[Question #8173] Further to 8163 & 7936

47 months ago

Teri advised that I post in this category to get your comments. All the full background is in my previous questions. I appreciate there is a lot there but I have had a miserable few weeks dealing with 3 doctors at my local clinic. Current symptoms as of now: redness and inflammation around the entire foreskin and under the foreskin on and below the glans; yellowish/sticky discharge; very painful and sensitive and hard to roll the foreskin back due to the swelling; discomfort while urinating due to redness around the urethra. In a few areas today the inflammation has caused a few areas to bleed slightly as well. Have just been put on doxycycline by the 3rd Doctor I've seen (1.5 days in only). Earlier suggestions were fungal infection, then Herpes, now bacterial (full history in the previous post). HSV1 and HSV2 blood tests negative. STD PCR test also done and negative. Even though my sexual history does not equate to it being an STD, doctors initially said they thought it looked like Herpes, then Chlamidya, but does not seem to make sense? Earlier urine test showed nothing, although a new one has been done along with a new PCR test (results pending). Initial result of new urine tests suggests an infection but culture test pending. I spoke to the Doctor today who said if there is still bleeding tomorrow then it may be necessary to take Zovirax and Doxycycline together as the bleeding is suggestive of Herpes.

My questions:

From my current symptoms, is this compatible with some kind of UTI or bacterial infection?
Would discharge normally suggest a bacterial infection of some kind? Do you get a yellow discharge with Herpes?
I have had a lot of tests already, but is there any diagnostic test you would suggest I redo or ask for in the coming days (I am meant to see the Doctor again on Saturday).
If bacterial, how long would it normally take for the doxycycline to kick in and start to improve matters.
The earlier topical treatment I was using (combo anti-bacterial/anti-fungal/ste

47 months ago

The earlier topical treatment I was using (combo anti-bacterial/anti-fungal/steroid): could that have obscured symptoms / complicated diagnosis and testing?
The initial urine test; bacterial & fungal swabs all came back negative from 2 weeks ago; however, what is the false negative on these? Especially if I was using topical anti-fungal cream at that time.

Thank you.

Edward W. Hook M.D.

47 months ago

Welcome to our side of the Forum and thanks for your questions. I reviewed your interactions with Terri and agree with all that you said. Let me summarize the situation as I see it and then make a few observations. Please correct me if I get something wrong here.

SUMMARY. This all appears to have started when you sought care for balanitis and the possibility of herpes was raised. It is not clear to me if your initial is it was for a new problem or something which might have gotten worse leading you to seek evaluation. Either way, you have now seen a urologist and two dermatologists, have been tested repeatedly with not very good tests for herpes with negative results, had PCR testing (of a swab or urine? Is a swab, where was it taken from?). You have also been treated with a variety of creams, oral fluconazole, and now doxycycline. Despite this, the balanitis appears to be getting worse with increasing erythema and a discharge under your foreskin (are you uncircumcised?).

INITIAL COMMENTS:

What is going on here is almost certainly not a STI. Your history of exposures is very low risk, your tests appear to be negative, and your non response to treatments all seem to point this out.

Medications have their own set of side effects and reactions. Some or part of what you are experiencing may be due to the medications. If you are now getting worse with the doxycycline, I would notify the provider who prescribed it and see what he/she wants to do. They may suggest stopping it as doxycycline has a number of cutaneous side effects. I would check with them before you stop it however.

You have now seen three different health care providers. While I understand the desire for second and third opinions, the fact is that with each new evaluation, your doctors will tend to try something different and are deprived of the opportunity to react to what has or has not happened. I suggest you go to the doctor you are most comfortable and try to see that person repeatedly. Sometimes these problems require some trial and error based on initial responses and test results.

Initial responses to your specific questions:

This may be a bacterial skin reaction or a medication side effect. I don’t think you mentioned a discharge from your urethra but discharge occurring under the fore skin. If there is no urethral discharge this is unlikely to be a UTI, prostatitis, or STI.

Nothing here sounds like herpes.

I’ll wait to comment on further testing until I hear from you what was tested and the specimen type.

There should be signs of an initial response within 2-3 days of starting doxycycline.

The chance that your topical obscured your test results is small

More comments later,after I review your responses. EWH

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47 months ago

Many thanks for your response and for reviewing everything. In reply:

This episode all started with balanitis (under foreskin) which did not respond to antifungal cream after 4-5 days, so I went to the urologist.
PCR testing was swab from under foreskin. Second PCR test (pending results) under foreskin and from urethra as well.
I am uncircumcised.
I have only been taking doxycycline for 36 hours so hard to say what impact it is having so far. I have stopped all topical applications for the last 2 days as advised by the 2nd dermatologist. I am desperately hoping that the doxycycline starts showing progress in the next 24-48 hours.
Visiting 3 doctors was actually due to the urologist referring me to a dermatologist, who unfortunately then had to travel after my first consult which meant I ended up seeing another dermatologist at that clinic when there was no response to topical Zovirax. I agree it is not ideal.
There does now appear to be some urethral discharge. Due to the topical treatments before it was hard to actually gauge this (or it developed/worsened later). The most recent urine test from 2 days ago apparently shows some signs of an infection but waiting for detailed culture results.

