[Question #4395] Confused - Risk, Timeline, Infectious?

29 months ago

I am a male who has had a few partners over the last twelve months, including my wife.  Outside marriage, I have used condoms for vaginal sex, but not always for oral sex - receiving only.  Tuesday - 8 days ago, I had unprotected oral sex and protected vaginal with a woman i  just met.  She assured that she had been tested 3 months ago.  I have been tested and have no stds or HSV at all. 

Afterwards, I felt very guilty and started to worry.  I took 1g of azithromycin on Wed evening.  I went to my local std clinic on Friday for Chlamydia and Gonorrhea testing -about 40 hours after the medication, 60 after sex.  I then had unprotected oral and vaginal sex with my wife on Friday evening.

On Tuesday morning - 2 days ago, I woke up with what felt like a bladder or prostate infection. I have mild prostaitis but this was worse. I went to urgent care and did a urinalysis and got tested.  There was blood in my urine, but no white blood cells. 

Separately,  I got my results from the Friday test and they were all negative.  

So, while I have read many, many entries on medhelp and here on Asha, I am still confused and worried.  I am curious about the following:

1) I know that I am at risk for Gonorrhea and NGU, with a slight risk for Herpes and Syphillis, although low. There is apparently very low risk for chlamydia from Oral sex.  Would the azithromycin have been sufficient - were I contagious - to get rid of NGU and Gonorrhea? What is my real risk for any of the infections one can get from oral sex?
2) Had I been infected with anything, would the azithromycin cause a false negative? In other words, would the negative results not be reliable?
3) With no white blood cells on Tuesday, does this mean I do not have NGU? 
4) Is it possible the incubation of an infection activated after the medication had run its course?
5) What is the chance I have infected my wife?
6) What could the bladder infection be?  Could this be herpes somehow? Could it be NGU from sex with my wife?  

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

Symptoms like yours usually are not due to STD. Gonorrhea, chlamydia, and other STDs that infect the urogenital tract primarily cause discharge, with or without painful urination. They do not generally cause urgency, frequency, bladder pressure, or other symptoms typical of prostatitis or urinary tract infections. In addition, STDs rarely if ever cause blood in the urine, but non STD genital infections or prostatitis can do so. So on the basis of your symptoms, most likely you are experiencing a flare-up of your previously diagnosed prostate problem. In addition, as you seem to know, oral sex can be considered safe sex. It isn't entirely risk free, but the overall frequency of all STDs is far lower than for unprotected vaginal or anal sex, and virtually zero risk for some STDs. 

Those comments largely cover your specific questions, but to be explicit:

1) It wasn't very smart to take azithromycin, especially in that dose. It would be effective against chlamydia (which is unlikely, as you already know) and most NGU, but not reliable against gonorrhea or syphilis. And treatment could make it much more difficult to accurately diagnose the actual cause, such as a urinary tract infection or flare-up of prostatitis. 

2) Yes, it is possible that azithromycin would make testing false negative, especially for gonorrhea.

3) Yes, absence of WBC is strong evidence against NGU.

4) I suppose this is possible, but the more likely explanation is simply that you have a problem for which azithromycin is entirely ineffective -- such as non-infectious prostatitis.

5) It is unlikely you have any infection that could be sexually transmitted to your wife.

6) Neither herpes nor NGU is a likely explanation for your symptoms.

If your symptoms continue, you should get direct medical care (in person) from a physician expert in STDs and genital infections. Even though the likelihood of STDs seems low, testing still would make sense. But for the reasons above, I anticipate that it's a prostatitis flare-up, unrelated to your extramarital sexual adventures.

I hope this information is helpful. Let me know if anything isn't clear.

29 months ago
Hello Doctor Hansfield,

Thank you so much for your prompt reply.  I think the work you have done on medhelp and now here constitute the best archive of sex health material on the entire internet!

A few clarifications and some additional questions:

My main issue is I am struggling with the timing of the flare up, which definitely seems like prostaititis.  But it coming in a time window where it could be NGU or something else has my anxiety level very high.  That said, I have more information.

When I went to get the urinalysis, they conducted Gon/Chlam/Trich urine tests - this was Tuesday, the 8th day after my unprotected oral sex encounter.
All of these were negative.  They put me on Bactrim and suggested I go to a urologist, which I have scheduled.


1) The most concerning thing you said was that I could have had a negative Gon test after taking the azithromycin. With another negative test on Tuesday, 
4 days later, do you think this is reliable? I have had absolutely no discharge, no pain urinating, just the dull ache of what I think is my prostate!
2)  Provided that Gon is ruled out, with no white blood cells in my urine, I can rule out NGU as well.  Chlamydia and Syphillis are also extremely unlikely.
So what does that leave me with - HSV 1?  No blisters or rashes at all, after 11 days, so I think I am ok there.
3) I am wondering if somehow I did get NGU from oral sex with my wife and that triggered the prostaitis, but again, no white blood cells, so I think that is not right.
4) I continue to have the prostate symptoms and will have these checked shortly by my urologist.  As you suggested, if my symptoms continue, then I should get testing. I wanted to go get tested today, but I wasn't actually even sure what to tell them, given that I think everything is ruled out.  What should I tell the clinic if I do go?
5) So, again, given this additional info, do you think I have any risk that a) I am infected or b) I have infected my wife.

Thank you again for helping me and for this amazing resource!

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
29 months ago
1) If azithromycin made the gonorrhea test negative, it would be because it cured you. Since your symptoms continued and the test was negative, you can be sure you do not (and did not) have gonorrhea. And as discussed above,  your symptoms are not suggestive of gonorrhea anyway.
2) Correct. Herpes (either HSV1 or HSV2) does not cause symptoms like yours. Never.
3) NGU also does not cause pelvic pain without urethral symptoms. We already discussed that absence of WBC also proves you don't have NGU.
4) I don't know what you think you need to be tested for. Wait for the urologist's evaluation and advice.
5) It was already clear you have no STD, and this additional information confirms that conclusion.

I'm also not convinced you have true prostatitis. This is more consistent with the male chronic pelvic pain syndrome (CPPS). This overlaps with non-infectious prostatitis, and some urologists consider the terms synonymous. In any case, it would mean no infection of any kind. Google CPPS -- spell it out. The WIkipedia article is good, and you can also find excellent information from the Stanford University Dept of Urology. I'll bet you see yourself in the information you read. As you will read, CPPS often is a manifestation of genitally focused anxiety, with pain caused by pelvic muscle tension -- i.e. this could be psychologically related to a sexual decision you obviously regret. Be entirely upfront with your urologist about all this. Also, my advice would be to NOT take the bactrim before you see the urologist. Probably it will make no difference in your symptoms, and it will definitely interfere with any tests for infection the urologist might recommend. Be prepared to discuss all this with the urologist -- you could even print out this thread as a framework for discussion.

Thanks for the thanks about our services. I hope the present discussion contributes to that appreciation.