[Question #4670] Persistent clear discharge

80 months ago

40yo M, physician, longterm female partner. This is a follow-up to prior, abridged prior hx and updated the last few weeks:

D0: Huge mistake, unprotected vaginal insertive intercourse 2/2 condom falling off w/ new partner; PEP initiated 8h p exp.

D7: dysuria, hypersensitivity develops at penis tip; no discharge, no other lesions

D11: Neg GC, CT Trich NAATs (repeat due to concern over volume of sample being too large)

D13: Consult (Plushcare), prescribed Azithro 1g, Doxy 100mg BID x 7d, no UA/swab done; Abx completed with some improvement but rebound in tingling, sensitivity, dysuria after.

D23: See urologist; Clean catch UA w/o WBC, neg LE. Urologist provides reassurance

D28: PEP completed

D29: New clear discharge in afternoon, cont. dysuria

D31: Go to public health STD clinic (large city). Clear secretions expressed from meatus and gram stained, no PMNCs; Neg GC, CT, HIV 4^th gen, RPR, HCV

D32-53: Continued intermittent clear dc, with increased volume pre-ejactulate with arousal; Abstaining from intercourse with long-term partner; masturbating q3-4d, post ejaculation with some continued clear discharge after for 1-2h each time. Also occasional small white spots in boxers. Dysuria fades slowly to 5-10% of voids per day. Hypersensitivity at penis tip persists.

D48: I ordered a Mycoplasma genitalium NAA (Labcorp), (FVU after not having voided for >2 hours): Negative.

D54-71: Discharge fades, but early AM discharge with nocturnal penile tumescence persists, still much higher in volume than I’d expect. Mild improvement in hypersensitivity but not resolved

D72-73: Urology f/u, neg clean catch UA, nl exam. Prostate nl on exam. Tells me that no additional testing is needed. That evening, note some more clear discharge, persisting through to D74, including an episode after urination/defecation.

Now D76: Dysuria still 5% of voids, continued penile hypersensitivity.

I know this is mostly anxiety driven, but the persistence of symptoms is driving significant anxiety:

1) Do I represent any risk to my longterm partner via unprotected intercourse? Even as a doc and part-time epidemiologist, as a patient I’ve lost my objective lens, esp with this clear discharge.

2) As the first MGenitalium test was at D48 (3.5 weeks after abx), could it be a false negative? Would you recommend any additional testing (UU for instance)?

3) I know a single episode of vaginal insertive intercourse is very low risk for HIV transmission, and PEP likely mitigates that even further. With a D30 neg 4^th gen, would a repeat test at ~80 days (11 weeks instead of CDC rec 12) be conclusive?

H. Hunter Handsfield, MD

80 months ago

Welcome back to the forum. I'll be taking your question this time, but I reviewed your recent discussion with Dr. Hook. (I'm not sure he knew of your medical background-- I ddin't see it mentioned on quick scan.)

You don't mention trichomonas, and I don't think you did so in your previous discussion. If you haven't been tested for it, arrange for a trich PCR, which is now commercially availalbe. To be clear, I very much doubt you have it, in absence of evidence of urethral inflammation. But for completeness, testing for T vaginalis makes sense.

Beyond that, we can't help much more. As you well know, symptoms don't always mean disease, and can persist long after the primary cause has abated or responded to treatment. A sprained ankle can hurt for months after all objective signs indicate complete healing, for example. The genitals are not immune to this. We're not going to be able to give you a clear diagnosis from this remove. One guess is that situations like yours -- which are quite common after treatment gonorrhea, chlamydia, or NGU -- may represent some sort of ongoing physiologic adjustment to previoius genital tract inflammation. In any case, I can give you virtually 100% assurance that you have nothing that will ever be harmful for you or for your current or futures sex partner(s). In dealing with innumerable such cases in my (and Dr. Hook's) decades' long experience, we have never seen anyone who later developed any significant complication, or whose sex partners developed anything clinically significant.

