[Question #7473] Urethritis

4 months ago
Hello doctor,

I asked a question a long time ago (Question #5003) about genitally focused anxiety. Turns out that's exactly what it was and my "pain" went away in the next couple weeks after that. However, now I have a new problem.

About 7 weeks ago (10/24/2020), I had unprotected oral and vaginal sex with someone I thought I knew well enough to not worry. I had a little anxiety over it, but eventually that went away. However, since last Sunday (12/6/2020) I've had the following symptoms:

-Burning/Pain when urinating, especially in the morning.
-Discharge on boxers (White/Yellow color).
-Burning/Pain when ejaculating.
-Itchy feeling in urethra and around anus (prostate?).

I went to the doc about some lower back pain I had on 12/03/2020 and all test results (including urinalysis) came back normal. However, I went back on 12/09/2020 for this and it showed a small amount of Leukocytes (White Blood Cells) in my urine. They did a gonorrhea and Chlamydia on a clean catch that both came back negative for yesterday and today the urine showed "No Growth". Considering these circumstances, I have several questions.

1. Could this be related to the sexual encounter I had in October? Mind you symptoms didn't come up until 12/06/2020.

2. Should I get tested for things other than gono and chlamydia (trich, m. genitalium, etc.)?

3. Could this be something I'll be dealing with the rest of my life? Something like prostatitis? I tried reaching out to my doc to see if they could prescribed antibiotics at least for the WBC count, but they won't be in until Monday to reply. She did tell me in person that she'd not want to prescribe antibiotics until a bacteria is found to be the cause. Can I wait that long for it to go untreated or will it only make it permanent more likely?

All your feedback is greatly appreciated. Thank you!
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
4 months ago
Welcome back to the forum. Thank you for your continued confidence in our services. And I'm happy to hear your GFA issues resolved after (maybe partly because of?) our advice.

Your symptoms and findings present a mixed picture. You may well have nonchlamydial, nongonococcal urethritis (NGU) from the sexual exposure described. Some of your symptoms (discharge, painful urination) are typical, but others are not (ejaculation pain, anal irritation); and the timing is longer than usual:  NGU symptoms typically start 7-10 days after exposure. Up to 2-3 weeks would be OK, but 7 weeks doesn't fit well at all. Other possibilities include prostatitis (either bacterial or non-bacterial), seminal vesculitis, or an uncomplicated urinary tract infection -- although UTI (and some cases of the others) would be expected to have a positive urine culture for typical UTI bacteria like E. coli or several others. How old are you, by the way? These non STI causes all are increasingly common as men age beyond 40 or so.

Because of the uncertainties, I think you're on the right track to raise the possibilities of both trichomonas and Mycoplasma genitalium. Either one might explain an association with the recent sexual exposure but with a longer than usual incubation period. Fortunately, reliable testing for both is readily available (by PCR) at most laboratories. I would also recommend re-testing for gonorrhea and chlamydia, preferably on a urethral swab specimen -- especially if you had a urine test last time. (Urine testing misses 5-10% of gonorrhea and chlamydia.)

It's always good to hear when a physician doesn't jump to antibiotics at the drop of a hat; antibiotic overuse is a huge societal problem, and withholding antibiotics often is a sign of a well trained and caring doctor. On the other hand, with NGU at least a fair possibility -- despite the unsually long incubation period -- I would have prescribed a 7 day course of doxycycline (100 mg twice daily for 7 days), the treatment of choice for NGU. (Single dose azithromycin also is recommended for NGU, but largely to treat chlamydia, which probably you don't have.) However, I would hold off on additonal treatment for trich or M genitalium unless or until you test positive for either one.

You might also chat with your partner about the situation. Given the uncertainties, it would be reasonable for her to be tested for gonorrhea, chlamydia, and perhaps trichomonas (but not necessarily yet for M genitalium).

I recommend discussing all this with your doctor, who as already implied seems to be very competent and caring. You could consider printing out these comments as a framework for discussion. I would enjoy the feedback if you do so.

