[Question #3591] 1 Night Stand and thick white discharge after a month.

34 months ago
Dear Doctor,

Thank you for letting a guy which stays thousands of miles away having a chance to ask an expert like you.

I am basically an Indonesian guy who is sexually inactive but unfortunately had acquired a weird infection on the genital area.

The first encounter was when an Indonesian prostitute performed a fellatio several years ago and I developed more than 1 blisters on the penis shaft and painful urination. I got myself checked after a year or so and found out there was nothing, not even a single STI were found on the blood tests, including HSVs.

The second encounter is what I'm currently worrying about. I went on a 1 night stand with a girl whom I assumed is sexually active (not a prostitute), we had sex 2 times during the night and the morning after. Right after a month, I started to develop an itchy urethra and thick white discharge appears every morning. I performed a "wait and see" approach but it didn't stop so I consulted with my GP and he decided to give me Zithromax. I finished the medication for 3 days and felt better. However after several weeks, I started to develop another same problem. I am waiting for my swab result tonight but still not able to pull myself together so I decided to post this question online.

I know this might be a small issue but really need your suggestions:

1. Are the symptoms described above suggest an NGU and should I be worried or is this something that can be dealt easily ?
2. For this 1 night stand event, should I get tested for HSV, HIV, Hepatitis, HPV ? What are the chances for these infections ? How long should I wait for a reliable test ?
3. Has the white discharge got something to do with my first encounter ? 

I think that's all I wanted to ask. Your answers are greatly appreciated.

Regards,
worriedman


H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
34 months ago
Welcome to the forum. Thanks for your confidence in our services.

The first exposure mentioned was years ago, but you don't say when the second occurred, but if I understand the timing of your symptoms, apparently it was within the last 3-4 months, right? From your description, it is certainly possible you acquired NGU. Symptoms usually begin within a couple of weeks, but a month may be possible, and the symptoms themselves -- an itching sensation in the urethra, white discharge -- are typical. So is improvement with azithromycin. And persistent or recurrent NGU after azithromycin treatment is quite common; it occurs in up to 10-20% of all men with NGU.

Some important information is missing. Were you tested for gonorrhea and chlamydia during the first episode? Did your GP diagnose NGU, or were you treated based only on your symptoms? Presumably you saw your GP again (or a different doctor or clinic?) for the swab test:  Were you also examined? Any rapid testing done, e.g. Gram stain, urinalysis, etc? What did that doctor or clinic say:  does s/he think you have urethritis again? Was no treatment given this time? The standard, recommended treatment for NGU is to give either azithromycin or doxycycline, and in event of recurrence, to treat with the opposite drug. So if you current doctor believes you have NGU, you should have been treated with doxycycline (or similar drug, e.g. minocycline). But perhaps s/he is waiting for the test result before deciding. However, if that test is negative, you still should be treated.

To your specific questions:

1. As noted above, your symptoms are typical for recurrent NGU and I suspect that's what you have. I expect the swab test to be negative for gonorrhea and chlamydia.

2. These other infections are very unlikely after any single exposure, or in people with symptoms like yours. The normal approach is to test for gonorrhea and chlamydia, and to collect blood for syphilis and HIV testing. (Your symptoms do not suggest either of these, but both are serious and testing is quick and easy and therefore almost automatic in situations like yours.

3. NGU or other urethral discharge infections don't show up a year after exposure. Even if you had such an infection that long ago, your immune system would have cleared it up by now. Almost certainly this problem is from the more recent sexual exposure. In any case, another round of treatment (probably with doxycycline) should take care of this, with no long lasting effects or complications.