With that as background, I will just comment that entirely clear urethral discharge is rarely pathogenic, and the absence of WBC (including leukocyte esterase testing) confirms that there is no inflammatory process. Even if you initially had NGU (which is by no means certain), it is now gone. So I am not at all surpriwsed t hat your urologist found nothing wrong and that all tests for microbial pathogens have been negative.

Those comments address your main concerns, but to explicitly reply to your three questions:

1) For sure no risk to your partner, especially if trich testing is done and negative. I would advise you to resume or continue your normal sexual relations with her. (Anecdotal reports by some patients suggest resuming sex may help such symptoms.)

2) The M genitalium nucleic acid amplification tests are believed to be highly sensitive; there is no realistic chance of a false negative result. U. urealyticum is a normal component of the genital microbiome, present in up to half of all sexually active persons. If it were causing any problem, you'd have genital tract inflammation as indicated by WBCs. In the absence of evidence of urethral inflammation (i.e. WBC, LE test), I would not undertake any further tests for any pathogen.

3) There is no realistic chance you have HIV -- indeed, I would have recommended against PEP in this situation. But the exact interval for conclusive testing, following PEP -- which could prolong the window periods if not effective -- isn't agreed by all experts. But most say 3 months (90 days) and some would recommend 6 months.

I hope these comments are useful and help you move on without so much worry!

HHH, MD

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80 months ago

Dr. Handsfield,

Thank you for taking the time to reply and for your reassurance. Impressed by the amount of effort all three of you put into this forum - There is no equivalent in my sub specialty/disease area. If there is any positive to have come from this scenario, it's that my knowledge base of the epidemiology and treatment of STIs has markedly expanded beyond the base I had acquired in medical school.

In response to your response:

1) I had a GC/CT/Trich NAAT performed on days 9 and 11; I repeated it on day 11 after doing some additional pubmeding and realizing the test characteristics shift a bit if the volume is >30cc and I was pretty sure my first sample was ~ 40-50cc. Both were negative for all 3 pathogens. As best I can tell, 11 days is far enough out for detection if T. vaginalis was the source of symptoms? Would repeat testing still be warranted?

2) I'm definitely reassured by your comments regarding MGen and UU ; Dr Cook had promised me the MG NAAT would be negative (as did the excellent PA I saw at the public health dept), but I guess I felt overly burdened by the combination of the repeated popping up of MGen testing in my social media feeds thanks to my googling, and having the access to order it. Perhaps I need a bit of an internet moratorium, but that's just not possible in our profession.

3) Regarding the third reply, I'll be sure to repeat the HIV at 90d as opposed to 80d. I was hoping to do it a bit earlier as I'd like to resume sexual relations with my partner but am too anxious to do so until I've settled the HIV issue (as infinitesimally small a risk as that might be). Is that anxiety unrealistic, or, as you note in the first answer, should I just proceed with resuming "relations"?

Lastly, and unrelated to initial comments, I read both the MSHC article regarding heterosexual dyads presenting for evaluation of NGU in the male partner and your related editorial. Fascinating stuff, though def. some issues with outcome misclassification and ascertainment bias as you highlight. Any additional work occurring in that domain? I recognize that my situation is not the same as those enrolled in that study, and that those results do not apply for me.

H. Hunter Handsfield, MD

80 months ago

1) Glad to hear you were tested for trich. 9-11 days is fine; no more testing needed.

2) I don't agree that an internet moratorium is not possible in our profession. Searching on particular topics doesn't happen spontaneously!

3) Yes, your anxiety about HIV is unrealistic. If I were in your situation, I would be having unprotected sex with my wife without worry, and probably would not have taken PEP.

4) Thanks for the comments about my editorial. Active research is underway in at least three centers on related topics, like NGU in relation to oral sex, and STI prevalence in partners of men with NGU. This work is still early, but with luck, we'll know more in the next 2-3 years.

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