[Question #4150] Urethritis : Mycoplasma, NCNGU, other ?

32 months ago

Hello, I am a gay man, 30, dealing with urethritis for 6 weeks now.

I'm with a guy for 3 months now, we have unprotected sex (both neg for reg std). I had sex with another guy, 2 months ago, with whom I had protected anal sex (I was bottom) and unprotected oral sex (both ways). I immediately started to experience tremendous guilt and genital focused anxiety. 2-3 weeks later, I started feeling discomfort in my penis tip/urethra and had obvious clear and cloudy discharges. My BF and I got both azithro/cefixime to cover gono/chlam, but all tests came back negative. My symptoms persist, so I tested for mycoplasma/ureaplasma (urethral swab), which came back negative.

I had 10 days of doxy. Symptoms left. 12 days after treatment ended, symptoms reoccurred. I then asked for both urethral swab and urine test for myco/urea. The second swab came back negative. Still waiting for the urine result. I am very scared about Mycoplasma, so I have been taking moxyfloxacin for 7 days now. Symptoms are gone, but I am terrified they will come back again. My BF never experienced any symptoms, 2 months after my encounter with the other guy.

Questions :

1- How is oral sex likely to transmit Mycoplasma ? And rubbing ?

2- Do Mycoplasma and other NCNGU usually clear on their own ? 

3- Is it safe to keep having sex with my BF and could he be more likely the source (rectal) ?

4- Even though discharges were not very present when the doctor made the 2 swab cultures, are sample results still sensitive and reliable?

5- If it's not Gono, Chlam, Myco or Urea, what could it be ? CPPS ? (very anxious here). And what treatments left ?


Thanks !

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

I'm afraid I'm not going to be able to answer these questions with the precision you would like. There has been almost no research on NGU in men who have sex with men (MSM).

First, you likely had NGU, at least when symptoms first appeared, based on the cloudy discharge. However, even that isn't certain, since you don't mention a finding of increased white blood cells in your urethra, which is just as important in making the diagnosis as abnormal discharge is. Second, But we do know that it's pretty common in anyone having insertive anal sex, including sex with regular partners. Some (most?) such cases are due to entirely normal fecal/rectal bacteria, like E. coli. Second, 2-3 weeks is a long time for onset of symptoms; NGU generally starts within 7-10 days, and it can be just a day or two for E. coli and similar bacteria. For these reasons, it is just as likely -- perhaps even more likely -- that your apparent NGU was from sex with your own partner and had nothing to do with the other contact a couple of months ago (as you suggest yourself in question 3). Third, oral sex can result in NGU, and probably can also be acquired from a regular, healthy partner with whom one has regular sexual contact. Some of these probably are due to entirely normal oral bacteria, and other cases may not be due to infection at all, but to some other inflammatory mechanism in relation to exposure to oral bacteria. (This is an area of active research, although entirely -- so far -- in straight men and their female partners.)

Exactly what "ongoing symptoms" do you have? If only urinary discomfort, urgency, etc -- i.e. without visible discharge -- it is likely you no longer have any infection at all. Failure of antibiotics to resolve symptoms, especially the specific drugs you received, generally is NOT evidence of a resistant infection, but rather evidence that no infection at all is responsible for the symptoms. So I'm not at all certain that either you or your partner should receive any more antibiotics.

"Mycoplasma" is a general term for a group of bacteria, and includes the ureaplasmas. Of the several types, only one, Mycoplasma genitalium, causes NGU, accounting for 10-15% of cases. It can be carried in the rectum and acquired by rectal sex. However, it is not known to be at all harmful in the rectum or in the partners of MSM with NGU caused by it. And no complications are known in men with urethral M. genitalium infection. So being "very scared" about it isn't really justified. It's may be harmless in this situation (although difficult to be certain in absence of research on this in MSM).

