[Question #6845] Infection/CPPS further clarification?

10 months ago
Dear Doctors,

Thank you to Dr Hook for his recent advice in my previous question. I am hoping to ask some further clarification on my situation.

I had a risky encounter involving unprotected oral and genital to genital apposition (tip of penis to vagina opening).

Symptoms started as red irritated glans, increased urge to urinate and uncomfortable abdomen. Also, tingling feeling in testicles and perenium. The symptoms can come and go to a degree and recently have started experiencing feeling of pressure in the rectum, also irritated feeling in the anus. I have noticed my ejaculate has reduced in volume and has a yellowish tinge, with jelly like clumps. This must surely mean some kind of infection?

Given how the symptoms progressed, it seems logical to me that I picked up some kind of infection in the urethra which has now travelled to the prostate. 

I have only tested clear  for chlamydia and gonorreah. I have also had my urine tested a couple of times using a dipstick and told it is clear, no sign of infection.  I assume this is for WBCs... Are these tests reliable? Would it matter that the test was in the afternoon? Would it matter that I drink a lot of water and so the sample would be quite diluted?

I have read a lot of conflicting information online about MGen and how it could possibly be transmitted through brief apposition?

Thank you for your help. 

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
10 months ago
Welcome back, but sorry you found it necessary. I'll be taking your question this time, but I reviewed your recent discussion with Dr. Hook. I agree with all he said -- and as a result, there's not much more to say.

Despite your seemingly "logical" conclusion, there is no evidence you have any infection of any kind.  The sine qua non of urethral infection is white blood cells (WBC) in the urethra, and it seems you respot several negative tests for WBC. The dipstick tests are highly sensitive and not likely to be affected by urine dilution. Further, no urethral symptoms, and certainly no STD, cause urge to urinate, abdominal discomfort, or testicular/perineal "thingling". And no symptoms of infection would be likely to come and go; that is, their on and off nature argues for a non-infectious explanation.

I'm glad Dr. Hook raised the issue of CPPS, as also reflected in the title you chose for this discussion. In a way, you can't have it:  "chronic" implies a longstanding problem. On the other hand, symptoms have to start sometime, and otherwise all you describe is consistent with CPPS. I might classify your problem as genitally focused anxiety. Whatever we call it, there is no evidence of any infection of any kind. The symptoms of either GFA or CPPS are believed to result from increased tension in pelvic muscles and perhaps bladder musculature. Just as tension headaches result from increased tension in scalp and neck muscles, anxiety triggers such muscle tension in the pelvis, bladder, etc.

As Dr.  Hook said, Mycoplasma genitalium is not known to be acquired by oral sex; several studies have shown that M. genitalium is rarely present in the oral cavity -- hence no possibility of transmission by such exposure. And in any case, all evidence is that you have no infection at all. I can't explain a yellowish tinge to your semen, but when senen is examined closely, such color variation is common and usually not abnormal. Be very careful searching online about M. gen. Much is unknown in terms of serious research, and certainly there are no data to suggest transmission by apposition without penetration. Personal opinions by possibly infected persons are the worst kind of evidence of a real problem.

I would advise sitting tight for a while, with no further attempts at either diagnosis or treatment; and if you have a regular sex partner, continue your normal sexual practices. (Some urologists believe frequent ejaculation to be helpful in people with symptoms like yours.) There is no risk of harm to your partner. If your symptoms persist more than 2-3 weeks, it would make sense to see a urologist.

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

HHH, MD
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9 months ago
Dear Dr Handsfield,

Thank you for the response, it has helped to settle my anxiety over this.

I think it would make sense that tension which is caused by anxiety could be behind much of what I have been experiencing. The problem is, any hint of symptoms can increase anxiety and it’s a vicious cycle!

I have noticed that symptoms can get worse after long periods of sitting, but that remaining active, stretching and not constantly focusing on the symptoms usually means they fade. Would you suggest that symptoms of an infection would be pretty constant, regardless of activity etc??

I still wonder, can tension alone cause things like inflammation and redness of the glans? 

I did have a referral to see a Urologist, however the coronavirus outbreak means this has been put on hold for the foreseeable future.

