[Question #3851] Medical Mystery?

33 months ago

Drs, 


Bit of background - M (27), exposure was on 21/02 and was unprotected oral sex on me (blowjob) from a mature heterosexual woman. It lasted between 20-25 seconds coupled with deep kissing. I started having pain and discharge in my penis on the 6th of march roughly.  This discharge and discomfort lasts to this date. Pain in the head of the penis and discharge is the constant, can be worse when I haven't urinated for a while but is there all day everyday. 


Discharge looks like pre-seminal fluid, it is small amounts (doesn't exit foreskin), stays on underside of penis. I had never had this prior to the incident. I had been put on Doxycyline which did not work so was changed to Azithromycin for 4 days and still no change.


Tests:

09/03 - Tested for chlamydia & gonorrhoea (Both Negative) Had been taking Trimethoprim for a while prior to this 

21/03 - Tested for Chlamydia, Gonorrhoea, Syphilis, HIV (All Negative)

09/04 - Tested for Mycoplasma Genitalium (Negative) - at this point the GUM clinic said they did not know what it could be

23/05 - Tested for Chlamydia, Gonorrhoea, Syphilis, HIV (All Negative) 

11/06 - Tested for Chlamydia, Gonorrhoea, Trichomonas, Mycoplasma, Gardnerella, Ureaplasma, Herpes 1, Herpes 2, Hepatitis B (All negative) all were urine tests aside from Hep B (these were done with www.better2know.com who support the terrence higgins trust)


These last tests when I arrived they said I would be doing a first of the day sample, but it was 4:50pm so I gave a sample having not voided for 3 hours or so, would these still be accurate?


1) Should I be considering any other tests?

2) Could this discharge still be linked to the sexual act (timing seemed spot on)?

3) Am I safe to resume unprotected sex?

4) I have not seen any sores - can I discount herpes (I recognise that the urine test above are not accurate for HSV1&2)

5) Do you know of any other possible causes of this?

6) Are all my tests conclusive? I appreciate your help as I seem to bamboozle logic at the moment 

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
33 months ago
Welcome to the forum. Thanks for your question.

Indeed this is a mystery, and I'm afraid I cannot solve it. You started with symptoms suggesting typical nongonococcal urethritis (NGU), which sometimes is acquired by oral sex. It also could have been gonorrhea, but less likely because gonorrhea symptoms usually are more severe and start within 4-5 days of exposure; and the the gonorrhea lab tests are highly accurate, so the negative result rules it out. 

In my opinion, even without out the answers, you were overtested. For example, Mycoplasma genitalium is never acquired by oral sex (it has never been found in the oral cavity). Gardnerella and Ureaplasma rarely if ever cause symptoms in men. Ditto for viral hepatitis.

Some NGU cases from oral sex probably are due to entirely normal oral bacteria that don't show up on any testing, but even these usually would respond to one or more of the treatments you had. Adenovirus, a respiratory virus that usually causes common colds and related syndromes, can cause urethritis, but usually with more severe symptoms (e.g. quite painful voiding, and redness/irritation of the meatus); and clears up on its own within a couple of weeks.

Some cases of urethritis may not be infectious at all, but represent an aberrant immune reaction. That would explain the negative results for all tests as well as continuing symptoms despite several antibiotics.

My final thought is that you might not have urethritis at all, but some other reason for increased urethral (or prostate gland?) mucus or other fluid production. Did the GUM clinic determine that you have increased white blood cells (WBC) in your urethra? If not, then the diagnosis of urethritis is questionable at best, supporting absence of either infection or an immunologic reaction.

Perhaps the most important bottom line is that there are no reports in the medical literature of men with symptoms like yours ever developing any sort of important medical problem, or of causing any health problem in their sex partners. Certainly I have never seen such a case in my 40+ years in this business. Accordingly, I'm confident you can move on with your life without worry about any serious outcome. I suggest ceasing all further attempts at diagnosis or treatment. You may find the scant discharge simply disappears with time.

Those comments pretty well answer your specific questions, but to be explicit:

1) I can suggest no further tests.
2) Maybe linked to (triggered by) that event, or maybe not. Any link is not necessarily an infection; see above.
3) If I were in your situation, I certainly would continue unprotected sex with my regular partner without worry. I would have done so as soon as the initial tests and first round of treatment had been completed.
4) There's no way this is herpes.
5) See above.
6) All your tests are conclusive.

Sorry I can't provide definitive answers, but I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD
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33 months ago
Thanks Dr. 

Do I not have all of the NGU bases covered? My only worry is that I may transmit something to my regular partner which I am terrified about. I was tested once for white blood cells early on and it was said that they saw no signs of inflammation from the discharge sample I gave. I had previously been unwell with a bladder pain which was diagnosed even after a cystoscopy, but after this I had been on trimethorpim for months, could this have caused some of the discharge and discomfort? I understand you are not a urologist, but I am just seeking general advice.. 

Have I covered all of the bases for things that could be transmittable? I know you said I have been over tested, but have I been tested for everything that could have possibly gone wrong. I have also been incredibly stressed for the last few months, to the point of depression, so I figure the prostate may have something to do with it. But as I say, my main concern here is transmission to others, which I am very keen to avoid.

I take it that most tests in the UK are mega sensitive and that none of the tests I have taken (bar HSV) have the possibility of missing something?

This has taken over anxiety wise in recent months and I would be willing to put it down to this solely in the absence of discharge. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
33 months ago
I've already said I am confident you have nothing to transmit to your partner. That's especially likely with this additional information:  absence of WBC and "no signs of inflammation" were evidence against infection of any kind. In my clinic, you would never have received any antibiotic or any testing other than gonorrhea and chlamydia.

You have indeed covered all the basis (repeatedly and unnecessarily) in regard to NGU.

Do your best to accept that all is well, nothing is seriously abnormal, that you only have a trivial symptom that doesn't mean anything. Not all symptoms mean disease!

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33 months ago
Thank you Dr. I understand, as you are probably aware that pain in the head of the penis and discharge after this incident is unnerving. The other question I have is based around STI's in the mouth. If I did not perform oral sex on her can I have anything in the mouth - for example if it were an infection, could I get it from her kissing me after oral, or if I touched her vagina inside and then touched my mouth with her fluids on my fingers etc?  I have had no tests of the mouth, but then I guess if all my genital tests are negative nothing is specific to the mouth and I am safe to resume not only penetrative sex but also oral sex?

From what I gather it is almost impossible for a man to get an STI of the mouth even from oral sex on someone who is infected? 

I take it that the tests I have had done would also be more than enough if it was fully blown unprotected vaginal/anal sex? 

I plan to visit a urologist to see if there is anything else wrong non sexual related as it had been nearly four months since this started. 

I appreciate all of your help.



H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
33 months ago
STDs don't travel through the body from an exposed site to somewhere else.

But you are wrong in the second statement. Oral STDs are not as common as genital (or anal), but they certainly occur with some frequency. The highest risk by far is from fellatio, i.e. penis to mouth. Transmission is rare, but not impossible, by cunnilingus (oral-vaginal contact).

The tests you had were sufficient no matter what sort of sexual contact you have or how often.

Feel free to consult with a urologist, but don't get your hopes up for a specific diagnosis for these symptoms, I am confident nothing phyiscal is wrong. I have to believe the pain, and perhaps even the apparently increased moisture, are due primarily to increased awareness of trivial symptoms or even normal body sensations magnified by some sort of unresolved anxiety over the sexual exposure described. Certainly you have no STD or any other infection from the exposure described.

That concludes this thread. I hope the discussion has been helpful. Best wishes.
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