[Question #4016] NGU concern

33 months ago
I'm a married guy who had unprotected extramarital sex twice with same partner; once on 6/22 and again on 7/6. On 7/16, after a solid week of guilt related anxiety and self examination,  I woke up to notice a small amount of clear discharge. On 7/18 I was tested and an independent testing vendor for chlamydia and gonorrhea,  both tests came back negative. I also had sex with my partner on 7/4. The discharge has co tinued, typically a small amount in the morning but later in the day as well. I woke up this morning with more and it was slightly cloudy.  I went to the urgent care and was given a new round of tests including urinalysis,  urine culture and the chlamydia/gonorrhea urine test. The urine test has come back negative for wbc. The doctor said I dont have a normal uti and that no wbc doesn't rule out NGU. He prescribed the standard single dose antibiotic. 

Questions: is he right about the wbc? Is it likely I do have ngu? Is it possible I gave it to my partner? Should she seek treatment? 

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

I'm not certain you have urethritis, i.e. urethral inflammation, NGU. The standard approach to diagnosis of urethritis is to document abnormal urethral discharge, and "clear" usually isn't considered abnormal; and to determine the presence of white blood cells (WBC), which apparently you don't have. (You said cloudy at one point, but it seems that has not been consistent.) So yes, your doctor is right that absence of WBC in the urethra or in the discharge is strong evidence against NGU.

That said, a standard urinalysis isn't sufficient to document WBC:  the discharge itself must be examined for WBC, or the initial part of the urine stream (the first 1-2 tablespoons) can be examined. In addition, however, the apparently scant moisture you have noticed often is not abnormal. Are you certain you're not just seeing residual pre-ejaculate fluid (pre-cum), which is normally present in many men in the morning, after the erections that normally accompany dream sleep? And scant clear fluid can often be seen at other times in healthy men. Are you sure you're not just looking more closely than before, because of your concern?

In the event you do have NGU, it's likely not an important health issue. The cause(s) of NGU following oral sex are not well understood, but some cases probably are not due to infection at all, but some sort of inflammatory response, perhaps in adjusting to a new mix of normal oral bacteria. Or even if those mouth bacteria are directly causing inflammation, there is no evidence of harm for either affected men or their regular sex partners.

Given the uncertainty, it was not unreasonable for you to be treated with azithromycin. If your symptoms continue despite it, and especially if proper testing definitely shows WBC in your urethra or in the discharge, another round of treatment with doxycycline for 7 days would be recommended. But I stress that we do not know if any treatment at all is necessary.

Whether to treat your partner is an even more uncertain issue. But in the absence of true urethritis, I see no need. If somehow I were in your situation, or if I were advising my son or daughter, I would not recommend it. My final thought is that it seems your doctor is pretty knowledgeable about these issues. I think you can safely follow his advice.

I hope these comments have been helpful, despite the uncertainties. Let me know if anything isn't clear.

HHH, MD

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33 months ago
A couple points to clarify: the discharge has gotten a little worse over the past few days and my urethral hole was "glued" shut this am. It's inconsistent, sometimes its definitely clear and almost water like. It's not constant though. 

The doctor was saying that it's likely I DO have NGU and that the lack of wbc in the "first catch" urinalysis doesn't exclude that. 

Just to clarify, this was vaginal and oral exposure. 

I've definitely been perseverating on examining myself. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
33 months ago
OK, got it. I agree, you probably have NGU. The discharge itself could be examined for WBC.

Also sorry I misunderstood you did have vaginal as well as oral exposure. Since you had sex with your wife after the other partner and before treatment, standard practice would be to treat your wife (and your other partner).

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33 months ago
Hi doctor. All my tests, including urine culture, came back negative. Since taking the antibiotic the discharge has gone away. Is it possible I did not have NGU? 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
33 months ago
There are no unequivocal, precise criteria by which to diagnose NGU. But it seems more likely than not. You should assume you had it.---