[Question #8520] Chlamydia: Not Going Away

43 months ago

Dear Doctors - thank you for the great services you provide!

Summary of my event:
Tested positive for Chlamydia on Christmas day 2021 (fun times). Gonorrhea and Microplasma were negative. My initial urinalysis taken a few days before did not show any elevated bacterias or white blood cells (which was surprising).

Shockingly, I did not have discharge. My symptoms were burning when I urinated or ejaculated, as well as pelvic pain/pressure, along with flank and back pain. I honestly didn't think I had anything, since there was no discharge.

I was prescribed Doxycycline on Christmas day - 100 mg tablets, to be taken twice a day for ten days. I finished the full course with no hiccups. At the end of the course, all urinary burning was relieved, but the pelvic pain/pressure persisted. The pelvic pain became slightly better (maybe 30% better?) but not much more.

On Jan 10, I was waking up with full-on pelvic stomach aches. There was no burning when I peed and no discharge - just continuous pelvic pressure. Went back to the clinic. Urinalysis was ran again and was completely clear. Nonetheless, was given a 1 gram dose of AZM. Took this dose on Jan 10, and immediately felt better - felt like pelvic symptoms reduced by 50% almost within an hour.

By Jan 12, the pelvic pressure was almost back to full-bore, along with emerging flank and back pain again. Was prescribed a z-pack. Took one 250 mg dose on Jan 12, and another 250 on Jan 13. Will likely take one later today. Upon taking the doses on Jan 12 and Jan 13, my flank and back pain are completely gone. My pelvic pain is about 80% gone. The only thing remaining is a small sensation (slight pressure) in between my belly button and penis.

Can I assume that another 1 or 2 dosages of AZM will arrest this completely? Or would it be good if I went to a urologist for further testing? I'm asking mainly because I'm starting to wonder if there's an infection present that is not Chlymadia (even though the basic urinalysis was clear). If n

43 months ago

Overall - I'm looking for reassurance that the AZM will take care of this. If for some reason you think something else is going on, kindly let me know so I can get higher medical help involved. Thank you all so much!

43 months ago

Forgot to mention - I am straight. All sexual activity was with women. There were two women I had sex with the week this occurred. I am pretty sure the Chlamydia came from a woman I had a fling with - no anal, but unprotected vaginal, three different times. I am in a relationship with someone as well, and we had unprotected vaginal and anal when we saw each other (again - the woman I had unprotected anal sex with, I was in a relationship with, and I am confident I did not get the STD from her).

H. Hunter Handsfield, MD

43 months ago

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

This is an interesting situation, and I understand your concern (and perhaps surprise) about your continuing symptoms after appropriate treatment for your chlamydial infection. But there is a straightforward explanation. Chlamydia (or gonorrhea) generally does not cause the kinds of symptoms that have continued after treatment, i.e. pelvic pain, back pain, or pelvic "pressure". (My forum colleague Dr. Hook was the senior investigator on one of the main published research studies that documents the absence of bladder/pelvic symptoms in men with chlamydia, gonorrhea or nongonococcal urethritis.) Painful urination due to urethral inflammation -- burning with voiding, perhaps with ejaculation -- does fit with chlamydia. Absence of discharge shouldn't be "shocking": half of all men with urethral chlamydia have little or no discharge. Absence of excess white blood cells is atypical, but quite common with chlamydia, especially on voided urine (as opposed to urethral swab).

Chlamydia is always susceptible to doxycycline, and there have been no valid scientific reports of it failing to cure uncomplicated chlamydial infection. And clearance of painful urination is consistent with cure of your infection. But your other symptoms have some other explanation. That they are improving with azithromycin could mean some other infection was responsible -- one susceptible to azithro but not to doxycycline. However, most genital tract bacteria are susceptible to one or the other, and absence of WBC in your urine also suggests no infection was responsible.

Possibly your bladder, prostate, etc -- the main sources of the persistent symptoms you describe -- were responding reflexively to inflammation from the chlamydial infection and this is now clearing on its own, i.e. not necessarily because of the azithromycin. No other STD is responsible: there are none that have been shown to cause bladder/pelvic symptoms in men. The "reflexive" idea -- which may have an anxiety component -- is suggested by the nearly immediate improvement after taking azithromycin on January 10. Antibiotics cannot work that fast: reduced inflammation due to infection takes at minimum of 24-36 hours. Azithromycin has anti-inflammatory properties, in addition to its antibiotic effect. But even for this, an hour probably is too soon for noticeable benefit.

