[Question #3364] NG Urethritis lenght of symptoms and possible resistance to treatment
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90 months ago
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Dear Doctor: I was diagnosed with NG urethritis 3 days ago after a sexual encounter with an escort 8 days ago with oral and vaginal sex protected with a condom. The day after the encounter, I noticed swollen lymph nodes on both sides of the groin, so I became panicked and went to the STD clinic. I started PEP with truvada an tivicay, and tested negative for herpes, hep C, vih and sifilis. I had an urine sample with a chlamydia and gono results pendant. 5 days ago, I started with redness on the tip of my penis, watery discharge and extreme pain when urinating on my penis and on its tip, so I automedicated with one dose of levofloxacin 500 mg which was left for other treatment long ago, but the day after it was worse so I went to the clinic again and got diagnosed NG urethritis and was given azithromycin 1 gram and 7 days of ciprofloxacin 500 every 12 hours. I saw the doctor looked at my sample on the microscope. Its 3 days after and ive been taking rigorously the ciprofloxacin, but the pain urinating and the redness are worse, the nodes are still there, and I started with morning milky discharge which I didn't have. With this said my questions are : 1.- Is normal to have more pain and more discharge after a dose of azithromycin 1 gram and starting the Cipro even if 3 days have passed (I'm on the 4th day right now)? 2.- Could it be the antibiotics didn't work because the levoquin created resistance? 3. When do you think the symptoms should end, specially the pain and discharge and when should I test again? Thank you for your time and responses.
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H. Hunter Handsfield, MD
90 months ago
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Welcome to the forum. Thanks for your question. There's a lot to it, but I'll try to break it down.
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I suspect your NGU is due to a virus. Viral infections account for around 5% of NGU cases. And as you may know, viral infections do not respond to antibiotics. Your symptoms are highly typical for viral NGU, namely prominent dysuria (painful urination), scant discharge, and "meatitis", i.e. redness and swelling of the urethral opening. Failure to respond and even to worsen in the first 2-3 days of antibiotic treatment also supports this possibility. Two viruses cause most such cases of NGU. Herpes simplex virus (either type 1 or 2) and adenovirus. Most new HSV is associated with typical herpes blisters and sores, in addition to urethritis -- although some cases have urethritis only. The other is adenovirus -- primarily a respiratory virus and a common cause of colds and/or conjunctivitis ("pink eye"). When sexually acquired, adenovirus usually comes from oral sex, sometimes by someone who has or recent had a cold, cough, etc. As might be obvious, such cases don't necessarily require sex with a new partner: a regular partner with a cold or with oral or genital herpes could be the source. Same for herpes, especially HSV1, the cause of oral herpes (cold sores etc).
Apparently the vaginal exposure with the escort was condom protected, but as worded I'm not certain about oral. If it was, your apparent urethritis may not be related to the escort encounter at all. Have you had sex with anyone else, e.g. a regular partner, in the 1-2 weeks before onset of symptoms? To your knowledge, does any such partner have herpes, either oral or genital? Or a current or recent cold or cough? Also provide more information about your negative tests for various STDs. Was your herpes test a culture or DNA test, e.g. PCR? If so, it's pretty certain you don't have herpes. However, it takes several weeks for blood tests to become positive, so a negative HSV blood test doesn't mean very much. But you should speak with your STD clinic about treatment with acyclovir or valacyclovir, which is recommended whenever viral NGU is suspected (show your clinic this editorial I wrote recently: https://www.ncbi.nlm.nih.gov/pubmed/28079750).
Ciprofloxacin is not recommended for NGU and not used by STD experts, but I don't think that's the problem; and in any case, the azithromycin is highly reliable against garden variety NGU. Taking a dose of levofloxacin would not have made an infection resistant and hasn't made any important difference.
Lymph node inflammation cannot start in under 24 hours. If that's part of the problem, it goes along with herpes (and maybe adenovirus?), and with catching the infection several days before the escort contact.
Those comments address some of your specific questions, but to be explicit:
1. No, such a delayed treatment response is not normal for most NGU. As discussed, it favors a viral infection.
2. No, levofloxacin (Levaquin) made no difference.
3. Most likely your symptoms will start getting better in the next few days, although it may take 1-2 weeks to clear completely. If it's herpes, an anti-HSV treatment will speed up your improvement.
I hope this information is helpful. Consider discussing all this with your STD clinic (you could print out this thread and show it to them). Let me know if anything isn't clear.
