[Question #5110] NSU follow-up

23 months ago
Hi Doc

Following up on NSU symptoms. Further to previous conversation, I have visited STD clinic in Australia after completing azithromycin and Cipro. They have tested for chlamydia and gonorrhoea again on  13 Feb (oral exposure mid December 2018) in addition to other tests for herpes, adenovirus, mycoplasma, ureaplasma. These tests were performed using three urethra swabs, first urine and mid urine. They have attempted to test by all possible means (as noted on the lab form) therefore multiple swabs and urine. No blood tests were deemed necessary due to previous tests performed and exposure as oral only. 

All the results are negative. Urine MCS on 10 Feb shows no sign of WBC or positive leuko (early Jan and late Jan urine has WBC's and positive leuko). On day one while they wait for tests, they have decided to give doxcy twice a day for 7 days. 

I don't have any itching and irritation symptoms which were regular in early Jan.  My urine is completely normal and I just felt pain ONLY one day since this started in Dec. No change on appearance on penis or surrounding.  

My only concern now is occasionally (may be once or twice a week) I see strains in my underwear. Its very minor just like few dots. I haven't noticed any discharge when I attempted to check and no pus like discharge since mid Jan. 

Do I still need to be concerned or am I in safe phase now? I didn't had sex not even oral since mid December. Just wondering based on your experience do you suggest to consult with another doctor or is this completely normal to see very very minor discharge here and there for male. 

Please advice

Thanks 
23 months ago
So far I have been tested for following: 

1. STD test pack by labcorp USA - NEGATIVE 
2. Chlamydia and Gonorrhoea - multiple times in US, UK, Australia (through swabs and urine) - NEGATIVE 
3. Virus tests - mycoplasma, ureaplasma, herpes, adenovirus (urine and swabs)  - NEGATIVE 
4. HIV, hepatitis, syphilis - NEGATIVE 
5. Physical examination at Std clinic - NEGATIVE 
6. Urine MCS in Dec, Jan, and Feb - POSITVIE  (noted excess WBC's and +eve Leukocytes in Dec & Jan) 
7. Urethra swab examined under microscopy at doctors clinic - POSITIVE (noted few traces of bacteria)

Medicines:
1. Azithormycin single does - 2mg
2. Cipro 500mg twice x 3 days
3. Doxcy 200mg twice x 7 days 


H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
23 months ago
First, please provide the thread number(s) for any previous questions you have posted, perhaps with different username(s). Second, there is a reason for the word limit that resulted in your question spilling over into a second window. When you post your comment with the previous number(s), also please compress your question to the set limit (maximum 1500 characters). The limit is intended to respect the moderators' time -- and should be quite easy if some of the information is available in previous threads.

Thanks--  HHH, MD
---
---
23 months ago
Follow up question # 4880

Apologies. I have compressed the query.

Further to previous conversation, I have visited STD clinic in Australia after completing azithromycin and Cipro. They have tested for chlamydia and gonorrhoea again on  13 Feb (oral exposure mid December 2018) in addition to other tests for herpes, adenovirus, mycoplasma, ureaplasma. These tests were performed using three urethra swabs, first urine and mid urine. No blood tests were deemed necessary due to previous tests performed and exposure as oral only. 

All the results are negative. Urine MCS on 10 Feb shows no sign of WBC or positive leuko (early Jan and late Jan urine has WBC's and positive leuko). On day one while they wait for tests, they have decided to give doxcy twice a day for 7 days. 

I don't have any itching and irritation symptoms which were regular in early Jan.  My urine is completely normal and I just felt pain ONLY one day since this started in Dec. No change on appearance on penis or surrounding.  

My only concern now is occasionally (may be once or twice a week) I see strains in my underwear. Its very minor just like few dots. I haven't noticed any discharge when I attempted to check and no pus like discharge since mid Jan. 

Do I still need to be concerned or am I in safe phase now? I didn't had sex not even oral since mid December. 



H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
23 months ago
OK, thanks for the clarifications and the shorter question!  

I'm glad to see you're in excellent care, assuming the STD clinic is one of the federally supported sexual health centres. Australia's SHCs, collectively, probably are the world's best network of STD/HIV clinics, generally very expert and widely respected world wide. (And if you were at the ones in Sydney or Melbourne, you have been to the best of the best.) In fact, I'll go a step further and guess it was Melborune. The Melbourne SHC has specifically done research on the causes of NGU, including orally acquired cases, including testing for adenovirus -- which is not a routine lab test for utethritis in most places but may be at the MSHC. As they probably told you, the negative results for Mycoplasma (genitalium?) and Ureaplasma were expected -- these are not carried in the oral cavity and therefore not found in NGU acquired by oral sex.

As we discussed last time, using ciprofloxacin in this situation was atypical. However, because the specific causes of NGU acquired by oral sex are unknown, and there is essentially no research on different treatment regimens, I cannot say it was wrong. But in any case, with continuing symptoms -- even without clear evidence of persisting urethritis (i.e. no WBC) -- it probably is reasonable to give doxyccyline a try. But because there is no clear evidence of urethritis, I'm not confident it will work. There's a good chance you some residual inflammation that is not due to active infection and therefore will not respond to any antibiotic.

So even if neither I nor the clinic can give you conclusive answers, there is a reassuring aspect:  NGU from oral sex is not known to ever cause important complications or serious outcomes. There are no reports of the kinds of things that can occur after gonorrhea or chlamydia, such as urethral stricture, epididymitis, and so on. Also there are no reported consequences in such mens' sex partners. You should ask these same questions of the clinic treating you, but I anticipate they will agree with all I have said -- and that this should include resuming normal sexual practices without worry of harm to either you or your partner(s).

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

HHH, MD
---
23 months ago
Thanks Doc - i have been to national std clinic. 

1. Is it possible to have residual inflammation due to no infection caused by std? 

2. Can a male have discharge with no underlying cause? 

3. If there is a discharge (very minimal almost ignoreable and not regular but leaves stain) does it needs attention and treatments?

4. Can i rule out viruses and infections? Or is there any scope this is undected despite many tests? Any risks for hpv as i am not sure if this has been tested. 

5. What would be your suggestion if you come across such patient? 

6. Any further tests would you recommend at this stage? 



I haven’t resumed unprotected sex as i wanted to wait and see if there is a scope to completely resolve this for my own satisfaction. 




H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
23 months ago
These questions have already been answered -- or at least the answers are obvious from things we have already discussed.

1. Probably yes.

2. Of course there must be a cause. But that cause isn't necessarily an infection and not necessariy a serious health problem.

3. If the discharge is so minimal to be "almost ignorable", then probably it isn't abnormal at all -- and should, in fact, be ignored.

4. No virus or other infection is the cause of this problem.

5. My advice if you were my patient is exactly what I have advised in this and your previous threads.

6. Already answered:  you should have no further tests of any kind and should continue your life without worry. You should resume your usual and normal sexual practices, as advised above.
---