I am glad that you agree that Herpes seems to be a red herring here. It did not make any sense to me when discussed and nothing in the tests indicates it as likely. By process of elimination it would appear that a bacterial infection of some sort is the cause, as the oral and topical anti-fungal, as well as the topical Zovirax, did not help? Or I have been unlucky enough to have a nasty combination of medication side effects that has led to an infection? Is there anything you would recommend I ask my doctor at my next consult in a few days? Or key things to look out for/monitor?

I also read online that balanitis can be triggered by sensitivity to certain soaps/creams/chemicals. I wonder if I may have an allergy or sensitivity to something in the topical treatments if there is a common ingredient that could trigger that? Have you seen that in your experience?

Edward W. Hook M.D.

47 months ago

Thanks for the additional information. It serves to solidify my sense that this is not an STI but instead either a primary dermatological problem, a medication side effect, or either of the above which has become secondarily infected with normal skin bacteria. If the doxycycline does not help after 2-3 days I would discuss stopping it with your doctor (but would defer to his/her assessment since they would have the opportunity to examine you and I would not). Management of infections occurring u der the foreskin can be challenging as the moisture closed in space make it hard to keep the area clean and dry which does promote healing.

I suspect this is a non-STI problem. FYI, there is a photograph textbook of genital dermatology in which less than 15 of the more than 300 pages was devoted to STIs.

I see no need for further testing for STIs. Hope this helps. EWH

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47 months ago

Thank you again for reviewing the information. Just to update you, I have now been on doxycycline for 2.5 days (6 doses taken) and had a follow up with my Doctor today. From the examination he said that the inflammation is showing slight improvement. Although I still had some yellow discharge this morning when I woke up, he said it is less evident than before. He wants to monitor it the next few days as the area under the foreskin remains inflamed and there is still some 'wetness' and I have a follow up booked in 3 days. From my side it is slightly better and has at least stabilised: the couple of areas that were bleeding slightly 36 hours ago have not done so again.

The urine test from Wednesday showed slightly elevated leukocytes, but the bacterial culture was not successful. My earlier PCR test (1 week ago) taken below the glans/under foreskin was negative for the 10 STDs tested. The new PCR (under foreskin and from urethra) taken Wednesday was negative for everything except 'Mycoplasma Hominis'. The Doctor says this should respond to my current treatment and says he suspects this is a case of NGU-related balanitis. He said Mycoplasma Hominis can be sexually transmitted but often isn't? I think with my history and after 2 negative PCR tests and HSV1/2 blood tests we can now categorically rule out STIs/Herpes?

Does this all sound consistent with my symptoms/experience? Does NGU/Mycoplasma Hominis normally respond well to doxycycline? In the event that there are not significant improvements before my next follow up in 3 days, what would normally follow next? (I can let you know after my follow up how things go.)

On a separate note, thank you again for the service you provide. I think the work your organisation does is very valuable, especially as even the medical professionals I have dealt with seem to find accurate advice/diagnosis challenging in this area.

47 months ago

P.S. A blood test taken yesterday also showed elevated Neutrophils and low lymphocytes (both slightly outside reference ranges), which my Doctor said is also consistent with an infection.

Edward W. Hook M.D.

47 months ago

Thanks for the follow up information. I’m pleased to hear that you are improving. Several comments in this final response.

First and foremost, you have ruled out an STI is the cause of the problems you were experiencing. Your negative tests should be believed. The elevated white blood cell count in your blood specimen and the white blood cells present in your urine specimen both are likely a nonspecific reflection of the local irritation/inflammation.

Mycoplasma hominis is normally present in the genitourinary tract of men and women and is not a infection which needs to be treated. Previous misinformation has led to a widespread misunderstanding that M. hominis is a pathogen which needs to be treated. This is incorrect. The organism is often susceptible to doxycycline and when treated may go away briefly only to return. There is no reason for follow-up testing for mycoplasma hominis.

A final suggestion which may be worth trying. The moisture and inflammation under your foreskin will heal more quickly if it is kept clean and dry. This is sometimes challenging to accomplish in uncircumcised men. I would suggest GENTLE washing with a MILD soap several times a day and then drying the area, again GENTLY ( as you know the skin under the foreskin is thin and easily traumatized) and perhaps with the assistance of a hair dryer set on low or no heat. The warm air from the hairdryer however sometimes will assist in drying.

I hope and trust that I will continue to go well. Take care. This concludes my responses as part of this thread. EWH

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