[Question #7181] Undiagnosed NGU

6 months ago
About 4 months ago, I started feeling severe dysuria and discharge, inflammation in tip of penis, and pressure/throbbing in the lower abdomen, pain when getting erection/ejaculating.  I was tested and treated for gonorrhea/chlamydia (1g azithromycin cetriaxone shot). My tests came back negative and my symptoms improved within a few days, but only the discharge seemed to completely go away. Over the next month, the girl that gave me the infection and I got tested for all the common STIs and came back negative for all of them. I also had a couple urine cultures come back negative and had a myco/ureaplasma test that I took about 4 weeks after the initial round of antibiotics come back negative. I was given doxycycline and azithromycin again (smaller doses over course of week) over the next few months and felt little improvement. The pain when getting erection/ejaculating did seem to get better. In my last visit to the urologist, I gave a semen culture which also came back negative. He said the next course of action would be a cystoscopy, but that the chances of him identifying the problem through that procedure isn’t high and it could do more damage than good. My most glaring symptom currently is the swelling at the top of penis, but that really varies in how bad it looks each day. Do you have any idea what infection caused the ngu, how it should be treated, if I should go through with the cystoscopy, or if I should get a second opinion? 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
6 months ago
Welcome fo the forum and thanks for your confidence in our services.

Sorry to hear of your difficulties. I'll start with the observation that you don't mention Mycoplasma genitalium, for which you might not have been tested; it may or may not have been included with your "myco/ureaplasma" test. If done and negative, good. If not, discuss testing with your doctor. M genitalium can be resistant to the treatments you've had; the drug named moxifloxacin often is necessary. Second, you don't mention Trichomonas. Trich usually causes no symptoms in men and I've never heard of it causing the dramatic NGU that started you down this path. But for completeness and certainty, it should be ruled out. A urine nucleic acid (DNA) test is readily available and highly accurate.

Almost half of all cases of acute urethritis have no known cause, so there's no surprise your and your partner's traditional STD tests (e.g. gonorrhea, chlamydia) were negative. Most are probably due to unidentified sexually transmitted bacteria. However, some are due to viruses, especially herpes or adenovirus. Adenovirus is predominatly a cause of common colds and other respiratory infections and is transmitted to the urethra by oral sex. Herpes usually is obvious because there are other typical symptoms and signs -- penile blisters/sores, partner with oral or genital herpes, etc. However, neither of these is known to cause the prolonged difficulties you hae experienced:  either one would have cleared on its own within a couple of weeks. Still, if you were my patient, I would request a herpes simplex virus (HSV) antibody test and perhaps even a urethral PCR for HSV.

It is possible that urethritis of any cause may sometimes trigger an immunologic reaction that causes ongoing inflammation. From both your symptoms, the negative results of all tests so far, and lack of response to all those antibiotics, I'm inclined to guess something like this is going on. If so, it's almost certainly not serious. I'm not saying it isn't uncomfortable or even overtly painful, but I doubt you have any currently active STD, especially if M genitalium has been ruled out. I also doubt this will ever cause any important or longstanding health problems (other than the discomfort) for either you or your current or future sex partner(s).

As for going ahead with cystoscopy, I have no particular advice. In my STD clinic, we would refer a patient like you to a urologist, just as have happened and then leave it in his or her hands. On the other hand, my experience is that such urological evaluations come up empty -- rarely with a clear explanation for continuing symptoms. In any case, before proceeding, I would discuss all this with your own primary doctor and/or the urologist. Consider printing out this reply as a framework for discussion.

I hope these comments are somewhat helpful. Let me know if I can help further. Good luck.

