[Question #7661] Potential STI risk and symptom

1 months ago
Hello sir,  I have questions on risk of STI and need an advice from you on my current condition.

Background information:
- Asian man in 30s
- circumcised

Most recent sexual contact:
- exposed to unprotected oral sex about a month ago.  Not sure about the giver's health condition/history.
- been sexually active, but always wore condoms during virginal sex. But occasionally exposed to unprotected oral sex.

Current condition:
- burning feeling during urination, but do not see white discharge on underwear etc.
- the burning feeling started after two weeks from the initial exposure (but some days the pain goes away some what and pop up again)
- went to a urologist after three weeks from the initial exposure and took an urine test for Chlamydia and Gonorrhea
- the doctor suspected a bacteria infection as the white blood cell count on initial urine test was at 10 - 19 HPF range.
- mentioned the doctor about the exposure above
- no fever and no skin outbreak around the genital area

Test result
- Negative on both Chlamydia and Gonorrhea 
- The doctor mentioned a possibility of mycoplasma
- Also the infection can be caused sitting for a long period

- the doctor prescribed Zithromax SR Dry Syrup (i.e. Azithromycin hydrate)
- took it in the past 24 hours
- as I write this, I feel very normal. I did not feel much pain (almost 0) on my most recent urination.

- what are the potential STI risk other than the two above? the doctor mentioned a possibility of mycoplasma.
- on my annual health check, the blood test result showed that I have relatively high uric acid. Can that be a cause of infection and symptom?
- Since this symptom is not caused by Chlamydia or Gonorrhea, is it highly liked caused by me sitting on the desk for a long time and lack or exercise? I was a very active person, but I gained about 10-15lb in 1-2 years period.
- I want to make sure I do not pass any STI to others, do you recommend me to get fully checked up for all STI?

Thank you for your help.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
1 months ago
Welcome to the forum. Thanks for your confidence in our services and a very clear question, with nice description of the context and medical evaluation.

It is very likely you have had nongonococcal urethritis (NGU) from the oral sex event. The timing is right -- and although absence of visibible discharge is atypical, the discomfort on urination and elevated urine WBCs go along with NGU. Your doctor was right about the possibility of gonorrhea, which is fairly commonly acquired from oral sex -- but the negative urine test conclusively shows you didn't have it (or chlamydia). The causes of NGU from oral sex are not known, but probably most cases result from entirely normal oral bacteria which cause urethral inflammation. The treatment you received is exactly right -- a single 1 gram dose of azithromycin is the standard recommendaton. Assuming you remain symptom free -- i.e. no recurrence of urinary discomfort or appearance of discharge in the next 1-2 weeks, nothing more need be done.

To your specific questions:

1) Other STI risks from oral sex include syphilis, herpes due to HSV1, and gonorrhea (as mentioned above) -- but that's about it. Mycoplasma and related bacteria (e.g. Ureaplasma) are rarely carried in the mouth. They are responsible for some NGU cases, but only from vaginal or anal sex. Azithromycin aborts most syphilis, but for complete certainty you should have a syphilis blood test 6 weeks after the exposure. No other testing is necessary at this time.

2) No STI causes elevated uric acid.

3) In general, it sounds like your doctor is pretty well up to speed on STIs in general and on NGU. But not perfectly so, given his or her comment about mycoplasma (assuming s/he knew your exposure included only oral sex). And s/he is entirely wrong about "sitting". In distant past decades, it was often believed that NGU was not an STD, but could result from such things as spicy foods, physical stress like straining e.g. weight lifting -- and perhaps sitting positions, although this is the first I've ever heard of that particular belief. Those beliefs are long past, and your doctor is just plain wrong about any association with sitting position or duration. Lack of excercise and your body weight also have nothing to do witih your symptoms.

4) You have had all the STI testing necessary in this situation, except for the precaution of also having a syphilis blood test in a few weeks. You could also include an HIV test -- but there has never been a proved case of HIV transmission mouth to penis, so testing would be only for reassurance, not because of any serious chance you were infected.

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

1 months ago
Thank you for the prompt and clear response sir. As for future prevention/action, I would like to ask following questions:
1. If I don't have any pain during my urination, does that mean I am fully free/cured from NGU? do you recommend another urine test after 7 days?
2. Is it likely to have a brith defect from this? (before the cure and after the cure)
3. Is NGU a more serious forum of infection (i.e. harder to cure) than the common infection such as Chlamydia?
4. Does urination right after the sexual encounter reduce such bacterial infection risk?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
1 months ago
1-3) These three questions are closely related to one another. Clearance of your symptoms is solid evidence the infection has been cured. NGU, whether from any source including oral, rarely causes any serious long term health outcomes and certainly not birth defects. NGU should be looked at as a minor medical problem, causing unpleasant symptoms but usually harmless. The minority of cases caused by chlamydia, and maybe Mycoplasma genitalium, can cause serious problems, but uncommonly. For the reasons already discussed, we know you had neither of these. That said, nonchlamydial NGU relapses after treatment more often than cases caused by chlamydia. Single dose azithromycin still works for the large majority of cases, but this is why my reply above suggests you be on the lookout for recurrent symptoms in the next 1-2 weeks. If nothing happens, you're home free and do not need examination, testing for urine WBC, or any other follow-up. And in case you're still worried about that possibility, it's no big deal:  relapsed symptoms after azithromycin usually resolve permanently with additional treatment, usually doxycycline. Don't lose any sleep over this.

4) Interesting and insightful question. Over the centuries, it was believed (or hoped) that urinating immediately after sex would reduce the risk of gonorrhea in men, and perhaps NGU. However, there is no evidence for it. The gonococcus (the bacteria that causes gonorrhea) immediately attaches firmly to susceptible cells in the urethra and is not flushed by urination. This has not been studied for chlamydia, M. genitalium, and certainly not for oral bacteria, but most likely post-sex voiding has little effect in reducing risk. That said, it's so simple, and obviously harmless -- and fits with many men's automatic inclinations anyway -- that you can easily find advice, including from professional sources, that urinating after sex may help prevent infection. This is best viewed as another old wives' tale -- old timey wisdom, like dressing warmly to prevent colds or flu, or not reading in dim light to avoid damaging the eyes. It's all BS -- charming BS, but still BS!
1 months ago
Very clear answers doctor. Thank you
Good to close the case.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
1 months ago
Thanks for the thanks. I'm glad to have helped. Take care and stay safe.---