[Question #7688] Series of symptoms without clear cause or treatment

54 months ago

I'm a 43 yo male who tested positive for hsv2 via blood test about a year ago. I most recently had sex in October (female partner, fully protected). About one month later, the head of my penis became very sore and sensitive, and small red dots appeared around the urethra. The dots disappeared in 3-4 days, but the sensitivity and pain lasted for over two months and still recur occasionally, and my urethra became swollen. Dr said cause was likely an injury and directed me to take Advil. In January, a red sore appeared underneath the tip of my penis. Dr said it might be syphilis and gave me an antibiotic injection. However, blood test came back negative for syphilis. I then began experiencing occasional mild to moderate pain during and after urination (and sometimes after ejaculation). I requested the standard panel of STI tests, all of which came back negative. Yesterday a small mildly itchy rash appeared on the shaft of my penis. Dr said sounds like hsv and suggested valcyclovir.

I'm dubious that the first symptoms were caused by injury (I don't recall injuring myself) or that the sore was caused by syphilis (my partner didn't have syhilis and we were very diligent about condom use in any event). Could all of these symptoms be a single event, caused by hsv or another cause, rather than discrete events? What can I do to stop this months-long, seemingly endless series of symptoms? Is it ok to have sex again after the rash clears, even if the painful urination continues, and my urethra is still swollen?

Also, this has all coincided with me staying at my mom's house in Hawaii (I normally live in California but am out here during the pandemic). On each of my last several stays here, I have experienced some penis-related symptom without a clear cause. Most recently, a dark scab/skin lesion appeared that the dr said was likely a mechanical injury, even though I don't remember injuring it. The time before that, I had very painful urination that went away on its own after I ret

H. Hunter Handsfield, MD

54 months ago

Welcome back to the forum. Thanks for your continued confidence in our services.

The main priority here is to sort out once and for all whether you have HSV2. Some of your symptoms are consistent with herpes, but most are not. More below about other possible explanations.

As this suggests, I reviewed your discussion a few months ago with Terri. I agree with all she said, including her advice that standard HSV2 blood test results have a quantitative component: if there was no numerical result in the report your doctor received, it still should be available from the laboratory. I encourage you to seek out that result, since up to half of all positive results are false, i.e. with numerical results (optical density [OD] ratio values) under 3.5. Or to have another IgG test, this time assuring it is the HerpeSelect test (done routinely at Quest Laboratories), which will will include the OD ratio. It is likely it will be under 3.5. Certainly the majority of the symptoms you have described are not typical for genital herpes. (Make sure an IgM test is NOT done. Some labs routinely offer IgM as well as IgG antibody testing, but the HSV IgM tests are notoriously unreliable and often confusing.)

As that implies, I doubt you'll see any improvement of your current "small mildly itchy rash" with valacyclovir. Keep taking it for now -- it it's herpes you should see improvement within 2-3 days and complete resolution of the rash over 7-10 days. Don't use any other treatments on it (creams etc) in the meantime.

Other options? Certainly not syphilis, based on your symptoms, negative blood tests in you and your partner, and lack of effect of the penicillin injection. In addition, I agree with you that an injury of any kind is unlikely. Even if that was the initial problem, it would not have triggered any ongoing symptoms. The only other common STD causing genital skin issues is HPV, but there is nothing at all in your description that suggests HPV, genital warts, etc.

So herpes is possible but doesn't explain most of your symptoms, and I'm sure you have no other STD. As I type this, the bookshelf at my left elbow includes the title Genital Dermatology Atlas. As the name implies, its 300 pages are filled with photos and descriptions of over 100 genital skin problems. All STDs (mostly herpes, syphilis, and genital warts) are covered in only 15 of those 300 pages. The point is that the large majority of genital skin problems are not sexually acquired or transmitted.

Are you uncircumcised? If so, "red dots" and irritation of the head of the penis (under the foreskin) suggest balanitis (the medical term for inflammation/infection of this sort), often due to yeast infection -- which can be shared with a female partner, but isn't considered an STD. Or "nonspecific" balanitis that often clears up with simple hygiene, i.e. foreskin retraction and soap and water washing a couple times a day. Balanitis could fit with a swollen meatus (urethral opening) as well. A non-STD urinary tract infection? Also conceivable but unlikely.

Unfortunately, that's about as far as this forum goes: we scope out STD (and HIV) problems, but are not a resource for answers about all genital symptoms or complaints. So my advice is to first sort out your herpes status, as suggested above -- with a good chance it will confirm you don't have HSV2. And second to see a specialist about your ongoing symptoms. A dermatologist would probably be best, although a urologist also might help. Speaking as a part time Hawaii resident myself, you should be able to find either one pretty easily.

I hope this helps. Let me know if anything isn't clear.

HHH, MD

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