[Question #3587] Urethral Burning/Glans Penis Irritation 6+ weeks, pain during masturbation

36 months ago
  • 11/17, Negative for all STD, including HSV1/2 Also neg 4 years ago.
  • 2/24/18, make out/unprotected oral from CSW, lasts approx 15 minutes. Hour drive home, hot shower.
  • ~1 week later, mild warmth inside Urethra
  • 1.5 weeks later, warmth becomes worse, mild burning inside my entire penis. No discharge/pain during pee, just always burning
  • (3/10/18) get STD panel. Negative other than HSV1 @ 3.67+.
  • Doctor prescribes Acyclovir, go to Urgent Care (3/12/18)
  • Urgent Care inspects (circumcised), opens tip/looks inside, says looks red but no signs of blisters/lesions
  • Does DRE, feel the pain shooting in urethra. Says prostate is 'boggy', prostititis. Prescribes Bactrim 10 days.
  • Take Bactrim/Acyclovir for 7 days, see Urologist (3/16).
  •  He does DRE, prostate doesn't feel swollen, one side appears softer than usual. Some WBC in urine/trace blood, says no UTI.
  •  Suggests Doxy, tells me to stop Acyclovir b/c not GHerpes, I stop Acyclovir, switch to Doxy.
  •  ~12 hours no Acyclovir, very bad tingling/itching on thighs and scrotum. No rash/blisters/lesions. Low back pain.
  •  Few days of Doxy, burning in Urethra subsides. Itching continues, no blisters
  •  Get Oral Thrush, prescribed Nystasin
  •  Jock cream/spray, helps, keeps coming back tho.
  •  Urinary Urgency/Frequency
  •  Weak stream
7 weeks post, all gone other than irritation that comes/goes in Urethra and tip after urination. Urination doesn't hurt. Pain prior to orgasm. Mild pelvic/back pain after orgasm. Is this atypical HSV Urethritis? Mycoplasma? Trich?
Edward W. Hook M.D.
Edward W. Hook M.D.
36 months ago
Welcome to the Forum and thank you for your detailed description of events.  Let me start by telling you that you are getting far above average health care- your evaluation for prostatitis with the DRE was top drawer care and appropriate.  The  therapies that you have received are likewise well thought out and sound quite appropriate.  Thus you start out way in front of all too many of our clients whose evaluations (or worse yet, self diagnoses) are off target and misdirected. 

Here is a summary of my thoughts:
1.  It sounds like you did have prostatitis.  the duration of prostatitis therapy is not well determined and I tend to err on the side of longer therapy-3-4 weeks with Bactrim.  It sounds like you did improve on the therapy provided.  Whether additional therapy will help is unclear to me (see below).
2.  There is little in your history to suggest HSV or other viral urethritis  All of these would have gotten better by now, with or without valacyclovir.  I agree with your doctor's decisions to discontinue acyclovir.
3.  Your oral thrush is a result of your antibiotics.  Don't worry about it.
4.  Your continuing symptoms sound like the sort of symptoms that many of our clients experience when they start a vigilant "crotch watch" looking for symptoms after sexual experiences.  Your unprotected oral sex does not put you at risk for mycoplasma and as I mentioned, there is nor reason to be worried about HSV.  Similarly, trich is not acquired from oral sex.

My advice, relax.  Discuss with your very good doctor about the possibility of further treatment of prostatitis (this may lead to another DRE) but otherwise try not to worry 

I hope these comments are helpful. EWH
---
36 months ago
Dr. Hook,

Thank you very much for your opinion and reply, I appreciate all that you do for people like myself that are in these situations.

I'm hoping you can provide a bit of clarity to me with regard to a few more specifics.

1. What do you think about my recent positive HSV1 results? Is it completely unreasonable to think that I could have a 3.67 IgG after 14 days, or is it plausible? I've seen some papers regarding seroconversion timelines for herpeSelect that suggest a range of 3-102 days with a mean average of 25 days. Does it make a difference in your opinion if I told you that the urgent Care ran an IgM which came back low positive 1.13? I went to an ID doctor and had the IgM and IgG run again @ 4 weeks and the IgM was negative and the IgG unchanged (3.7). I know experts stress that the IgM is flawed, but how much so? Could something completely unrelated to HSV1/2 set it off? I'd be lying if I told you I wasn't concerned that I may have gotten GHSV1 from this experience via asymptomatic shedding.

2. I am doing all that I can to relax but this pain is still very real to me and I'm concerned of being intimate with my long term girlfriend for fear of transferring something unknown to her - is there anything else I should test for in the STI category that could explain this 7 week long NGU style burning sensation? I plan on telling her about it because I don't want a relationship built on lies, but I want to have my facts straight first if I can.

3. Lastly, since this woman was a CSW and likely saw multiple men beforehand on the same day that I saw her, is it in the realm of possibility that she may have performed unprotected oral on someone with HSV2, and then by performing oral on me afterwards, transferred it to me?