Going back to the fellatio exposure a year ago and getting penile "blisters and painful urination" soon afterward, this sounds like you had genital herpes, probably due to herpes simplex virus type 1 (HSV1), the only type frequently carried in the mouth. Your negative HSV blood test does not mean you didn't have herpes. It takes up to 4 months for the HSV blood tests to become positive. Also, up to 30% of people with HSV1 do not develop positive blood tests at all. However, genital herpes due to HSV1 causes infrequent recurrent outbreaks and is uncommonly transmitted to partners, so this probably doesn't matter very much. And it has nothing to do with your current symptoms.

I may have more to say if you would like to fill in the missing information and the results of your current swab test. In the meantime, I hope these comments have been helpful.

HHH, MD
---
34 months ago
Thank you Dr. Handsfield for your prompt and informative reply.

To clear up the missing information:
1. The second exposure occurred exactly on 22nd of February 2018.
2. On my first exposure, the only test I did was only blood tests for couple of months and stopped after a year and a half or so which all came back negative. My GP treated me only based on symptoms and visual observation. I also had urine test but it happened days after treatment so I guess it was useless since nothing was found. I was given accyclovir (definitely wrong spelling) for HSV treatment and antibiotic for other infections that might occurred during that time.

Going back to current time, yesterday night the swab test suggested I was infection with Gram positive coccus-shaped, small and aligned 2 by 2 (I just translate this to english since the result is in my language). My GP is sending me another antibiotic today for the treatment. 

My follow up questions are as follow:

1. Is the Gram-Positive easy to be treated ? And is this always 'sexually transmitted' or is this might just be a result of poor hygiene ?
2. My latest HSV blood test result after more than a year from the first exposure was shown to be negative and according your reply there is still chance that I have the infection but the blood test failed to acquire it. How certain are you with this ? is it close to 100% ?
3. Does testing for HIV and any other dangerous infections provide reliable result by now (17/04/2018) ? I want to have a reliable result because testing for HIV will extremely destroy my eating appetite for a day or two.

Thank you Doctor.
 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
34 months ago
Thanks for the clarifications.

1) The gram positive cocci on gram stain are not the cause of your infection. Such bacteria are normally present in the urethra. As I said above, since you were already treated with azithromycin and your NGU recurred, the next antibiotic should be doxycycline. If your doctor prescribes something else, I suggest you get another opinion from an STD specialist.

2) Despite the negative blood test, it is very likely you had genital herpes from your distant past exposure; otherwise the doctor would not have prescribed acyclovir. As I said above, up to 30% of people with HSV1 do not develop positive blood tests. But as I also said above, genital HSV1 (the only type from oral sex) often does not recur and is uncommonly transmitted sexually to partners. So this isn't something for you to be worried about.

3) All HIV blood tests are 100% reliable any time more than 8 weeks after the last possible exposure, so you can safely be tested now. Don't be anxious about it:  the chance you caught HIV is almost zero. You can expect a negative test result.

---
34 months ago
Hi Dr. HHH,

I just received my antibiotic medication, identical to the one that you prescribed (Doxycycline). I'm gonna take the medication 200mg per day for 7-10 days course. Once the course finishes, I would then have my blood tested for STIs.

Thank you for your support and answers, I greatly appreciated them.
Have a nice day ahead.




34 months ago
Hi Dr. HHH,

Sorry to bother you again with another response. As I am writing this, I actually just woke up in the middle of the night due to an irritating itchiness in my urethra. I am taking Doxycycline for 2 days now and still don't feel any better. Is the delay reaction of the medication normal or do you suspect I am taking an inappropriate medication ?

Thanks Doctor.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
34 months ago
Doxycycline is the standard treatment in this circumstance. It can take a few days for symptoms to resolve. If you still have these symptoms and discharge after 5-6 days, return to the doctor treating you. If you continue to have evidence of urethritis, i.e. continuing NGU, then the next step would be treatment with both metronidazole (or tinidazole) for possible trichomonas; and moxifloxacin for possible Mycoplasma genitalium.

We have gone beyond the 2 follow-up comments and replies included with each question, so that completes this thread. I hope the discussion has been helfpul. Best wishes.
---