Now to your specific questions, as best I can answer them:

1) No mycoplasmas, including M gen, are carried in the oral cavity, at least not in women and probably not in MSM. Therefore, oral sex is not a risk for it.

2) There has been no research, in either MSM or straight men, on the natural course of untreated NGU, so it is not possible to say whether and how quickly such infections might resolve on their own, whether or not M genitalium is the cause. However, we know that in women most infections are gone when those with genital infection are tested 3-6 months later. Most likely this is true in men as well.

3) At this point, I see no reason to not continue (or resume) your normal sexual practices with your partner, including unprotected oral and rectal sex.

4) It's hard to know exactly what mycoplasmas you were tested for, or exactly what test methods were used. There are no standard, FDA-approved tests for any genital mycoplasmas, and especially not for M genitalium. Most labs that offer such  tests have done their own quality control and results may be reliable, but it's difficult to be certain. But on balance, my guess is that your negative results are reliable, regardless of absence of urethral discharge at the time.

5) I'm glad you raise the possibility of genitallly focused anxiety and/or chronic pelvic pain syndrome (CPPS). You don't give enough information about your specific symptoms at this time for me to say much about it. However, this is often (usually?) the explanation for persisting symptoms after multiple courses of antibiotic treatment.

I hope this information is helpful. Sorry about the lack of clarity on many of these issues, but let me know if you have further questions.

32 months ago

Thanks for the fast and very complete answer, Doctor HHH. I've been passing the 6 last weeks reading your interventions on medhelp and I must say it's a privilege to be answered by you. Now, I am sorry I couldn't give you more details, I wanted to respect the ~1500 characters limit for a single post. Here are some more details :

- Everytime I mentionned mycoplasma, it always implied mycoplasma genitalium (and Ureaplasma urealyticum, by extension).

- As far as I know, no white blood cells measurement has been taken out of my urethra during the 4 test panels I had.

- I went to the GUM clinic few times, the doctor didn't want to test my partner's rectum for mycoplasma genitalium (they say it’s a urethral disease…), neither they would give him doxy/moxifloxacin for parallel treatment, so I am worried to catch it back if it's now cured.

- Following my exposition with the other guy, I started having urethra tingling after 15 days, then discharges after 19 days post-exposure. Discharges were scant first, then more considerable after few days, especially in the morning (had few white stains in my boxer). Doxy stopped symptoms for a while (see below).

- At the moment, I don't have any symptoms (I am on day 7 of 10 on moxifloxacin, symptoms stopped on day 4). I experienced the same pattern with doxy, but when I ended up doxy, 12 days later, I had the same symptoms recurring: mild urethral discomfort and obvious mix of clear watery and white mucous discharges, especially in the morning.

- Tests (swab/urine) are using laboratory in-house PCR/NAAT (not the real-time one, but the longer one). Hopefully it is reliable, but I can’t tell for sure.

- I indeed learnt about CPPS because of your interventions on medhelp and I am sure that, at some point, NGU or not, my head (and body) is challenging me at creating/amplifying some body feelings. I am insanely afraid of pain/suffering and I am very intolerant to any kind of sore/discomfort (I am followed for GAD and OCD). I am being obsessed with this situation, I barely slept within the last 6 weeks, imagining I am condemned to suffer from an unknown/uncurable disease for the rest of my life. I know, it sounds sad (and it is).

If you don’t mind, I would have 3 other questions:

- What should I do if symptoms reoccur again after the treatment ends? I will surely ask for a white blood cells measurement, but is there’s something else I can do?

- Since my symptoms are clearing on moxifloxacin, should my partner take them too, to avoid ping-pong transmission ?

- I read first void urine was preferred for mycoplasma detection, but is a sample made 2-3 hours post- micturition still reliable ?

Again, many thanks, and sorry for the long reply.

