[Question #7291] Underwear stain after first urination in the morning

6 months ago
32 y.o. Asian male
Sep5-Unprotected v and oral sex with partner (A)
Sep6-Unprotected v and oral sex with partner (B)
Sep16-18-Yellow-green underwear stains seen waking up in the morning, throughout the day. Pain during urination. Penis tip sticking to underwear. Penile discharge. No other symptoms.
Sep19-Went to a non-STD clinic, doctor diagnosed it as Gonorrhea and/or Chlamydia. No tests performed. Given Ceftriaxone 250 mg intramuscular injection, and Azithromycin 500 mg per tab (2 tabs).
Sep19/20-Met A and B separately, doctors gave them same treatment as me. No tests performed.
Sep21-No pain during urination anymore. Tip of my penis not sticking to underwear. No visible penis discharge. However, still observed yellow-green underwear stains upon waking up in the morning, not sure if there was also during the day. A and B did not report any symptoms starting from this day.
Sep22-29-Still had greenish underwear stains upon waking up, although getting fewer in number. Wearing fresh white underwear after showering.
Sep30-Oct 1- No greenish underwear stains from waking up and after first urination.
Oct2-4 - No greenish underwear stains upon waking, however, after first urination, saw a single green underwear stain, also noticed urine colored stain, circular in shape, just below the greenish underwear stain.
Does this mean that the Ceftriaxone and Azithromycin treatment failed? If so, what should be my next steps for me and my partners?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
6 months ago
Welcome to the forum. Thanks for your question.

Obviously you have had sexually acquired urethritis. I's unfortunate you were not tested to know the cause; that's really poor care by the clinic you visited. If and when you need future STD evaluation, go elsewhere -- or at least insist on proper evaluation. That said, at least they treated you correctly. There are mixed guesses about the specific STD you had. The long incubation period until your first symptoms (11-12 days) suggests chlamydia or non-chlamydial nongonococcal urethritis (NGU). Although colored ("greenisg") discharge is somewhat more typical of gonorrhea, the relatively slow resolution of symptoms also favors chlamydia or NGU.

As just implied, it can take a week or two for symptoms to clear entirely. However, you're now at about 2 weeks. In up to 15-20% of NGU or chlamydial infections, persistent or recurrent symptoms occur. This is most common with azithromycin treatment. You should see a doctor in the next few day for reevaluation and, if persistent urethritis is documented, treatment with doxyxycline. If urine testing is available for trichomonas and Mycoplasma genitalium, that also is recommended. Try to find an STD or infectious diseases specialist; if your local or state health department has an STD clinic, that would be a great choice.

It probably goes without saying, but you need to be not having sex until this is sorted out completely and you are entirely asymptomatic and, if you are re-treated with doxy, until a week or so after completing that treatment. Plan on not being sexually active for at least another couple of weeks. And if you hook up again with A or B, not until they have also been treated.

Both partners A and B should have been contacted the day you were treated. If not done yet, for sure inform them now that they likely have gonorrhea or chlamydia and should be treated -- and ideally tested as well.

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

6 months ago
To answer your concerns, yes A and B were treated on Sep 19 and 20 respectively, with Ceftriaxone and Azithromycin.

To give you an update, until Oct 6, I was seeing a small green spot every morning. However, starting Oct 7, I did not see any small green spot upon waking up, although there were still some urine-like stains.

I followed your advice and went to an STD specialist this morning (Oct 10). I explained to him the full history, and he inspected my penis and commented "there is still some redness in the urethra". He then immediately injected me with ceftriaxone, (sorry I was not able to question it because the doctor was too fast) and prescribed the following for me and partners A and B: Doxycycline 100g 2x a day for 10 days, Metronidazole 500g 2x a day for 10 days, Ciprofloxacin 500g 2x a day for 10 days. There were also some additional medicine just for me: Sulfur soap, Redwin cream.

I asked the doctor if I needed to have testing for Gono/Chlamydia, and he said that he doesn't want to risk me going to the lab because I might catch COVID. Also, I don't think that there are existing tests for trichomonas and Mycoplasma genitalium here in my country (Philippines).

I have the following questions:
Would you recommend having A and B tested for Gono/Chlamydia before I give them the medicine set above? I ask this because both girls are quite apprehensive about taking medicine, especially if I don't have evidence I can show them (i.e. my own lab results) that they need to take it. If yes, please let me know what to tell their doctor, and what test should be done (NAAT)?
I will be starting the 3 drug treatment tomorrow morning (Oct 11) after breakfast. However, I am curious as to why the green spots are not present anymore. I saw a previous ticket (5110) and you mentioned something about "...residual inflammation that is not due to active infection and therefore will not respond to any antibiotic." Is it possible that happened to me too? I know that even if I get a urine test, it might be a false negative because I was injected ceftriaxone again.

I will use my last reply once I finish my treatment and see the STD doctor for a follow-up. Thanks.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
6 months ago
I continue to not understand the policies and approaches of the doctor you have seen. I have to wonder whether you're really seeing a legitimate STD specialist:  certainly none who I know would have re-treated you without more evaluation and evidence you still were infected. Going to a lab for testing is risk free in regard to COVID, assuming proper distancing, masking, etc; and there's no reason to "go to a lab" for STD tests, which can easily be collected in the doctor's office or clinic and sent to the lab. Certainly that's the case in the US and most industrialized countries, and I would think in the Philippines as well.

I doubt you needed the additional treatment. Even if you did, your partners do not need re-treatment just beause you were treated again -- unless you had sex with them since their first treatment.