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

HHH, MD
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4 months ago
Thanks for the prompt reply doctor!

Yours and Dr. Hook's comments have become a staple of reassurance for me the many times I've been through STD scares. All the ones I've had previously were most definitely my mind playing tricks on me. this time, however, I definitely "feel the burn" and have the WBC's and discharge to back up my claims rather than just having guilt over something that isn't really a reason to feel guilty over.

Anyways, I'm 29 years old, 6'2 and 275 lbs. I'm currently working on losing weight, but last week basically splurged and went off my diet eating what I want. I've read that this can be a potential cause of my discomfort as well, and while I was eating unhealthily when symptoms came up, I don't think there's a correlation.

I talked with my partner yesterday and she said before we had sex, she tested negative for "everything" including Trich. She hadn't heard about M. Genitalium however, so maybe the doc didn't check for that. She just had a check-up yesterday also and results should come in by Monday at the latest.

I'll send a message to the doctor about all that you recommend (Urethral swab and PCR's for Trich & M. Gen). Couple more questions I have for you:

1. Are there any other tests I should get done to rule out Prostatitis, Seminal Vesculitis and other specific diagnoses? While I don't think these are the causes, you can't be too careful.

2. Should I try and have my doc prescribe me antibiotics awhile? I don't want to wait too long and be stuck with burning pee/ejaculate the rest of my life.

Thanks Doctor HHH!!!!
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
4 months ago
1) I've already indicated the additional tests I would recommend...

2) ...and already said how I believe you should be treated with doxycycline, and the reasons. It has already been too long without treatment.
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4 months ago
Dr HHH,

I apologize for the repeat questions I had. I’m just really nervous about it all. While still trying to look at this logically, I’m letting my emotions get the best of me. I just want to be able to feel normal again if that makes any sense. Hopefully getting treatment/diagnosis will bring me there.

Would you be able to keep this thread open so I can let you know what my results are? 

Thanks again!
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
4 months ago
Don't overreact. Find a way to get treated with doxycycline.

As you apparently understand, this thread would normallly be closed at this point. However, I'll leave it open for one more follow-up comment. I suggest waiting until you've seen or spoken with your doctor and have been treated with doxycycline for a few days and can report how your symptoms are doing. I won't have any other comments or advice until then.

In the meantime, try not to be overly worried. The chance is low for any complications or long term consequences.
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4 months ago
Hello doctor,

It's been a long week, but I finally something conclusive. Tests I had done:

-Gonorrhea: Urine Test - Negative
-Chlamydia: Urine Test - Negative
-Trichomonas Vaginalis: First Void Urine PCR - Negative
-Mycoplasma Genitalium: First Void Urine PCR - Positive

My doctor said she didn't deem it necessary for a urethral swab for gono and chlam because the urine tests were highly reliable (FYI, I took these tests after not urinating for 4+ hours). With this diagnosis, I have a couple last questions for you:

1. Should I insist on a urethral swab for gono and chlam?

2. My doctor did prescribe Doxy 100mg twice a day for 10 days. So far I've taken 3 pills (1.5 days). Should I stop treatment and request the Moxifloxacin at this point? If so, how much?

3. My game plan from here is to complete treatment, ensure symptoms have gone away and retest 2 weeks after. Anything else you think I should do?

Thanks for all your help Doc!!! 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
4 months ago
Glad to hear the additional test results and that you've started doxycycline.

1. You have had two (three?) negative urine tests; there is no need for urethral swab testing.

2. Take the doxy as prescribed. You definitely should not take moxifloxacin, given your negative test for M. genitalium. (In addition, your exposure was protected vaginal and unprotected oral -- but M. gen does not infect the mouth or throat and therefore cannot be acquired by oral sex.)

3. The first part of this statement is fine: complete treatment then be on the lookout for symptoms over the next 1-2 weeks. In the absence of recurrent symptoms, you will not need retesting for anything. (Of course there is no point in retesting for infections you never had!

That concludes this thread. Thanks for the thanks -- I'm glad to have helped. Best wishes and stay safe.
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