[Question #6849] Help diagnosing a STD

10 months ago

It all started a couple of years ago when I had protected sex with a stranger. After a couple of hours I immediately noticed redness on my scrotum, moist skin and a weird feeling that is something between itching and burning. About a week later I began to have tingling in my legs and bumps on my anus that were diagnosed as haemorrhoids (not sure that was a correct diagnosis). A week later I did a blood test for STDs (repeated it in a month and 3 months). The only positive results at the time were Chlamydia IgG and HSV-2 IgG, both IgM were negative. My doctor assured me I am fine, my symptoms slowly started to fade, but were still reoccurring in week intervals. A few months later I felt better, convinced myself I was fine and I started a new relationship. Right after I started having sex again the scrotum redness and itching came back. The only other new symptom I had is a frequent need to urinate, but no pain and no discharge. My new girlfriend started having similar symptoms, but for her it got much worse with time. It started the same with a weird feeling of itching or burning, but progressed to move severe symptoms including white/yellow discharge, pain during sex, small bleeding after sex, cessation of menstruation and gastrointestinal issues. We both got tested multiple times for STDs including HPV, Chlamydia, Gonorrhoea, Trichomonas, Mycoplasma and Ureaplasma from both urine and swab samples, but all results came back negative (PCR). Her gynaecologist diagnosed a PID and a closed fallopian tube, so we both got treated with Azithromycin. That seemed to help and her condition improved. It was good for around a month and then again all the symptoms came back for both of us.

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
10 months ago
Welcome to the forum and thanks for your confidence in our services.

This is a difficult situation. Nothing you describe suggests you have or had any STD. First, no STD (or any infection of any kind) can start to cause symptoms in "a couple of hours"; generally never before 2 days (or maybe sometimes as quick as 36 hours). And none of your symptoms fit with any STD. Some of your partner's current symptoms, especially vaginal discharge, spotting after sex, and of course PID could be from STDs. However, these are common symptoms of various non-STD gynecologic problems as well. Gonorrhea and chlamydia are the main but not the only causes of PID, and some PID is not sexually acquired at all.

The test results you report are reliable. But tell me more about trichomonas and mycoplasma testing. Trichomonas doesn't cause PID, but it would still be good to know that this (in both you and your partner) was a nucleic acid amplification test (NAAT, also called DNA testing), not not just looking at discharge microscopically. Were you tested for Mycoplasma hominis, M. genitalium, or both? M. hominis is a normal bacteria in the genital tract and never causes disease; it really shouldn't be included in STD test panels. Same for Ureaplasma. However, M. genitalium could be significant and you and she should be tested for it if not done already. If positive, it could conceivably explain some or most of your partner's problems, but probably not your symptoms. Importantly, M gen is often resistant to azithromycin.

Could there be other, as yet unidentified STD bacteria that might cause some or all these problems? Maybe -- medical science is learning of many bacteria that are undetectable with standard testing. However, there is little suspicion of this for males with symptoms like yours. Your partner's symptoms are the greater concern and she of course should continue to follow up with her gynecologist. With recurrent symptoms, especially PID symptoms like lower abdominal pain, she probably needs re-treatment and probably with more than azithromycin. (AZM alone is not the usual treatment for PID; other antibiotics generally are included.)

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

HHH, MD
---
---
10 months ago
Thanks for a quick reply. Trichomonas, Mycoplasma hominis and Mycoplasma genitalium were negative on a urine test for both partners (PCR method). 

The only bacteria that was isolated once in the urine is for both partners is Enteroccocus Facealis. Klebsiela Octa and K. Pneumonia were isolated once but only for the male partner more then a year ago.  Could some of those bacteria (that I am aware can cause UTI) explain the other symptoms or are they just a consequence of low immune system duo to something else?

Everything you said  is clear, but I do have some follow-up questions:
  • You are confident that this cannot be Chlamydia or Gonorrhea, because the PCR tests from urine and swab would caught them?
  • What antibiotics would you recommend in such a non-specific case, where the symptoms are there, but the bacteria cannot be isolated? 
  • Should both partners take antibiotics at the same time? And then I guess avoid sex for some time?
A very difficult situation for me indeed, which cause me a lot of nerves and money for testing with no concrete results so far...
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
10 months ago
The urine organisms are entirely normal -- they reside in the intestines of everybody. Small amounts in the urine typically result from contamination of the genital area. You correctly understand they can cause UTI, which is diagnosed when the organisms are present in large number; all labs have automatic standard procedures to test the amount. If your doctor(s) didn't contact you to treat a UTI, you can assume they didn't meet that threshold. None are sexually transmitted. In numbers below the UTI threshold, detection of these organisms is meaningless.

The gonorrhea and chlamydia DNA tests (technically not PCR, but similar) are extremely sensitive; they rarely miss infection, especially when there have been a number of such tests.

Based on all you've said so far, you don't need treatment at all. Standard PID treatment for non-hospitalized patietns usually is doxycycline, often with metronidazole (both orally); preceded by a dose of ceftriaxone by injection, but often omitted if gonorrhea has been excluded. In apparently non sexually transmitted cases, there is no need for partner treatment. Whether or not to avoid sex in this situation is more to potentially avoid pain than to prevent an infection going back and forth.
---
---
10 months ago
Thanks. We both had UTIs lately and received treatment for the mentioned bacteria (it was detected >10^4). None of us had UTIs before, soi t's hard for me to believe that could be a coincidence.