HHH, MD
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90 months ago
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Hi Dr and thank you very much for your time and responses. I will try to respond the best I can your questions:
The oral sex with the escort was condom protected, but she inserted the condom in just the tip of the penis and started perfoming oral sex immediately covering the totality of the gland, but not totally covering the entire penis with the condom, which she did in a matter of 20 or 30 seconds. The herpes test , as far as I know, was a Herpes immunoassay gG2 test, from venopuncture (the results say a window of 102 days). The lymph nodes are bilateral, painful, swollen, and started to be exact at 52 hours after exposure with the escort, with one very noticiable at the left at first, and after that two on the right and another smaller on the left inguinal area, and they were the first symptom. Syphilis was an rpr, and hepatitis C was an antibodies test. I have the hep b vaccine, so dr told me not to test, and vih test was a rapid one. I haven't had sex with anyone 1 month prior to the onset of symptoms. she didn't confess any ilnesses or had any visible sores, and my stable partner is clean. This girl told me she was 100 percent clear, but I don't believe her.
With all this said, and thanking you again for your time and responses, do you believe its still herpes virus or could the chemichal agent of alcohol have any relation? If herpes or adenovirus, could I ask you what you think about possible prognosis of living with this and when should I test again? I don't have any genital sores (I do think though that I have had already previous oral herpes), but if I ever got them in a genital outbreak it would end my current relationship with my stable partner in the worst way possible if she discovers it since she doesn't have it, and I think it would definitely affect my sexual life with future partners. I thank you again for your time dr and I would definitely ask for an acyclovir or vala treatment.
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H. Hunter Handsfield, MD
90 months ago
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If you have had oral herpes, you're immune to a new infection with HSV1, which is the only type likely from oral sex. With that information plus no sores, you can be pretty sure your NGU isn't herpetic. The risk of adenovirus should have been low if there was no oral contact with the head of your penis and the meatus, but I can't say it was zero. 52 hours is more consistent with the lymph nodes being involved from that event than "the day after the encounter" as you wrote initially. So you may well have adenoviral urethritis. Not all adenoviral or other cold virus infections cause symptoms; that your partner didn't have an obvious cold doesn't make much difference.
Could alcohol or other chemical irritant do all this? Urethral pain yes, but not soreness and other symptoms that last for a few days, and not the lymph node inflammation. I'm pretty sure this is an infection, not chemical irritation or allergy. But I also very much doubt herpes, for the reasons above.
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90 months ago
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Thank you for your time and response again Dr. This will be my final follow up according to the rules of the forum. To better and finally understand, If I was tested for herpes virus 2 via Herpes immunoassay gG2 test and it was negative (which was 6 days after the encounter) and also had protected vaginal and protected oral sex on that encounter (2 times on the encounter, the condoms where intact, but she used some kind of brown lube), and being positive in that ive had oral herpes, does that exclude too the possibility of contracting genital herpes hsv2 in this encounter (which I understand is different than oral or 1 type) or I could STILL have that? Does the nature of extreme burning pain only when urinating and not having any other sores make any difference between supporting the herpes possibility vs the adenovirus possibility?
Finally I will ask for possible herpes and adenovirus follow up and a prescription for acyclovir with your editorial, in the clinic. Thank you dr and sorry to bother but the feeling of having using protection and still get something that would be potentially for all life, (which I understand could be genital herpes 2 ,I don't know about possible genital adenovirus prognosis and recurrence), destroying my current relationship and causing serious problems for potential future ones, and still don't having a conclusive cause of this, is extremely frustrating.
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H. Hunter Handsfield, MD
90 months ago
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Apparently you misunderstand herpes terminology. Genital herpes is not called herpes type 2, and oral herpes is not called herpes type 1. The numbers refer to the virus, not the body area infected. The two types of herpes simplix virus are HSV1 and HSV2. Either one can infect either the genital or oral area. But oral HSV2 is rare; therefore, genital HSV2 almost never comes from oral sex, only by genital-genital (or genital-anal) contact.
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And as I already said, since you probably have had oral herpes, you already have HSV1 and are immune to a new infection with it. So there was no risk of genital herpes due to HSV1. And for the reasons above, also little or no risk for genital HSV2. For those reasons, it is unlikely your current problem is due to herpes, making adenovirus more likely. Other viruses that may infect the oral area (various cold viruses, etc) probably can do the same thing. These and adenovirus do not recur and are not known to be sexually transmitted from the genital area.
For those reasons, I don't really understand why the STD clinic did an HSV2 blood test. In any case, it takes several weeks to become positive, so your negative result a few days after the escort exposure only means you were not previously infected with HSV2; it says nothing at all about the cause of your current NGU. If a later test becomes positive for HSV2, it would indicate a new HSV2 infection, but for the reasons above, I'm sure that will not happen.
For the reasons above, I doubt you have urethral HSV1 either. However, if your urethritis is continuing, you could ask the STD clinic about having a swab test for HSV1, either culture or PCR. There are no readily avaialble tests for adenovirus or other viruses that might be responsible. However, it really isn't important at this point. It is unlikely you have anything that will bother you in the future, once your symptoms clear up (which will happen soon); and, once it clears up, nothing you can transmit to partners.
That concludes this thread. I hope the discussion has been helpful. Best wishes to you.