Do you know whether my urine sample for Chlamydia and Gonorreah would have been through other lab tests as a standard procedure. For example, would this also be checked for signs of WBCs?

Do you know of any cases where infection might be present, perhaps in the prostate, therefore WBCs would not show up in urine? I have read accounts of people having prostatic fluid or semen tested before they were able to find out exactly what infection they had.

Thank you again for your advice.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
9 months ago
I'm glad to have helped so far, but probably can't be of much additional assistance. Anxiety/stress won't cause a rash or red marks of the penis, but most genital rashes and skin problems aren't STDs. Your other symptoms also continue to be most suggestive of the physical manifestations of anxiety or other emotional origin. Routine urinalysis always includes WBC testing, usually by leukocyte esterase dipstick. It's possible to have prosatitis with negative urine WBC testing, but STDs don't cause prostatitis.

See a doctor when you can. But really no hurry. Your symptoms might be uncomfortable, but they do not suggest anything serious. I've never seen a patient with CPPS or similar sympotms who turned out to have any serious health problem. Sorry I can't be of more help.
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9 months ago
Hello Dr Handsfield,

Thank you for your additional input. I have browsed other questions on this forum and it does seem that there are many others in my position - either through guilt or anxiety over a regrettable encounter. You must be very used to dealing with cases like this and I am very greatful for your patience and expertise.

It would seem that a large part of dealing with this is going to be mental - I am struggling to accept that following a risky encounter, there is not some kind of infection or pathogen which causes my symptoms. I have been through stressful situations before in life, such as family bereavement, and I have never experienced symptoms like this.

Please can I clarify some points with you, in the hopes of moving forward with this. When my symptoms initially presented, they were more around the urethra rather than the Prostatitis/CPPS type pains. These initial symptoms were increased urge to urinate, a heaviness in the abdomen and irritation at the tip of the penis and urethral opening. I have read in a number of places, including the NHS website, that increased urge to urinate can be a symptom of Urethritis??

My initial testing was a urine sample, checked with a dipstick. This was clear, then my next step was a Chlamydia and Gonorreah Test at the GUM clinic. There are of course, many other tests which can be taken for further pathogens. Does this imply that testing for WBCs with a dipstick does not rule out urethra infection, if we need to test individually for each possible cause? I am a little bit worried that my urine dipstick was clear but there is some other infection that was missed?

These initial symptoms waxed and waned over a couple of months when I then started to develop additional pain/irritation in the rectum as well as the feeling of pressure like sitting on a golf ball. Urinary symptoms and irritation at the tip of the penis also continue in parallel. Again, all of these symptoms continue to wax and wane. The way these symptoms developed over time, from urethra to prostate, has me a little concerned over some kind of infection which has spread over time? How plausible would this be?

Thank you for any insight you can offer.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
9 months ago
There have long been somewhat different perspectives on urethritis and related issues on the two sides of the Atlantic. Certain investigators in the UK believe the symptoms cited indeed can be due to urethritis, but it is controversial; and Dr. Hook, my co-moderator on this forum, is co-author of a study of men with urethritis in an STD clinic, and specifically found no symptoms of the sort you mention or that some authorities in the UK believe. The American (and Dr. Hook's and my) viewpoint is supported by the known anatomy and physiology, including nerve supply, of the upper and lower genital tract. There is no plausible reason why inflammation in the urethra would cause an urge to urinate. In any case, even in the UK, experts would not diagnose urethritis in absence of white blood cells, generally detected by urine dipstick. Not all chlamydia or gonorrhea results in increased WBC, but most infections do. That both WBC and gonorrhea/chlamyida testing were negative further confirms you do not have urethriitis. Finally, urethritis symptoms do not wax and wane; that pattern is much more consistent with blader and pelvic muscle tension than with infection of any kind.

Please note my last comment before this one. You have nothing that will ever harm you or a sex partner. Period. In my 40+ years in the STD business, I have never once had a patient with symptoms like yours who had any sort of serious health outcome. This is an issue of comfort, not harm.

That concludes this thread. And because repeated questions on the same topic are not permitted, and this being your second, it should be your last. Thanks for your understanding. I hope the disucssion has been helpful. Best wishes and stay safe.
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