My last follow-up questions:
  • Do you think the UTIs are a consequence of a low immune system or simply a separate infection that has nothing to do with the other symptoms?
  • Whatever this is I am pretty sure we are passing it to each other via sex and it seems to be easily transferable. Anything comes to mind that would do this? The initial symptoms we both share are itching/burning, scrotum redness and frequent urination.
  • Based on my original symptoms I thought I had HSV-2 and not haemorrhoids as diagnosed (they did not hurt, and I never had them after that). My IgG was positive back then and now it's negative. Is that enough to diagnose an HSV-2 infection that would explain a lot of my symptoms? Although not UTIs.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
10 months ago
Interesting about your mutual UTI diagnoses. With what organisms? (Same one in both of you?)

UTIs are rare in younger males (under 50) except those who have had urinary tract instrumentation (e.g. a catheter during hospitalization). When UTI does occur in younger men, it indicates a need to evaluate for urinary tract abnormalities that predispose to UTI, such as kidney stone, partial obstruction to urinary flow and -- perhaps signficantly -- prostatitis. But prostatitis is not sexually acquired or transmitted. In any case, you should speak with a urologist about work-up for potential underlying causes.

However, none of this necessarily means the two of you are transmitting UTIs back and forth or that your UTI has anything to do with your partner's apparent PID. If her symptoms seem to follow renewed sexual activity, that doesn't necessarily mean an infection is being transmitted. Sex itself could alter your partner's vaginal ecology in a way that causes symptoms. Among other things -- I should have thought to ask this previously -- does she have bacterial vaginosis? BV is an overgrowth of mostly normal vaginal bacteria, but some cases may be the result of shared bacteria between partners; whether or not some, most, or nearly all BV should be considered an STD is a matter of ongoing debate among the experts who study it. And significantly, BV is almost uniformly present in women with PID. The main symptom is vaginal odor, often "fishy", and often strongest after sex; and often vaginal discharge. This is something for her to discuss with her doctors. BV has its own treatment, which often includes sexual abstinence or consistent condom use for several weeks.

As for herpes, no way. HSV doesn't behave at all like this, and the fluctuating positivity of the blood test means it's negative. Don't be misled by websites listing such things as tingling or itching as symptoms of herpes. Herpes lesions may tingle or itch, but ithing or tingling of intact skin in never herpes. 

Threads normally are closed after two follow-up exchanges, but I'll leave this open for another round. I'm interested in hearing more about your UTIs and whether your partner has been evaluated or treated for BV.
---
---
10 months ago
The only organism we both had isolated from urine is Enterococcus Faecalis (10^4). Last time I saw my urologist he did diagnose me with prostatitis.
But I thought some bacteria must have caused that prostatitis (and other symptoms)? And why has it become chronic when I am only 30 yo and in good general health? 

I don't think she ever had BV, as there was no "fishy" odor and her vaginal discharge was more cloudy/white then yellow/green, but I am not 100% sure.
Based on our discussion, you opinion is that this is not an STD, but an UTI caused by the overgrowth or otherwise normally present bacteria? Why is my immune system then not able to fight this?

10 months ago
Correction, I was diagnosed with Uretritis, not Prostatitis.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
10 months ago
Yes, I remain confident that no STD explains any of the problems you or your partner have described. Nearly all UTIs are caused by "normally present bacteria". Did you have good evidence of urethritis, i.e. urethral discharge and perhaps painful urination? If not, prostatitis seems more likely. And do you and your partner have anal sex? Fecal bacteria like E. faecalis are entirely normal in the rectum: and many cases of urethritis due to fecal bacteria follows exposure during anal sex, although that's not the only possibility.

"Chronic" doesn't allude to the patient's age, but to the duration of a clinical problem; plenty of chronic health conditions occur in young persons. There is no underlying immune system problem that leads to prostatitis, urethrits, or UTI. For prostatitis, one reason for chronic infection, and for infections difficult to cure with antibiotics, is that the prostate is a "sequestered site" with poor penetration of many antibiotics into prostate tissue.*

All things considered, I remain confident that your and your peartner's health issues arentirely outside the STD realm. So that concludes this discussion. Thanks for sharing it with us. (FYI, Dr. Hook has been following this discussion. He agrees with all I've said.) My closing advice is that if your and/or your partner's symptoms continue, consider asking for referral of the two of you to an infectious diseases specialist. As my replies have implied, these are complex issues:  some gynecologists, urologists, and general physicians might be equally knowledgeable as an ID specialist in these arenas, but most are not. In any case, I hope this discussion has at least started you down a path to resolution once and for all. Best wishes.

* Not to get too far into the weeds, but perhaps you'll find it interesting that this is probably an evolutionary benefit, i.e. genetic selection to prevent penetration of environmental toxins into certain organs. You can understand how not contaminating sperm or semen might have an evoluationary advantage by fostering healthy conception. Other similarly sequestered anatomic sites with poor antibiotic penetration are the central nervous system and the eye. Again, perhaps you can understand the evolutionary selection behind it.
---