[Question #3558] Anxious after oral exposure - discharge

36 months ago
Dr HHH/Hook

25/M/UK (high STI rates in UK) - Received 10-30 secs of unprotected oral (BJ) from hetero woman and kissing on 20/02. Started to have pain in head of penis soon after with discharge starting on roughly 06/03. Thin discharge, looks like pre-cum (it's not) and is present every day at regular intervals with discomfort. Tested 09/03 with a profile 3 from here - https://yoursexualhealth.co.uk/our-tests/ (conscious of WC - please look on link). These came back negative but I had been on trimethoprim 100mg for a while before (stopped 7/8/9 or so days before test) could this make results unreliable? was the window long enough for those infections to be picked up? reliable? 

Tested again 28 days post exposure at UK GUM clinic (21/03). Tested for chlam, gon, syphilis, HIV - Negative. I know this is too soon for Syphilis and HIV accuracy, but are the others accurate/conclusive? Discharge still present 04/04 so doc prescribed doxycycline 100mg for ten days for suspected NGU (even though swab seemed fine for bacteria (he said some are hard to see). Symptoms include pain in penis and discharge still - not huge amounts but there regularly and painful. On day 5 of doxy - minimal improvement - what now if no improvement?

Was waiting until 12 weeks for conclusive test taking for Gon, Chlam, Syph (big worry) & HIV - can I still do this or would doxy mean it's a now 15 week conclusive (sites say to wait 3-12 weeks after doxy to test for accuracy on any tests?!). I am worried it'll mask tests, how long should I wait. 

The other person involved tested 2 wks after contact (I asked) - NEGATIVE for chlam, Gon, syph & HIV - useless though as she didn't have mouth swabs only genital & blood and could have been outside window for some of these or prior to her becoming pos?

Please help, Nervous.   
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
36 months ago

Welcome to the forum and thanks for your question. I'm happy to comment, but in person examination is just about always more reliable than a distant opinion like this, especially when qualfied experts are involved, like typical UK NHS GUM clinics. If there is any conflict between me and the clinic on diagnosis, further evaluation or treatment, I would rely more on them.

 Your symptoms are a bit confusing:  discharge with onset ~2 weeks after exposure is consistent with NGU, as ultimately diagnosed at the GUM clinic, pain is uncommon in NGU. Herpes is a possiblity, but when it causes NGU, uusally there also are external blisters or sores. Or perhaps a non-STD viral infection, e.g. adenovirus. Adeno isn't an STD in the usual sense, just a cold virus that happens to also have predilection for the urethra. This would be even more likely if you also had typical cold symptoms at the time, e.g. sore throat, nasal congestion, or conjunctivitis (pink eye). Failure of your symptoms to improve with the first few days of doxycycline tends to support a viral cause, such as herpes or adenovirus -- so this is something to discuss with the clinic.

The most important lab test result so far is the negative gonorrhea test, twice. Trimethoprim could affect gonorrhea testing, but if it did so, it also would have prevented or cured the infection in the first place, so the negative result in presence of discharge is strong evidence the discharge was not due to gonorrhea. Also, gonorrhea discharge, with painful urination, almost always starts within 5 days of exposure. The other tests in "Profile 3" just wasted money. Most of them are not carried at all in the oral cavity and therefore cannot be transmitted by oral sex; and most are non-pathogens, causing no disease at all. Chlamydia obviously is disease causing, but it's uncommon in the oral cavity rarely if ever transmitted by oral sex. In any case, these negative results also support the possibility of viral urethritis of some sort.

Syphilis testing is reasonable, but the risk was exceedingly low and your symptoms don't suggest it. Heterosexually transmitted syphilis is currently quite rare in the UK, and although oral sex is a possible transmission route, it's not a common one. There has never been a proved case of HIV transmission mouth to penis, so that's almost impossible in this situation. In any case, the standard syphilis and HIV blood tests are conclusive any time 6 or more weeks after exposure; you don't need to wait 3 months. And there is no point in testing again at any time for gonorrhea and chlamydia.

My suggestion is that you return to the GUM clinic, especially if your symptoms are continuing, and follow their further advice. You could print out this thread as a framework for discussion about next steps.

I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD

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36 months ago
Dr HHH,

It is great to hear from you - I appreciate your response, although it leaves me somewhat confused. I will put my questions in bullet point format, hope this doesn't come across too blunt. I Visited the GUM clinic again tonight and this will have reference through my questions. Apologies if I am asking questions I should've asked her - I was a late notice appointment, she was wanting me out of the room before I sat down and I didn't get to ask many Q's. 


1) I have not seen any blisters on my penis but could have missed some? I had what looked like a whitehead spot on my scrotum but it went after two weeks and the nurse said she thought it looked like an ingrown hair - likely? I have had no coldsores and the lady said she had not ever had one either?