I'd like to believe this is just bacterial prostatitis from one of the hundreds of oral bacteria that I may have been exposed to, but this burning keeps me up at night, not because it hurts really, but because it's cause is unknown to me. Doctors have been unable to find any bacteria in any urine samples, even post prostate massage urine samples. Would it be in my best interest to ask them to test my semen for bacteria as well? I'm seeking a second opinion from another urologist because my urologist won't prescribe me more antibiotics because he can't find a bacterial cause, but I know that as you mentioned, longer treatment is sometimes required. 
Edward W. Hook M.D.
Edward W. Hook M.D.
36 months ago
I think you are overthinking this.  Straight to your questions.

1.  Nothing in your history suggests recently acquired HSV of any sort.  This is early for a blood test to be positive for recently acquired HSV and you have had no symptoms suggestive of herpes.  IgM tests for herpes are meaningless and no expert recommends their use.   I urge you to put your concerns about herpes aside.

2.  There is no reason for further testing.

3.  No, the scenario you describe is implausible. 

Culture of ejaculate is sometimes helpful however this is something I suggest you discuss with your doctor.  EWH
---
36 months ago
Hi again Dr. Hook,

I know that this forum teeters very cautiously on the subject of "recurring questions" (i.e., panic questions), so I hope you will entertain me and understand that it not my intent to cause further harm to myself (or others that may read this).

However, I have gotten a second opinion regarding my situation from another Urologist (though I did not disclose my HSV1 status, this was not intentional, he just kind of fired so many questions at me that I couldn't get it out). As a reminder, it has now been nearly 8 weeks since my "risky encounter".

He did another DRE, and said that my prostate is boggy - though not warm. He did a pretty thorough and lengthy exam, and he found one particular spot that was sensitive that I could feel up my urethra. He does not know if it is an infection, and so far has not suggested checking my semen for any bacteria. I have also gotten another HSV test which returned a 3.56+ for HSV1 again, and again a negative for HSV2. To keep score, my HSV1 numbers have now been: 3.67 (LabCorp), 3.7 (LabCorp), and 3.56 (Quest).

He prescribed me 7 days of Cipro, which is scary in itself (I've seen the FDA black box warnings, not a great read), and 14 days of Naproxen. Told me to take them together until finished and return to him for exam again in 2 weeks, or to call in 1 week if symptoms have not improved. I've also seen a pelvic floor therapist this morning and had an exam, and she says my pelvic floor muscles seem strong and do not appear to be over stressed, so she does not believe I have Pelvic Floor Dysfunction, though she welcomed me to try the elctro therapy anyway in a month or so.

Since my last post, I've had:
- 1 small red dot appear on my rear and 1 on my thigh, saw a dermatologist and she said it seems like garden variety acne and wasn't overly concerned. Neither of them was painful or incredibly itchy.
- almost constant lower back pain that seems to persist even while using naproxen
- this dull ache in my shaft (middle) of my penis
- this dull ache in my glans after urination
- muscle twitching throughout my body, biceps, calves, left eye, and everywhere in-between that come and go.
- after the Pelvic Floor Therapist did some squeezing exercises with her finger in my rear to test for pelvic strength, I started having a dull pain in my lower left abdomen which she said isn't a normal repercussion of that test and might indicate something going on.
- today I had another bout of urinary frequency, I voided, got back to my desk, and almost immediately had to void again. THIS is where I got concerned. For the first time in this whole experience, when I voided the second time, I felt a very sharp sting at the tip of my glans as the urine was leaving my urethra. It was very brief, only a second, and afterwards urine flow seemed fine. Urine was almost completely clear.

Since that stinging, I've had another bout of urgency - however, the dull ache inside my urethra stopped for a pretty substantial period after that, before finally just returning now. I want to live a full and honest life, and need to know with the most clarity possible what is going on with me. With that being said, I hope you will entertain a few final questions which I promise will NOT lead to further panic follow-ups.

1. Considering my original exposure (making out/unprotected oral), if I HAD contracted HSV1 from this experience and got it in both locations, could that cause my body to work "double time" to produce IgGs and explain a high positive (3.5+) after only 2 weeks? Or are you still convinced this isn't related to this exposure? After my positive test result I felt burning and tingling all over my body both in my genitals and on my lip, which may have been psychosomatic I know, but have never had an "obvious" lesion in either location in 8 weeks.
2. Does any of this sound like Herpes Neurologica ? Specifically, the constant lower back pain and the twitching in my muscles. I've been taking Magnesium suppliments to see if they would have an affect on the muscle twitching but so far haven't made any difference.
3. Is it possible that I had a stone of some sort that was either missed on a kidney ultrasound (I had my kidneys and my testicles checked), or that was in my bladder? Perhaps the stinging sensation that I felt briefly was me passing the stone, and would explain why the dull burning was gone for a longer period before returned in my shaft? During my Pelvic exam today she scanned my bladder to see how well I voided, and I'm wondering if maybe she 'kicked something loose'.
4. Likewise, would a stone cause low back pain? Would I expect that pain to go away after the stone is passed?
5. Could this be any other form of viral urethritis, such as cytomegalovirus or adrenovirus? Could any of these (including herpes) cause a boggy prostate?
6. If, to the best of your ability, you still do not believe this is HSV or any other STD, could you perhaps recommend where I should go next? Do I see a Neurologist assuming I have some (unrelated) nerve problem? Do I see a spine/back doctor for compression issues?