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
32 months ago
I don't want to second guess policies at the GUM clinic. But M. genitalium is commonly present in the rectum. OTOH, as discussed above, you have an inflated view of M genitalium and its dangers. It might make sense for your partner to also be treated with moxifloxacin, but I'm really not sure it's necessary. I would suggest you continue to discuss that aspect with the GUM clinic. (You might consider printing out this thread as a framework for discussion.)

To your three remaining quesitons:

1) Your symptoms won't necessarily recur yet again. But if that happens, I would suggest professional reexamination, this time to include evaluation of urethral WBC. That said, probably urethral or lower genital area discomfort, without visible discharge, could safely be ignored. Despite your fear of symptoms etc, most people (probably including you) can learn to live with mild, chronic symptoms once it is clear that they don't indicate a serious or dangerous health problem.

2) As noted above, a case could be made for treating him with moxifloxacin, but this decision requires judgment of a knowledgeable physician directly involved in your care, not a distant online forum.

3) "First void" and time since previous urination are separate issues. It should always be first void, i.e. the first 15-30 ml of urine. 2-3 hour since previous voiding should be fine.
32 months ago

Hello again. Thanks for your input and advice Dr. HHH, it's warmly welcome.

I just received my urine test results for Mycoplasma Genitalium yesterday and it's negative again. The test has been ran into a governmental hospital, so I assume it's quite accurate. Strangely, moxyfloxacin stopped the symptoms within 4 days only, so I suspect another [maybe normal] bacteria is in cause, but I can be wrong as I am not a specialist. In any ways, my partner will ask his private Doctor (who is a STD specialist too) about taking some meds (or not) to try clearing up any ping-pong transmission possibility.

Also, when I said my partner and I were STDs free, I cheated a bit to keep the initial post short and sweet. Actually, my partner is HIV+ (undetectable for 3 years now, followed every 3 months) and I am on daily PreP. 

That being said, I would have few last questions:

1- Considering my partner is HIV+ undetectable and I am on daily PreP, does carrying a potential NSU increase my chances of getting HIV?

2- I know it might sound weird, but I'm often told my urethra is quite big, so I am wondering if it does grab bacteria more easily than some other people, which could lead to this kind of infection?

3- Being "top" for me is something new, I rarely topped in my previous relationships. How likely my urethra will adapt to my new partner’s bacteria (rectum, throat)?

4- Assuming discharges would come back again and no bacteria is found, can I just ignore the whole thing and keep on having unprotected sexual intercourse? I am concerned about passing some bacteria to others or aggravating my own situation.

5- I would like to know how likely false-negative can happen when discharges are observed ? I got tested for Mycoplasma 14 days after the end of doxy treatment, which means 2 days after the discharges return.

Thanks a lot for your precious answers, Dr. HHH.

* PS : I will probably open another ticket for another distinct issue, as I am dealing with few molluscum too (seems like a badluck rarely comes alone).  

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
32 months ago
1) There has been no research on NGU as a risk factor for HIV. But this really doesn't matter:  being on anti-HIV therapy with undetectable viral load prevents HIV transmission with nearly 100% effectiveness. Presence or absence of other STDs probably makes little if any difference.

2) I cannot imagine this makes any difference in risk of STDs or any other infections.

3,4) Again, there is no research on this. For most people, there is no adaptation at all, at least no symptoms. It's probably unlikely -- but all persons participating in unprotected insertive anal sex should be aware of the risk of infection with normal intestinal bacteria, causing urethritis or a more typical urinary tract infection (UTI). But if you have no symptoms, you can safely assume you have no infection of significance.

5) This is an impossible question to answer. Some cases of NGU may be due to bacteria that have never been identified. A negative result for any particular known cause (gonorrhea, chlamydia, M genitalium, herpes, trichomonas, and a few others) does not prove there is not some other, unidentified infection.

Molluscum contagiosum is an uncommon STD in persons beyond their teen years. It can happen, but I would suggest you be sure the diagnosis is correct before asking  a new forum question about it.

That concludes this thread. I hope this discussion has been helpful.