All things considered, I'm confident your chlamydial infection is gone and that your remaining symptoms will also continue to resolve; they do not suggest any ongoing infection or anything serious.

I'm concerned by your follow-up comments about your two sex partners. You likely are correct about the likely source. However, this can be difficult to know for certain, and standard advice for persons with chlamydia is that all sex partners in the past month (sometimes up to two months) be treated (and ideally tested) for infection. For sure your "fling" partner must be told she likely has chlamydia, if you haven't yet done so. If there was any overlap at all -- meaning sex with your regular partner after you had sex with the other woman, then your current partner could be infected and should be treated. (This also may mean you have been reexposed -- although perhaps with no risk, if you were taking doxycycline or azithromycin at the time.)

Thanks again for an interesting question, and one that may be educational for forum users in general. I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD

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43 months ago

Dr Handsfield - thank you for your kind attention! Some notes -

a. I definitely informed both women. The woman I was in a relationship with was super proactive, sadly tested positive for Chlamydia too and took doxy. The one I had the fling with - she was super lax about it all (lol) - but she said she would get tested.

b. I should add - I got tested on Jan 10 and I tested negative for Chlamydia. My urine also had a more comprehensive analysis, and all came back negative (no infections it seems - no blood in urine). In turn - you are correct - my pelvic pain has been coming from something else. On the basis of your answer, I stopped all AZM. So far, the pain has stayed very low. I still feel a minor amount of pressure in my pelvic area - but testing negative reduced a lot of stress.

My final questions:

1. Let's just say my pelvic pain/pressure (which is now extremely small) is truly a bonafide medical issue, that is not stress related. Can you at least give your best guess at what could account for it? Of note, again, I am a 41 y/o male, my physical health is excellent and I'm multi-ethnic.

2. If the pelvic pressure gets worse, what doctor would I see to rule out anything medical? Would that be a urologist?

3. Naturally, the girl I had the 'fling' with - of course I'm now concerned about HIV, as we had sex on three different occasions, unprotected. I did not have unprotected anal sex with her (fortunately). The practitioner on Jan 10 didn't even take a blood sample for HIV because she said the exposure was such a low chance, and on top of it, I had no ARS symptoms. Overall - if a woman has Chlamydia, are the chances of exposure through vaginal sex considerably higher? I should add, I am circumcised.

Thank you again for your kind attention. This forum is such a great stress-reliever, compassionate and insightful. I hope you and Dr Hook keep up the fantastic work you do.

H. Hunter Handsfield, MD

43 months ago

Thanks for the follow-up information. Glad to hear you informed both partners!

1. I'm also happy to hear these symptoms are resolving. I indicated my best guess at the cause in my comments above: once one area of the genital tract is inflamed (such as your urethra, due to chlamydia), it is plausible that other anatomic areas -- prostate, bladder, etc -- might respond indirectly with muscle spasm or other mechanisms that could cause discomfort. This is what I meant by the term "reflexive". In other words, not due directly to chlamydia, but in response to the irritation it caused. However, there has been no research on this, so it's really just an educated guess. The emotional possibility also is very real. (By analogy, nobody questions tension headaches resulting from stress, anxiety, etc. The mechanism of headache is stress or anxiety leading to increased tension in muscle of the neck and scalp. It's easy to understand how genitally focused anxiety -- a natural reaction to chlamydia symptoms -- might do the same in pelvic area muscles.)

2. I suggest crossing this bridge if and when you come to it. Your symptoms clearly are improving and probably will be gone entirely very soon. Should they return, you could see a urologist, who might evaluate you for prostatitis -- but would also understand what I have said about genitally focused anxiety.

3. Catching HIV in this sort of situation is exceedingly rare -- i.e. agree with the practitioner's advice that HIV testing wasn't necessarily required. On the other hand, it is normal to include HIV testing in anyone with a newly acquired STD -- the risk is very low, but nobody can say it's zero. On that basis, in my clinic we would advise an HIV blood test 6 weeks after the sexual exposure when chlamydia likely was acquired. You definitely can expect a negative result, but better safe than sorry. (Syphilis testing often is also recommended at 6 weeks, but doxycycline for a week is 100% effective in eliminating syphillis before it can cause active infection, so it isn't necessary in your case.)

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