2) If it is adendovirus, they do not test for this so how would I know/would this solve itself? I don't feel overly unwell aside from anxiety and genital symptoms - could I pass this kissing my other half??

3) I had taken 5 days worth of Doxy up until today (of ten day course) the GUM nurse said if it's not better by now it's not working - she said they would have only given me a 7 day course and my GP over prescribed. She instead prescribed me Azithromycin 250mg - she gave me two to take in front of her and a further 4 tablets - one a day for four days. She said that if this doesn't clear it she doesn't know - the doc and her think its Mycoplasma Genitalium - Thoughts?

4) I have read that if it is mycoplasma is pretty much incurable due to the lack of cell wall and I am terrified that I will not get out of this mess?! I know you have said that Mycoplasma is not transmitted orally so now I feel in a bit of a dead end as that is what they have guessed, I reinforced it was oral. She ruled out Gon and Chlam as she said my trim 200mg would not have affected it as I stopped taking it a few weeks before the test? I struggle to rule anything out until the Discharge is gone! 

5) The nurse said that IF this is MG (it takes two weeks for results due to the complexity of the test - She took a urine sample and I had not urinated for 3/4 hours) then the Azithromycin would help it in a few days and the discharge would disappear (true?) - she said to test again at 90 days to be sure it is not syphilis, gon, chlam & HIV - she said that the Doxy wouldn't mask syphilis as it's only cured after 3 weeks of treatment so would show up in a test if I had it?

6) I have not had any Chancres (I don't think?) and it has been 49 days since the event, would this rule out syphilis along with my 4 week test?

7) My scrotum also seems to be inflamed - I take it this isn't a symptom of any STI? I have put chest pains and fatigue down to anxiety but I am just nervous. 

Is there anything else you can think in your expert advice this could be? I know you are unable to be 100% as this is the internet and not your practice.

I really appreciate your help and guidance. Any support is very welcome as I am extremely anxious. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
36 months ago
1) You would not miss herpetic blisters/sores if you had any. And it would not be just one. An ingrown hair (folliculitis) diagnosis is straightforward and not likely missed herpes.

2) Testing for adenovirus is rare, not generally available in most STI/GUM clinics. And in any case, if that's what you've had, by now the test would be negative. This problem clears on its own.

3) You've had correct management for NGU:  either doxy or azithromycin and switch to the other if the first doesn't work. M. genitalium is believed to pretty much always cause discharge. Although MG explains some cases of treatment-resistant NGU, MG is known for sure to not be carried in the mouth or throat (several studies have looked, with consistently negative results) and thus not acquired by oral sex. A viral infection is a lot more likely.

4) You read wrong or misundertood. Indeed MG can be difficult to treat, but it is never incurable; there are effective antibiotics, just not ones that are used routinely for most NGU. Anyway, for the reasons above, it's not a consideration for you. (Please also note that there are several Mycoplasma species. Only one, M. genitalium, is an STD or cause known genital symptoms.)

5) Not all GUM clinic nurses, even well trained ones, are likely to be aware of hte data on M gen and oral infection. If she does not, probably the GUM specialist physicians in the clinic will be aware. In any case, I suggest printing out this discussion for them; they might appreciate it. This link is to the introductory paper in a supplemental issue of the Journal of Infectious Diseases, published a few months ago -- summarizing all the available research from a symposium on the topic. One or more of the papers addresses absence of oral infection. The second link is to one of the better research papers showing lack of association of MG NGU with oral sex. And finally an editorial accompanying the latter article.

6) There is no realistic chance you had syphilis, but if you did, the azithromycin and doxycycline would have cured it and your test will never turn negative. So you can be sure you don't have syphliis now and probably never did.

7) Anxiety seems a good bet for this symptom. You are correct that no STI would cause scrotum pain, irritation, etc.

My bottom line? Viral or some sort of non-infectious (chemical? allergic?) urethritis seems most likely. If not done, and if your urethral symptoms are persisting at your next GUM visit, they might consider a urethral PCR for herpes (it would almost have to be HSV1), and maybe adenovirus if their lab has that capability. But if the symptoms are improving, as I suspect they will soon, consider an immediate and follow-up type specific HSV serology, to see if there is conversion from negative to a positive result for HSV1.

I'd love to hear what your GUM nurse and/or her medical director have to say about these comments. But in the meantime, you should say relaxed. Almost certainly this is and will never be anything serious. (Even genital herpes due to HSV1 usually isn't an ongoing problem, with few recurrent outbreaks and low risk of transmission to partners).
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H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
36 months ago
The third link should be https://www.ncbi.nlm.nih.gov/pubmed/16388479 


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36 months ago
Hi Doc,

Thank you for your answer. Can I just ask for clarification on one point you made - you said my syphilis test would never turn negative? 

