[Question #6144] Follow up to #6099

16 months ago
Brief description.  Unprotected encounter with escort.  Following testing done thus far:
•2 negative Chlamydia/gon urine tests.
Negative urethral swab for HSV PCR (both 1&2)
•1 urine dip stick “moderate” leukocytes 

I was treated with 1 gram Azithromycin followed by 250 mg once daily the following 2 days.  Also treated with 2 grams of metronidazole.

I haven’t seen any discharge at all.  My main symptoms are burning in my penis.  This seems worse while holding urine and immediately following urinating.  Randomly I have pains on each side of my groin and lower back however I think some is anxiety.  

I plan to go back to my doctor in a couple days.  He’s thinking maybe protate issues, but I’m skeptical since it appeared after this encounter and I’ve never had prior issues.  Should I consider maybe m. Genitalium testing?  Any advice/suggestions I could possibly pass along to my pcp?  I just want to put this behind me and go back to life as usual.  Maybe rekindle some romance with my spouse,  but I want to be safe also.  Thank you in advance!
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
16 months ago
Welcome back to the forum.

It now seems liess likely that you have (or had) urethritis and I'm confident you have no STD. A single urine dipstick positive for leukocytes is the only objective evidence you provide of the possibility of urethritis, and that can give false positive results. It would make sense to repeat it; I'm guessing it would now be negative. Despite that test result, In the absence of noticeable discharge (by far the main symptom of urethritis, a lot more common than urinary discomfort alone) and with the negative infection tests you had, plus lack of improvement with azithromycin and metronidazole, all argue against any STD. 

A "prostate issue" certainly could cause symptoms like this. However my advice would be to delay evaluation for it for a few weeks. In the meantime, I would suggest no firther treatment and see what happens with your symptoms. If they persist say 3-4 weeks more, at that time evaluation for chronic pelvic pain syndrome (the more up to date name for chronic, non-infectious prostatitis) and other issues probably would make sense. In the meantime, you can be confident you have no STD that ever will cause serious health problems in you or your sex partner(s). You can safetly continue or resume unprotected sex with your spouse. Indeed, many sexual health experts recommend that sexual release is helpful in situaitons like yours.

I hope these additional comments are helpful. Let me know if anything isn't clear.

HHH, MD
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16 months ago
I forgot to add that my doctor also did HSV blood testing as basically a base line test.  I’m supposed to retest in 8 weeks.   Results came back today and I’m definitely nervous:
IgM Type 1/2-positive
IgG Type 1 positive (I expected this from oral cold sores in the past)
IgG Typ2 negative.

No index values available.  I’ve read the IgM is useless, but possibly indicates a recent infection.  The timeframe adds up plus the lack of antibiotic response.  I had the PCR urethral swab 10 days post encounter and I believe 5 days after symptoms started.  Questions....

•Is the PCR urethral swab accurate in this timeframe?  False negative?
•Have you seen HSV 2 show up in this fashion ie; urethral burning, no lesions seen, with a negative swab test?  

Urination has never been painful. I still have the urethral discomfort. In fact it’s maybe worse again.    I guess I’m VERY curious what the chances are.  Preferably from an expert in this field!  I’ve shared our previous exchange with my doctor.  He’s personally never seen HSV present like this but says it’s possible for sure.


H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
16 months ago
In theory, IgM antibody appears early then disappears as an IgG antibody response develops -- and hence indicates early infection. However, it just doesn't work well for HSV infections:  IgM is often absent in early infection, can be present in late infection, and -- most important -- often gives entirely false positive results. That's the most likely explanation of your test result. 

As for PCR testing, it only detects active infection. Among people with known herpes, PCR testing is positive under 10% of the time. However, if herpes were the cause of your continuing urethral symptoms, I would expect a positive PCR -- so that result is moderately reassuring, although not proof against herpes.

All things considered, based on initial symptoms, continuing symptoms, and all available test results, I believe there is no chance at all that genital herpes explains your symptoms.
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16 months ago
I’m trying to think logically here but want your opinion.  So yesterday the burning somewhat resolved.  This morning I woke up with almost no pain.  Went to the bathroom and burning urination and definitely hurt with a bowel movement.  Like the skin was super raw when I wiped.  The burning in my urethra has returned and can be intense.  I’ve noticed this a couple other times in the last 2 weeks.  Pains in my lower back and burning down both legs and in my feet also.

Is there a possibility that hsv2 can be reoccurring like this over the course of 2 weeks with initial infection?  Kinda like all the lesions stay inside my penis or anus and keep recurring?  It’s the only plausible explanation I can come up with since no antibiotic helps.  

I’m going to do another blood test in 8 weeks that will give me the answers but everyone keeps saying this can’t be hsv2.  

Thank you for all the help you’ve provided!
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
16 months ago
I'm not sure I understand the relationship between your urethral and anal symptoms. Having urethral pain during a bowel movement suggest prostate gland inflammation, but prostatitis is rarely due to STD, and also would not cause anal pain or anal area skin being "super raw". And the intermittent nature of your pain is peculiar.

With these evolving symptoms, I suggest you be reexamined in person, perhaps with repeat tests for both urinary tract infection and STIs, likelin including HSV by PCR; and a digital rectal exam to evaluate your prostate. Don't rely only on repeat blood testing in a few weeks. 

That concludes the two follow-up comments and replies included with each question and so ends this thread. Please resist the temptation to return to the foum, at least until you have seen an expert in person. This forum is not a substitute for direct medical care!

Good luck. I hope this additional discussion has been somewhat helpful.
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