[Question #7367] NGU??

5 months ago
About two weeks ago I had a sexual encounter with a girl from a night club. We had protected vaginal sex for most of the night and then for roughly a few minutes had unprotected vaginal sex. About a few days later I began experiencing itching/irritation around my urethra and burning when urinating. I also developed a white/yellowish  discharge most noticeable in the morning but semi consistent throughout the day. I have been to two different doctors have been tested for gon/chlamydia/HIV, hsv 1/2, syphilis, multiple times and all have been negative. Urine analysis twice was also negative. One doc did give me 1g azithromycin and a shot of rocephin that did ease the burning but I’m still experiencing discharge a little over a week after treatment What else could this be? Could it be herpes?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
5 months ago
Welcome to the forum. Thanks for your confidence in our services.

I agree that all you describe is entirely consistent with NGU, from the timing after a new sexual exposure (several days) to the symptoms described and, perhaps, a slow response to treatment. I'm a bit puzzled why there were "multiiple" tests:  a knowledgeable health care provider would have observed the discharge at the first visit, sent the lab specimens you describe, and given exactly the treatment you received. Perhaps your initial provider isn't all that experienced with STDs and the second one was?

Based on your symptoms, it could have been gonorrhea, but the standard tests for gonorrhea and chlamydia are highly accurate, so you can be sure you didn't have either one. About 30% of NGU cases are caused by chlamydia. The other common cause, Mycoplasma genitalium, is responsible for 10-15% but isn't included (yet) in most routine STD testing. Even with the most sophsticated available tests for unusual causes, the exact cause of NGU is unknown (and with current tests unknowable) in about half of all cases. You were treated appropriately:  the ceftriaxone (Rocephin) was in case you had gonorrhea and azithromycin for chlamyida or NGU.

The timing of your improving symptoms is typical. Give it another several days. If you reach 10 days after treatment and still have symtpoms -- especially if visible discharge is present -- recheck with whichever doctor seemed more on top of things (probably the second). When NGU persists or promply recurs after azithromycin, the standard recommendation is to re-treat with doxycycline for 7 days. (If doxy is used initially, azithromycin is given next.) A test for M. genitalium is recommended if available. If that returns positive and symptoms persist -- or if symptoms continue or promptly recur after doxycycline -- then additional treatment with moxifloxacin is often used. But most likely you'll never get to that point.

Could it be herpes? Almost certainly not. HSV can cause urethritis, but usually with typical blisters/sores on the penis; and herpetic urethritis is far more painful than you describe.

No sex for the time being, until all this is sorted out and you have been asymptomtic for a couple of weeks. If you're in contact with your partner, she should be informed, tested and treated.

Finally, don't lose a lot of sleep over this. Nonchlamydial NGU has never been known to cause serious outcomes either in affected men or their sex partners -- no urethral stricture, epididymitis, infertility, or other problems that can occur with chlamydia. 

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

HHH, MD
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5 months ago
Hi Doc
Thanks for your reply. So I went back to my doctor and he did a swab test now which came back negative for presence of bacteria. I guess they couldn’t grow anything. The swab had ample discharge on it so I am shocked nothing was found. He said after the gonorrhea/chlamydia Tests plus the swab  the next step was to send me to a urologist for further evaluation since he couldn’t find anything. 

On Saturday I decided to see another doc in the area and he went ahead and gave me doxy for 10 days 200mg a day. Should I suggest to to him the MG test if the doxy doesn’t work? That seems to fall in line with your recommendations. I’m on day four of it and I think it is helping slow the discharge. I still see it in my underwear when I wake up but not as much in my urethra. I always could squeeze it out in the morning but it is less now,  but still there. Burning is virtually gone. I still have some slight burning after urinating probably once a day but never during urinating. When should I expect my discharge to be gone and for me to be symptom free? I’m concerned because no one seems to know what this is and I don’t know if seeing a urologist will make a difference over the three primary care docs I have seen. I am hopeful the doxy works and I can put this behind me. It seems like even if my partner and I had done a full STI panel before sex I still would have gotten this and that is troubling me for future encounters with stable new partners like a new gf. 

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
5 months ago
It sounds like doxy is working, with symptoms improving on schedule. Stop sqeezing to look for discharge; that can actually create more discharge and delay final resolution. If you stop seeing spontaneous discharge and underwear staining stops, you're home free. As for "no one seem to know what this is", see my original reply:  the cause of NGU is unknown and unknowable in half of all patients, so your situation is typical.

Most likely your symptoms will clear entirely and nothing more need be done. If you have still another recurrence of symptoms, that's when to test for both M genitalium and Trichomonas vaginalis; or to treat with moxifloxacin and metronidazole (for both of these) if testing isn't available.

I see no need for a urologist at this point. My STD clinic handles several patients a month with exactly your situation. We never find urology consultation helpful or necessary. Some urologists are expert in STD issues, but most are not (in the US).
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