[Question #391] Severe dysuria ! Help

34 months ago
I start experiencing severe urethritis symptoms last Saturday ( mild burning from last Tuesday ) . Pain severe enough where I can't urinate at times. Had unprotected oral sex 3-4 days before symptoms started. Didn't have access to lab , treated myself with suprax + azithromycin at recommended doses . When burning didn't go away in 2 days , I gave myself with ceftriaxone Im 250+ azithro 1000 , and started doxy 100 mg bid . On Saturday pain became very severe ( severe burning with urination) , reloaded with 500 Im ceftriaxone ( thought was failure of treatment ) , and started acyclovir (thought of atypical manifestation of hsv , being only urethritis without any skin lesions ). Didn't treat with more abx as robust gon/clam are unheard of. Continued doxy and added Bactrim bid for possible uti. No improvement in the symptoms after 3 days of acyclovir. I Did tests including urethral swabs , microscopic eval of the discharge came , negative for chlamydia , gonorrhea , hsv1&2,negative for hiv. ua positive for rbc , calcium oxalate ( previous hx of stones , I think it's a red hairing, I had stones before I know I still have they never presented like this) . I had mucousy discharge , that has improved , but stickiness at the meatus is presents Had a tender right inguinal lymph node that has much decreased in size and tenderness . On Sunday i had right sided conjunctivitis that is almost resolved and one day symptoms of cough and runny nose which has resolved on Monday . I'm currently on cipro 500 mg bid for urethritis came recommended at the clinic where i had my testing done (though levo 500mg qd would have made more sense ) when i did my testing. I repeated my test a second time at different lab and came back negative as well.  I have to take azo ( which is making the urine orange ) and cranberry pills to be able to urinate still with considerable amount of pain.  Ejaculation is painful as it goes through the urether. Is this adenovirus urethritis ? Or should I treat for Mycoplasma Genitalium ? Fungal infection? Is there any room for steroids to relief inflammations ? What should I do ? 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
34 months ago
Welcome to ASHA's Ask the Expert forum. Thanks for your question.

You present a very interesting case!. I'm happy to help. Please clarify one aspect:  you consistently write that you diagnosed and treated yourself, but unless you are a health professional with easy access to clinical services and labs, most of this would normally be undertaken by a physician. Are you under professional care or entirely on your own? Whether it's you or someone else, your management has been almost textbook perfect for the various STDs that could cause this problem -- somewhat overtreated, but with obvious attempt to correctly cover gonorrhea, chlamydia, NGU, herpes, and even non-STD UTI.

But I believe I know exactly what is going on: I believe you are correct in speculating about adenovirus. Indeed, I could copy your question and use it as an ideal case to teach med students and residents about adenoviral urethritis. Adenovirus is primarily a respiratory pathogen, but some strains readily infect the urethra. Typically adenovirus urethritis symptos are dominated by urethral pain and dysuria (painful urination) with scant or no discharge. Onset 3-4 days after an oral sex exposure is typical; infection typically comes from a partner's oral cavity. And most dramatically in your case, simultaneous conjunctivitis is very common, and your other upper respiratory symptoms also are consistent. Finally, it sounds like your urethritis symptoms are improving gradually, more or less on schedule. I expect they will be entirely gone in a few more days. There are no reported long term complications.

So at this point I strongly recommend you stop all treatment and cease any additional diagnostic tests. For sure don't treat or test for M genitalium, which is not known to infect the oral cavity or be acquired by oral sex (and your symptoms aren't typical for it). Steroids probably wouldn't hurt at this stage, but there are no data and I don't think they would help; better to just let it clear up on its own.

Here is a link to a recent report reviewing NGU due to adenovirus. Several others also have been published in the past 20 years. http://www.ncbi.nlm.nih.gov/pubmed/26574571

I hope this has been helpful. Best wishes and happy new year--

HHH, MD


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34 months ago

Dr. Handsfield,

Thank you, your response offered great deal of answers. as you have suspected, yes I have been Flying solo on this one. tried to go by the guidelines, sometimes hard when your symptoms are not improving fast enough; however when I didn't see the clinical the expected results I started thinking of an atypical infection . It is hard when it happens , but it happen to healthcare provider as well, with a great deal of embarrassment as you can imagine.  your opinion came highly recommended before I settle on this diagnosis.  any specific time line  for symptoms resolution before I start to worry again ? if you leave this trend open I will try to update you on the symptomatic improvement in few days.  Please feel free to teach the impressionable young minds on the expanse of my severe urethral pain ... :)

thx again :)




H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
34 months ago
Cases of adenovirus NGU aren't all that common. I've only cared for a few cases over 40 years and did not follow those patients once the diagnosis was made. Most of the published reports describe initial presentation and I don't recall whether any followed the natural course; I haven't comprehensively reviewed the literature. I think most are free of dysuria within 10-14 days, but it wouldn't be surprising if there is a lot of variability. As long as your symptoms continue to improve and eventually resolve entirely, even if it takes longer, I think you can safely go forward without worry about other etiologies.

Thanks for the thanks. Happy new year.

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