As far as I am aware, she did not have a cold sore when she gave me the 10/15 seconds of oral (she told me she had never had one but I don't trust her - she is 37 so I believe she has a long sexual history). At 50 days out (contact - 20/02) I have not seen any large sores or groups of sores on the head of my penis of foreskin/shaft (I have been studying my penis 10 times or so a day). I get red dots from time to time at the base of my penis that look like spots but they go in a day or so and could be irritation or where theres tiny hairs? I am now terrified of HSV1 genitally (I know you say it is not a big deal but this happened outside a relationship which I know in my head is already over). What is the possibility of her passing it to me by oral one time? IF she had it, what are the chances? is there caveats? 

I have looked inside my penis tip and urethera today and I have seen it is very irritated inside the meatus - there looks like several pin prick sized (tiny) red dots, that could well be the red veins on the surface - could these be herpes sores? I have had the discomfort for weeks and weeks (It started before the discharge in early march) - I call it discomfort as it does not sting when I pee, but sometimes I get flashes of discomfort when sitting etc and sometimes after peeing but not really during flow - could these be herpes sores? or would they be bigger and more painful? or could this just be inflamed because of NGU possible infection?

Even if I was to test for HSV  it would take over 3 months for an accurate test? Which test? (GUM don't bother testing as it's permanent) The GUM nurse was dismissive, as said that Herpes would not have caused discharge and discomfort for this long of a period? the discomfort seemed to start soon after the contact with discharge starting later.

IF and it's a big IF the azithromycin clears the discharge, do I have anything to worry about (would this mean it was some kind of NGU?) and will the aggravation hopefully go? If it is NGU and it clears because of medication could it recur? 

I was also kissing her deeply - but have not had a cold sore on my lip? does this make any difference with your thoughts as HSV1 always has cold sores?? Maybe a few more cuts and ulcers inside the mouth but not sure if these were hepatic and may be caused by stress. I have never had a cold sore as far as I am aware - sometimes spots of lips (mainly off lip but touching) but these are whiteheads (I am spot prone). 

When I pull my foreskin back there are obviously red/blue etc veins, on the  inside of the foreskin there is a tiny pin pricked size red dot with a little white centre, it is not raised, or deep, and was probably there before - looks to be slightly under the surface, sound ok? (hasn't changed in appearance since first noticing it weeks ago (probably over inspection). 

I plan to test at 90 days for chlam, Gon, Syph, HSV 1/2, HIV, HepA,B,C - is there anything else which (ignoring current results) could have been possible?! I understand that I was low risk - but I am doing this for my partner more than anything. You seem confident this is a harmless and non-permanent form of uretheris? 

I know a lot of symptoms are down to anxiety, sometimes pain in arse, sometimes pain in bladder/pelvis area etc 

Also, I understand that I have had two replies (after you have replied to this one) but my case seems to be somewhat of an anomaly - therefore would you allow me to revisit this thread one more time after I have visited the GUM or had results as they do not seem to know their stuff as much as you... If not I will pay again. Plus, just to clarify - after having discharge for so long - it is ok to have what looks like moisture inside the urethra because this is different to discharge?

I understand my questions are discombobulated and dotted around but i'd appreciate you trying to sift through them, you're helping me stay sane!

Kind regards, 

Anxious 



 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
36 months ago
I'm afraid you're asking and expecting more than is practical or intended for a forum like this. These questions get into details requiring clinical judgment that really needs in-person evaluation and care and all these issues would be more effectively addressed by the GUM clinic during your follow-up visit. I would also urge you to cease all self-examination. Self assessment of the urethra is notoriously unreliable, especially by anxious, medically untrained persons. And your description of the appearance of the head of your penis (or inside of the foreskin) doesn't sound abnormal. In both cases, await the GUM visit and then accept their judgment about it, which will be much more reliable than any speculation I might make. Also you should not plan on any particular set of follow-up tests. Some of the ones you mention make no sense. Here too, let the GUM clinic make their recommendations and then follow them.

I will add that even though I have speculated that herpes could be an explanation for your symptoms and findings so far, it's very unlikely. But here too, follow the clinic's recommendations. And don't make any of this more important than it is. The probability is low that you have anything important to your health or that of your partner, and at this point I am not convinced anything is abnormal at all.

We've gone well beyond the norm for our services, and it is unlikely I would have anything important to add, or that I would not agree with whatever evaluation and recommendations you receive from the clinic, so that will have to end this thread. If things remain unresolved afterward and you'd still like another round, you'll have to start a new thread at that time.

But I do hope the discussion has been helpful. Best wishes.

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