[Question #4203] Symptoms and possibilities

32 months ago
Hi Doctors HHH and Hook:

Background
My wife and I have an open relationship. I have been with several women in the past two months. She has had no recent partners since her last STD Check. 

Between 7/24 and 8/15 I had 3 new sexual partners. All included protected vaginal sex and unprotected oral sex (giving and receiving). Each partner early to mid 20's and non CSWs. I tested negative for gonorrhea and chalmydia on 8/20. On 8/23 I had a new partner, also early 20's, non-CSW. We had protected vaginal sex, although I did have to change condoms due to partial ejaculation in the first condom. She also performed unprotected oral on me. On 8/28 I had unprotected sex with my wife two times. 8/29 I noticed some off-white discharge first thing in the morning and some mild irritation later that day in my urethra. Today, 8/30, the discharge has become more pronounced and almost constant. I told my wife about the symptoms, and I got tested via an online service at lab corp for Gonorrhea and Chlamydia. I should have the results tomorrow or Monday.  

While I wait I have the following questions: 
1) It seems as though I've acquired sexually transmitted urethritis. Given the timeline of things, does it make sense that the new partner on 8/23 was the likely partner from whom I contracted this? Or, was my test of 8/20 valid, given it had only been 5 days since my last potential exposure? Both tests were urine test NAAT. 
2) If this is Chlamydia, is it possible that it was from oral sex? I've read on the forum that chlamydia presents low/little risk, but my condom didn't fail. Perhaps I transferred it to my urethra via my fingers while changing condoms? I don't know. 
3) Is there any possibility this is NOT due to an STD? I am guilty of obsessively checking my urethra (OCD), and I read some literature that suggested urethritis can be induced by over manipulation of the penis. I've also wondered if prostatitis is a possbility. 

I will update you with my test results as soon as I receive them. I
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
32 months ago
Welcome and thanks for your question.

Almost certainly you have urethritis, which is virtually always an STD, especially in someone at relatively high risk as you are. There are two broad types, gonorrhea and nongonococcal urethritis (NGU). About one third of NGU is caused by chlamydia, but most cases of urethritis are due to neither gonorrhea nor chlamydia but to a variety of other causes. In most cases, no particular cause is known. This is especially true of cases acquired by oral sex, which almost never are due to chlamydia. Gonorrhea typically starts to cause symptoms within 3-5 days, chlamydia or NGU 7-15 days, and sometimes up to a month. To your speciific questions:

1) As implied by these comments, you didn't necessarily acquire this infection from the most recent partner(s). Any and all partners with whom you have had sex in the past few weeks will need to be notified and treated and, preferably, tested for gonorrhea and chlamydia. Since this could reflect unrecognized condom failure, all partners need to be notified, and it includes your wife. (If your wife also is having other partners, she could be the source of your urethritis.) There is no way you're going to be able to know with certainty the partner from whom you caught the infection.

2) Chlamydia is only transmitted by vaginal or anal sex -- or only very rarely by oral.

3) There is almost no chance this is not an STD.

Finally, it sounds like you're trying to diagnose and perhaps treat yourself. That would be a mistake. You need to see a physician, preferably one expert in STDs, for complete evaluation and treatment. You also need testing (in a few weeks) for HIV and syphilis.

And by the way, as implied above, if both your gonorrhea and chlamydia results are negative, it does not mean you don't have an STD. You do. It will just mean you have NGU, i.e. one of the majority in whom the specific cause is unknown or not easily diagosed.

I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD
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32 months ago
Thank you for the prompt reply. 

I received my results from LabCorp and they were negative for both gonorrhea and chlamydia. 

A few follow up questions: 

1. Can I conclusively rule out gonorrhea and chlamydia based on these results? I had discharge at the time of my test.  This was one one week post my last exposure.

2. I’m assuming I have NGU . It confuses the heck out of me, and I plan to see a doctor tomorrow. I plan to take this post, as well as my test results . Is the logical next step for them to look for bacteria in my urine or with a. Swab? 

3. If no bacteria is present, is it safe to assume I acquired it virally, in which case I simply wait for it to pass? I want to avoid taking an antibiotic if it’s unnecessary. 

4. It seems like NGU is basically unavoidable if having oral sex  and there’s basically no end to what can cause it. Any advice to avoid it moving forward? 

5. You said to notify my partners but for what? How can I ever know what caused the NGU? 

Sorry to ask so many questions it’s just one of those stds you don’t learn about until you have it ! 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
32 months ago
I'm glad to hear you're seeing a physician. Good move, and a good idea to print out this thread as a framework for discussion. However, you have some mistaken perspectives on NGU.

1) Yes, you can be confident you have neither gonorrhea nor chlamydia. The standard tests are highly sensitive, rarely missing either infection, especially in men with overt discharge.

2) Indeed you have NGU. I doubt you're actually all that confused; it sounds like you just don't yet know all the important facts about NGU. No, it is not necessarily logical to look for other bacteria. Some doctors would check men with urethritis for bacteria that cause non-sexually acquired urinary tract infections, i.e. a standard urine culture. However, we generally don't do that in STD clinics. They're almost never positive except sometimes in men who have had anal sex, who can be infected by normal fecal bacteria like E. coli. There's really no need to check for other known causes of NGU, such as Mycoplasma genitalium and Trichomonas vaginalis, unless initial treatment isn't effective. And as I said above, for many cases of NGU (around 40%) the cause is entirely unknown and all tests are negative.

3) And for that reason, the answer here is no:  absence of proved bacterial infection doesn't mean the cause is a virus. Although certain viruses cause a few cases (e.g. herpes, adenovirus, each causing only 1-2% of cases), the large majority almost certainly are bacterial, even though the exact bacteria involved aren't known. We know this because almost all cases respond to antibiotics; viral infections are never improved with antibiotics.

4) I'm not sure where you came to believe that NGU is unavoidable with oral sex. Definitely not true. The large majority of oral sex exposures cause no urethritis. The main prevention strategy against NGU is the same as for all STDs:  preferably limiting sex to committed monogamous partners; otherwise, condoms for vaginal or anal sex. (Could be used for oral sex as well, but most persons find condoms distasteful for oral sex -- literally and figuratively -- and in general oral sex is low risk for all STDs.

5) Some causes of NGU may be harmless for partners. But it's impossible to know, so standard practice -- and universal recommendation from all STD experts -- is that all partners should be treated as NGU itself is treated (i.e. doxycycline or azithromycin).
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32 months ago
Thanks Dr HHH

these will be my last questions 

1) when i say it’s unavoidable I guess that I really meant there’s no way to screen for it. So even if a new or existing partner has a negative std panel, she could still pass along bacteria causing urethritis via oral or vagina sex.  Correct me if I’m wrong, but even a comprehensive std panel won’t be able to detect ngu, right? 

2) I’ve read In past replies where you said ngu is relatively benign. That said, is it safe to assume that with prompt treatment neither myself or my wife have any long term health risks from this? 

That’ll be al the questions I have. The discharge has basically stopped, as has the burning on urination. While the infection may have already cleared itself I’m still headed to the doctor Tuesday (Labor Day weekend) for evaluation and treatment. Thanks in advance for the great resource. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
32 months ago
1) Yes. Comprehensive STD testing, even if negative, cannot exclude the presence of the various bacteria that probably cause NGU (probably more than one).

2) Also correct, as you have seen in other threads. Fortunately, NGU normally isn't serious or severe and is not known to cause frequent or serious complications.

Indeed I recommend you follow through with plans to see your doctor on Tuesday.

Thanks for the thanks. I'm glad the discussion has been helpful.
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