[Question #5080] Follow up #4732

79 months ago

Hi doc,

This is a follow up from my previous conversation.

After last time my symptoms somehow dissapeared 1 week after 1g azithromycine.

As all doctors couldn’t find any infection, I continued having unprotected sex with my partner.

2-3 days after having sex, my symptoms returned, first urethral itch, later come and go testicle and perineum pain and heaviness.

My urethra also appeared glued shut.

After a few weeks also yellow underwear stains appeared. I have very slight clear watery (sometimes sticky) discharge. (Mostly after urination), all day long.

I went to my GP who did now a full check with urethral swab (labo) and a urineanalysis (by labo) this was morning urine after not urinating whole night.

The results from swab were ‘no puss cells, no bacteria found’

The results of Urineanalysis were 1 x WBC and 3x RBC

They did cultures for urea- and mycoplasma (negative), normal culture: negative growth.

I also did pcr tests for chlamydia, gonnorea, trich, mycoplasma gen., ureaplasma spcs, gardnella, HSV. All negative.

(i did a lot of testing PCR all negative, different labs)

I took 1,5g azithromycine, didn’t work anymore

1 week doxy: no effect

1 week minocycline: no effect

1 week 500mg azi *6 days: no effect.

1. Do you think this is a NGU? (All negative tests, fully protected initial exposure, but still discharge and penis discomfort)

2. Could it be a test was not accurate or the DNA mutated, so it’s not detectable?

3. Is a urethra swab sent to a labo for microscopic analysis reliable? If there are no pus cells, is this the same as PMNL’s?

4. Would you continue treating? In Europe docs do evidence based medicine, so they won’t give me more antibiotics seen the negative tests. Would you give Moxi?

5. I went to 2 x URO’s; they diagnosed with CPPS, and advice Pelvic Treatment. But I still think it’s a urethritis, seen the discharge.

Have you seen this before?

Thanks!

H. Hunter Handsfield, MD

79 months ago

Welcome back, but I'm afraid this forum can't help very much. As in your discussion with Dr. Hook, you give mixed evidence about the likelihood of an STD like NGU, prostatitis, or something else entirely. But the overriding conclusion and the weight of evidence is that you have no STD. I'll point out that some cases of lower genital tract inflammation -- urethral, prostate, etc -- are not infectious, but inflammatory responses not due to any known bacteria, virus, etc. That could explain why you have some symptoms that could be inflammatory but lack of response to antibiotics. CPPS remains the best bet by far; CPPS and prostatitis can cause urethral discharge.

Those comments pretty well answer your questions, directly or by implication. But to be explicit:

1) This is not NGU.

2) The DNA tests for all STDs are highly accurate. You can be sure you have none of the things for which you were tested. There is no such thing as "DNA mutation" that would miss them. And the absence of WBCs on various exams is further evidence against infection.

3) Yes, this is fully accurate. WBC and PMNL are virtual synonyms: polymorphonuclear leukocytes -- PMNLs -- are the standard inflammatory white blood cell.

4) I recommend against any further testing for any STD.

5) As noted above, discharge alone doesn't mean NGU as opposed to CPPS or non-infective prostatitis.

Let me know if anything isn't clear-- HHH, MD

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H. Hunter Handsfield, MD

79 months ago

Another possibility, which I hesitate to raise because it is rare and unlikely: But if you are from (or have visited) parts of the world where certain types of the parasitic infestation shistosomiasis (due to Schistosoma mansoni or japonicum) is common -- parts of the Caribbean, Asia and elsewhere -- this might be worth checking out. If from those areas, ask your urologist -- or see an infectious diseases specialist or a urologist familiar with tropical diseases. Don't get me wrong -- your symptoms aren't typical for urinary tract schisto, but maybe working checking out if geographically appropriate.---
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79 months ago

Thank you for your quick answer.

I will work with my doctors to find the cure.

I don’t think Schiso is very common in Europe.

Just a few questions out of curiosity:

1. Some articles on the internet disagree on the sensitivity of a urethral gram stain for the diagnosis of NGU, they mention that discharge is more likely an indication of NGU instead than the diagnosis of more then 5 PMNL’s, what is your opinion?

2. 2 times all symptoms resolved in 48 hours after azithromycine and came back a few days after intercourse. Only the 3rd time azithromycine didnt work anymore. Could an unknown bacteria become resistant to AZM?

3. Just to be sure: Pus Cells in urethral smear are the same as PMNL/WBC? Or is pus cel a dead wbc?

4. 2 days before the urine culture/smear I finished the minocycline cure, does this could influence the results? I was still symptomatic at that time.

5. Could a Candida infection cause urethritis? My partner was having a candida at that time and was treated for that.

6. I know it is a difficult case, but do you think this resolves by itself?

Thanks

79 months ago

Doc,

I think this thread went lost.. thank you

H. Hunter Handsfield, MD

79 months ago

Apologies for the delay in getting to your follow-up question.

Correct schisosomiasis is not a possibility if you haven't traveled outside Europe.

1) Most experts consider the presence of WBCs as an absolute requirement to confirm presence of urethritis. Dishcarge without WBCs is always considered to have a non-infectious cause. But detailed research has not been done and exceptions might exist.

2) Following up on the possible non-infectious issues, azithromcycin and the tetracyclines have strong anti-inflammatory properties, in addition to acting as antibiotics. Apparent response might reflect suppression of inflammation rather than a particular bacteria.

3) All those terms are synonyms, no different meaning between them.

4) Minocycline could cure an infection or perhaps suppress non-infectious inflammation

5) Candida probably causes some cases of urethritis. It's diagnosed more frequently in the UK (and maybe elsewhere in Europe?) than in the US -- hard to know if that's a real difference, or different underlying beliefs about it, leading to more or less vigorous attempts to document candida in the urethra. Personally, I'm not a believer and tend to think it's overdiagnosed in the UK. But I have no solid data to back that up.

6) There are no reported cases of important complications in men with these sorts of problem, in them or their sex partners. No urethral stricture, epididymitis, infertility, or any other of the complications sometimes associated with gonorrhea or chlamydia. I'm confident no serious harm will come even if this never is clearly resolved.

Sorry that I can't be more helpful. But I hope the discussion has been helpful.

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