[Question #4516] dysuria/NGU?

81 months ago

I developed a burning sensation after urination ~1wk after a sexual encounter with condom failure. No discharge, no other ulcers or anything initially, but did develop some vague scrotal pain without orchitis or epididmyitis. 11d after exposure, NAAT for neisseria, chlamydia, trich negative. Spoke to a PCP, who prescribed azithro 1gm and doxy 100mg BID for 7d, which were completed. There was no UA or smear at that time. With those antibiotics, I saw some improvement but not complete resolution, i.e. the dysuria persisted (i'd had some intermittent discomfort previously which I attributed to cycling for several years) so this was a bit confusing for me. I then saw a saw a urologist, he performed a clean catch UA which was normal, and he noted no external findings. He advised symptoms can persist for several weeks.

1 week ago, (10d post antibiotics) after a moment of arousal, I developed some clear discharge from my penis. My dysuria was still present. The scant discharge lasted 1 hour or so, then stopped. I went to a public health clinic 2 days after this episode. Doc there did a smear and gram stain of urethral secretions (which were clear), which was negative (no PMNs). He repeated GC, CT, which were negative. Since then, I've had some intermittent scant discharge, viscous and clear, very small in volume. Not sure what I should make of this. Based on criteria I can find, in the absence of mucopurulent discharge and with the negative gram stain and UA, I don't think I meet criteria for "urethritis", but was hoping to get an expert opinion. My urologist, after conversation via phone, thinks this may be secretions from cowper's glands, doesn't recommend additional testing at this time. Can I be reassured by the 1) scant clear nature of discharge, and 2) negative urethral secretion smear and negative LE at the urologist office? I picked up some UA test strips as well, and have had persistent FVU negative LEs as well. Should I be pursuing viral or M. Genitalium?

Edward W. Hook M.D.

81 months ago

Welcome to our Forum. I happened to be on the site around the time your question arrived so you are receiving a response which is quicker than is typical for the Forum. Follow-up responses may take long as well.

At this time you have proven that you do not have an STI and, in all likelihood, you did not have an infection following your recent condom failure. While the onset of your symptoms about a week after the condom failure is certainly suggestive of STI, the fact that your tests were negative rules out those infections. Currently available NAATs tests for STIs are the most sensitive tests for these infections we have ever had and their results should be believed. You may have had non-chlamydial NGU at that time but, if you did, the azithromycin and doxycycline you took would have cured this.

In follow-up your urologist did a good job of evaluating you and I agree that in some patients symptoms may take a while to resolve. Alternatively, you may not have had an STI at all and your symptoms may have been coincidental and due to something else. Your follow-up evaluation at the public health clinic was also thorough and supports that there is no infection present at this time. This:

1. I agree with your urologist. No further testing is needed.

2. You have effectively ruled out the presence of any STI from the exposure you described.

3. I agree that there is no evidence that you have urethritis at this time.

4. Your symptoms could be cowper's gland secretions, non-infectious prostate irritation (you mention that you are a cyclists- some bicycle seats can lead to prostate irritation) or your awareness to genital sensations may have been heightened to the point where you are noticing symptoms that you might not have noticed otherwise.

At this point, I would not pursue further diagnosis. If you had M. genitalium the recommended treatment is combination doxycycline/azithromycin and this infection typically shows inflammatory cells in urine or on stain of genital secretions, neither of which you do. Further, nothing you describe is suggestive fo a viral STI. My advice is the same as that of your urologist- I would do your best not to worry and not recommend further evaluation at this time. EWH

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81 months ago

Dr. Hook,

Thanks for the prompt reply. I'm awaiting initiation of intercourse with my longterm partner until a 3 month HIV test (I was given PEP 8h post exp and completed the 28d course). Other than waiting for this, do you feel it would be safe to resume unprotected intercourse? As a healthcare provider, I'm definitely suffering from a bit of PubMed-itis after this episode, which is only further evidenced by my perseverating over MDR M. genitalium.

Thank you again for your time

81 months ago

And to follow-up on the last question prior to your reply - The public health office was able to express the secretions for their gram stain via squeezing the penis a bit and then holding the slide to the meatus, with the clear viscous discharge transferring to the glass slide, not via a swab. Would this function as well as a swab from a test characteristic standpoint? As best I can tell the answer to this is yes?

Thanks again

Edward W. Hook M.D.

81 months ago

Regarding your final comment, I can assure you that it is normal to be able to express small amounts or urethral secretions in the manner you describe. Believe the absence of WBCs.

Regarding testing for M. genitalium, there is no reason not to test if you think it will be helpful to you. I do not feel it is needed and will go on record however as being confident that your test will be negative if you choose to test.

Hope this helps. EWH

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81 months ago

Dr. Hook,

Thanks again. Based on your and my urologists comments, I’m leaning towards no additional testing. If I can’t shake the MG concern over the coming weeks, is there a particular lab that you have confidence in? In reading about this in the prior weeks, it Seems NAAT is the most sensitive- would a service like mylabbox suffice?

Hoping I can convince myself this is an unnessecary additional stressor....

Edward W. Hook M.D.

81 months ago

That is the course I would take. If you do opt to test for Mg, You are correct tht a NAAT test is most sensitive. There are no FDA proven lab tests for Mg in the U. S. but tests from most big U.S. laboratories seem to be reliable. EWH---

80 months ago

Dr. Hook, thanks again for all of your advice. I tried my best to move on from this, to no avail due in part to a few days of increased pain and dysuria and some more of the clear discharge I had described before, perhaps increased in volume. So I used an online service to order the MGen NAAT through Labcorp 3 days ago. The result surprisingly came back this AM and was negative.

Despite my inability to heed your excellent advice, I am hopeful this provides me with some closure. As I've seen you and your colleague both note on other threads, with this combination of negative testing for trich, Chlamydia, Neisseria, MGen, a negative RPR, neg HCV, and neg HIV (with one more pending at 90d post exposure), as well as multiple negative UAs, a negative urethral smear, and nl evals by urology and a specialized STI clinic, I can be confident that I do not represent a risk to my partner, and my symptoms are mine alone to bear and to deal with.

Is this interpretation correct? If so, I will gladly proceed on with my life. Thank you again for taking the time to do what you do on these forums, and to be a calming source of information for so many of us.

Edward W. Hook M.D.

80 months ago

I agree with your assessment. At this time there is no other STI to rule out. Time for you to move on without concern.

This will complete,this thread. Take care EWH

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