a relationship issue, not one of sexual safety or transmission risk to her.

So deal with the prostate/urinary infection, and the possible connection (figureatively and literally) with your intermittent anal discharge. But put herpes all STDs out of mind.

Take care and stay safe.

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