HHH, MD
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6 months ago
Thanks for the reply. To answer some of your questions, I was pretty confident that I had mycoplasma or ureaplasma upon my first visit to the urologist, so I made sure those possibilities were tested for. I had read the test may not be incredibly accurate and the fact that I took antibiotics a few weeks before might have been a cause for a false negative. I’d like to get tested again now that it’s been almost two months since I was on antibiotics, but it was a pretty expensive test ($700). Should I ask my doctor to prescribe me moxifloxacin to see if that is effective? I also tested negative for trich, and both the girl and I tested negative for both strains of herpes. I never had any sores or anything. I had also thought there was a chance it could have been adenovirus since the girl had been having some cold-like symptoms the week we had sexual contact, but my urologist said that would usually go away in 2-4 weeks. Are there any other viral infections that cause the symptoms I’ve described that I should be worried about? As of right now, my urologist seems to agree with you that i am probably having an immunologic reaction that is causing the inflammation. If that’s the case, how much longer should I expect this the persist? Is there anything that can be done to speed up the recovery process? He’s prescribed me a steroid gel to reduce swelling, but after using it for a couple weeks, it didn’t reduce the inflammation much if at all. I am still concerned that I might still have an ongoing infection because while the dysuria and overall pain I was experiencing has gotten significantly better, there are still times when I I think I feel them, along with the pressure in my lower abdomen and feeling slight pain after ejaculating. However, it may be psychological, so I’m unsure. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
6 months ago
I'm not sure why you were "confident" you had mycplasma or ureaplasma. Except for M genitalium, genital mycoplasmas and most ureaplasmas are normal genital bacteria and cause no disease. Don't waste money on additional testing except maybe M gentalium as discussed yesterday. Glad to hear of the negative trich and herpes results.

Glad to hear your urologist and I are in agreement. I remain confident you have no STD at this time. If an STD was the initial problem, it's now long gone: with the possible exception of M gen, there is no possible STD that would not have responded to the antibiotics you received. Aside from M gen, I would cease any additional tests or other attempts at diagnnosis of any infection, and would not recommend any more antibiotic treatment. Since inflammation is possible, I would think a trial of a nonsteroidal antiinflammatory drug like naproxen, celicoxib, etc might be worth a try.

Besides inflammation, I agree with your onw judment that much of what you are experiecing has al psychological origin. (And when someone suspects his or her own problem has a psychological origin, usually s/he is right!)  In any case, if you were my patient, I would deny any request for additional infection testing or antibiotics.s, but might try the NSAID idea.

As before, I suggest discussing all this with the urologist. But in the meantime, do your best to stop worrying. Not all symptoms indicate disease or likely harm. I've dealt with hundreds maybe thousands of patients with such problems over the last 50 years and I've never seen one who later developed anything serious. Consider just living with it for a few months and see how things go.
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6 months ago
The reason I thought it was M genetailium was because my symptoms seemed to  be almost exactly the same and all my other tests came back negative. I was also suspicious I may have gotten it from oral sex because the girl was having some symptoms like a cough, sore throat, and headaches. She didn’t remember having unprotected sex with anyone else and performed oral sex on me on far more occasions than we had regular intercourse. Would there be any test for M genetailium that is fairly accurate? I read about Hologic’s Aptima M genetailium being the most accurate test. Would I t be correct to assume me testing negative using this test after being off antibiotics for almost 2 months would mean I beat whatever  infection  I had?
Like I guess what I’m asking is if it was caused by an unknown bacteria, would that Have shown up in a urine cultures I took if the infection was still present? I also wanted to ask about the immunologic reaction. What exactly does that mean? Is it always something that goes away with time or is it sometimes permanent? How long does something like that generally persist? Again I’d really like to know if there’s anything I can do to get back to normal as soon as possible. Please let me know what you think.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
6 months ago
Your symptoms conceivably could be due to M. genitalium, but they aren't typical for it. M. gen symptoms are identical to all other kinds of NGU:  discharge (usually mucoid, not thick pus) and slight discomfort when urinating. More severe symptoms like your original ones probably occur from time to time, but the ongoing symptoms you have had in the last couple months are not typical. Also, M gentalium is rarely detectable in the mouth or throat, and therefore oral sex is rarely if ever the source. All cases are acquried by vaginal or anal sex.

Because you haven't been tested yet for M gen, I still think it's a reasonable last step. The Aptima test is the one to have. A negative result will be conclusive. (Should it happen to be positive, it won't necessarily explain your current symptoms, but wait to cross that bridge if you come to it.)

The immunologic businss is speculative; there has been no research on this. However, in my nearly 50 years in the STD business, I have never seen a patient with symptoms like yours that didn't clear up within a few months. Whether immunologic or not, it's probably harmless. As I implied above, an NSAID like naproxen conceivably might help your symptoms if there is an immunologic component. Don't get your hopes too high, but it would be reasonable to discuss with your urologist.

That completes the two follow-up exchanges included with each question and so ends this thread. I hope the discussion has been helpful.
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