Again, I know this forum frowns upon panic questions, I am just desperate to get to the bottom of this so that I can move forward in the best way possible. If you could entertain me just one more time, I promise not to make this an ongoing tale. Thank you very kindly.
36 months ago
Hi Dr Hook,

I apologize for posting again but I noticed that you've addressed a few other posts today but didn't have any additional comment for mine. Its been 8 weeks now and even with multiple different antibiotic therapies, sitz baths, anti fungal creams, a soak in an apple cider vinegar concentrated bath and a change in diet I still have this dull burning in my urethra and itchy dull pain on my glans penis and shaft. 

Did you have any further comment or thoughts on my condition? How confident are you that it's not trich? I've been hearing some similar stories online where flagyl seemed to make a difference.

I'm not sure if you've just missed my post on accident or are intentionally not replying, but I would appreciate if you could comment, even if it's just to say you have no further comment, so that I know to stop checking here for more ideas.

Thanks very much
Edward W. Hook M.D.
Edward W. Hook M.D.
36 months ago
thanks for the reminder.  I must admit, I missed your follow-up.  Sorry.  Let me also once again tell you that I am impressed with your urologist and the quality of the evaluation you are receiving.  He is a "keeper".  Stick with him, not all patients are so lucky. 

I would also say once again that little here suggests and STI tome.  Receipt of oral sex is low risk and your symptoms do not match well with STI.  In fact, a recent study we conducted which has not yet been published showed that urinary frequency and urgency are not suggestive of STI.  They do support a unrialy tract problem such as prostatitis however. 

As for your specific questions:

1. Considering my original exposure (making out/unprotected oral), if I HAD contracted HSV1 from this experience and got it in both locations, could that cause my body to work "double time" to produce IgGs and explain a high positive (3.5+) after only 2 weeks? Or are you still convinced this isn't related to this exposure? After my positive test result I felt burning and tingling all over my body both in my genitals and on my lip, which may have been psychosomatic I know, but have never had an "obvious" lesion in either location in 8 weeks.
I remain convinced that your HSV-1 is not related to this exposure.  No lesions, no change in antibody index all validate my opinion.  I should add that peole almost never get infected with HSV-1 at multiple locations.

2. Does any of this sound like Herpes Neurologica ? Specifically, the constant lower back pain and the twitching in my muscles. I've been taking Magnesium suppliments to see if they would have an affect on the muscle twitching but so far haven't made any difference.
No, it really does not sound like a neurological manifestation of HSV of any sort.  I think your HSV antibody test results are unrelated to your current symptoms.

3. Is it possible that I had a stone of some sort that was either missed on a kidney ultrasound (I had my kidneys and my testicles checked), or that was in my bladder? Perhaps the stinging sensation that I felt briefly was me passing the stone, and would explain why the dull burning was gone for a longer period before returned in my shaft? During my Pelvic exam today she scanned my bladder to see how well I voided, and I'm wondering if maybe she 'kicked something loose'.
These questions are better asked of your urologist than me.  Renal stones however can cause some of the difficulties you describe but not the prostate abnormalities.

4. Likewise, would a stone cause low back pain? Would I expect that pain to go away after the stone is passed?
See above.  Yes, if you were passing a stone, once it was passed the discomfort would resolve abruptly.

5. Could this be any other form of viral urethritis, such as cytomegalovirus or adrenovirus? Could any of these (including herpes) cause a boggy prostate?
No, viral infections do not cause the constellation of symptoms you describe and the time course is off- far too long. 

6. If, to the best of your ability, you still do not believe this is HSV or any other STD, could you perhaps recommend where I should go next? Do I see a Neurologist assuming I have some (unrelated) nerve problem? Do I see a spine/back doctor for compression issues?
My recommendation would be to stick with your urologist and see how that works out.

I hope these answers are helpful.  As you know, since this is my 3rd reply to your questions, this thread will be closed later today.  I will point out again however, this set of symptoms really does not suggest an STI of any sort and I urge you to look elsewhere for explanations.  Take care.  EWH


---
36 months ago
Dr. Hook,

Thank you for your prompt response to my questions after reminder - I figured it was probably missed considering the timeline.

I am very appreciative of your time and input for myself and everyone else who struggles with these types of issues - I think I will continue to move forward under the assumption that this is either a very pesky bacteria, or a fungal issue of some sort. Thank you for providing this service, and take care. I hope to never have to speak with you again (no offense!). Feel free to close the question, I think I am satisfied with moving beyond this scare.