[Question #5780] Clear discharge for almost 5 months of unknown etiology

18 months ago

I’m 36 yo with a h/o NGU (2- 3x) resolved each time w/ azithromycin or doxycycline now w/ persistent urethral discharge x 5 months and urinary symptoms.

I had a sexual encounter with a woman on 3/1/19. She performed oral sex on me and my penis brushed up against her vagina before I wore a condom for the rest of the encounter.

I developed clear urethral discharge with a tingling sensation 1-2 days later. On the 3^rd day I took a Z pack which I completed. Symptoms persisted and NAAT for ureaplasma, mycoplasma was negative, G&C cultures was negative, HIV/RPR/HSV1&2 was also negative. I took metronidazole to cover for potential trichomonas.

17 days later same symptoms persisted so I took doxycycline bid x7 days. Still no resolution in discharge persisted and I progressed to have dull pain in my abdomen and testicles. Testicular ultrasound revealed possible epididymitis and hydrocele.

Took levofloxacin x 17 days. This relieved the pain in my testicles but I still had: clear discharge, occasional dysuria and dribbling when urinating, urinary frequency, urgency, dark and foul smelling urine, and intermittent dull LLQ pain.

Cystoscopy, r/o urethral stricture only trabeculations in my bladder were noted. An u/s of my prostate revealed 2 calcifications (possibly from previous infections).

An ID doctor thought I had NGU and prescribed 3 weeks of doxycycline. Symptoms did not resolve. All repeat STD blood and urine testing were negative.

About 100 days after the sexual encounter the results of a first void urine culture came back positive for m. morganii & e. faecalis. I took 13 days of Cipro. Subsequent cultures were negative. Doctors believe the specimen may have been contaminated.

Results of urodynamic testing are currently pending.

Edward W. Hook M.D.

18 months ago

Welcome to the Forum. thanks for your questions. I have several comments and suggestions regarding this somewhat unusual situation:

1. The first question is how much urethral discharge is present (is it present all day or just in the morning) and whether or not your urethral discharge is inflammatory or not (this is best determined with a gram stain of urethral secretions using a specimen collected using a swab inserted a little bit into the urethra. A certain (variable) amount of urethral discharge is present in most men but goes un-noticed. When the discharge has PMNs in it, it is inflammatory and more likely to be infectious.

2. Was your test for "mycoplasma" a test for Mycoplasma genitalium or M. hominis. M. genitalium is a recently appreciated pathogen which causes persistent urethritis in men and may be resistant to azithromycin, doxycycline and levofloxacin.

3. If your tests are negative for M. genitalium as well as gonorrhea and chlamydia, and having ruled out urinary tract pathology, the good news is that complications are VERY rare and you are not a threat to the health of sex partners.

4. I too am skeptical that your positive cultures for m. morganii & e. faecalis are significant.

I hope that this perspective is helpful. EWH

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18 months ago

Dr. Hook, thank you for your prompt response.

1. The clear discharge is present all day. I wake up with discharge and throughout the day my foreskin is moist, which wasn’t the case prior to this encounter (except for the two or three previous times I was diagnosed with NGU). I also have increased pre-ejaculate, which is not normal for me. I’ve requested smears and no urologist nor infectious disease doctor will do it.

My first question is do you have any suggestions on where I can get a smear done in the New York area?

2. Both M. genitalium and M. hominis were negative.

My second question: is it possible that I’m harboring bacteria from oral sex in my urethra and this is now part of my flora?

Edward W. Hook M.D.

18 months ago

Thanks for the additional information.

1. I'm surprised no clinician will perform a smear. Why do they say they won't do it? In the New York City area there are excellent City STD Clinics which are affiliated with CDC sponsored STD Prevention Training Centers. I would contact them to find out where you can get a urethral gram stain. Is it possible that you are looking for signs harder than you might have in the past? We do know that increase vigilance leads to noticing more detail. There are no STIs the increase the volume of pre-ejaculate

2. Thanks for the information on M. genitalium. This, with your other negative results makes it unlikely that your increased discharge will lead to complications or is due to anything that you could transmit to another person to cause them harm.

3. The science of how the bacteria which colonize a mucosal surface (i.e. the "microbiome" of the mouth, the urethra, other mucosal surfaces) change or are transferred from person to person. We do know that long term partners tend to share similar microbiomes but how quickly that occurs and how often if persists is not fully understood at the present time.

I realize this is frustrating for you. I hope the information I have provided is helpful. EWH

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