[Question #9041] Worried about NGU

36 months ago

Hello,

I'm writing to you with concerns from a little 'whitish' urethral discharge I noticed yesterday night, along with a certain burning sensation in the urethra that lasted pretty much overnight. Actually, I happened to withhold the urination that preceded the penile discharge for quite a while yesterday - in the middle of some intensive work - and I was also very sweaty due to the heat/humidity in the room.

As I tend to be over rather concerned for a few days following 'risky' sexual exposures (such as receiving unprotected fellatio), my instinct yesterday was to gently squeeze the tip of the penis before the long-awaited urination (checking for discharges in fact), and that's when I was shocked when I saw something 'milky' coming out. The urination per se wasn't painful, but again, a burning sensation primarily.

Here is the thing: I had a sexual encounter with an escort on July 26, during which unprotected fellatios and two protected vaginal intercourses took places (no condom breakage that I could see). I'm a heterosexual man in my 40s, by the way. The girl assured me to get tested on a regular basis and communicated clearly about it.
Prior to this exposure, I had a very similar encounter with another girl on June 25 (I had seen her 2 weeks before too), but no urethral discomfort at all following that (something I checked for carefully I think). Last night was the first time I experienced what I described above.

I did text the escort I saw on July 26 today and she replied that she hasn't had any STI symptoms, nor her regular clients have reported STD-like symptoms to her.
Back to my symptoms, I haven't seen any more white discharges since last night (even upon milking the tip of the penis) and no discomfort during urination either. Just a mild tingling sensation here and there overall…

Based on this, could yesterday's discharge be due to something else (not STD, I mean)? Also, if mine should be typical NGU symptoms, could I have gotten them from the girl I saw a month earlier on June 25?

Do you think a urine test for gonorrhea and chlamydia is enough to clarify everything, or I also need a specific one for NGU? I don't know where I could get an NGU test near here actually. Would a urologist be in the position of performing them, if that's the case? Would you in my place pursue any testing at all, or wait in case the symptoms should disappear (or get worse)?

If my diagnosis turns out to be NGU, do I need antibiotic treatment, or it depends on the gravity of the symptoms? Also, is NGU contagious to my regular female partner?

Sorry for so many questions. I'm particularly worried also since I have an overseas trip this coming weekend...

Thanks a lot!!

Edward W. Hook M.D.

36 months ago

Welcome to our foreman thanks for your question. I’ll be glad to comment. The presence of a whitish/milky urethral discharge and burning on urination, even if you had withheld urination for some time before you noted it, warrants further evaluation. My advice would be to get checked.

Following your exposure to a commercial sex worker, your receipt of unprotected oral sex put you at risk for both gonorrhea and Nonchlamydial NGU. In addition, with your earlier, June exposure there is a possibility of chlamydial NGU as well. My advice would be to have a urine test both for gonorrhea and chlamydia as well as a test for white blood cells in your urethra. The ladder test can be performed using a urinalysis which is somewhat less sensitive than a direct swab but also less uncomfortable. It is recommended that if you choose to seek testing, you avoid urination for at least an hour before your test specimens are collected. , The urine specimen did you test should be collected using the initial portion of urine during urination, not a midstream specimen.

Treatment recommendations would depend on the results of your tests and the degree of suspicion by the clinician who sees you. It is debatable whether non-chlamydial NGU resulting from oral sex requires treatment or places a partner at risk but at the present time you simply do not have enough information to make judgments regarding appropriate treatment.

Regarding your regular partner, my advice would be to abstain from unprotected intercourse until you have a firmer diagnosis. There is of course the possibility that your test will be negative and if that is the case, you do not need treatment and your partner is not at risk but until you have been tested I would be cautious.

I hope this information is helpful to you. If there are further questions please use your up to two follow-ups for clarification. EWH

---

36 months ago

Thanks so much, Dr. Hook. Before I use my follow-up questions, could you please let me know what kind of clinicians usually perform tests for white blood cells in your urethra? Is it something that a local LabCorp can do, or I need to see a specialist (e.g. a urologist)? Thanks again

Edward W. Hook M.D.

36 months ago

2nd response. In the U.S. a public health STI/sexual health clinic would be best and typically can see clients quickly. Beyond that, while most primary care clinicians should be able to perform the assessment, all too many clinicians simply treat patients without knowing what they are treating, reasoning that the best approach is to treat “just in case”. When symptoms persist this causes problems. Whomever you see, please make sure you’re tested before taking antibiotics.

EWH

---

36 months ago

Many thanks again Dr. Hook. Actually, I had more questions to ask you as part of my 2nd follow-up, but I just limited my previous message to the clarification on the clinicians you wrote I should seek. Would you kindly allow me to ask a couple more questions as part of my 2nd follow up? I would really like to save my last follow-up after the test results are ready. Thank you.

Edward W. Hook M.D.

36 months ago

You may ask additional questions. Please be complete. EWH ---

36 months ago

Thank you, Dr. Hook, for allowing me to complete my 2nd follow-up. What I meant to ask before mainly had to do with the evaluation of my initial symptoms. It's true I did notice some white discharge on Saturday evening upon milking the penile tip (along with a burning sensation), but this didn't happen again afterwards, even with some vigorous squeezing. In the case of STIs - especially Gonorrhea, isn't the discharge happening on a regular basis once it stats AND spontaneously, i.e. without milking the head of the penis? I would also imagine that once the symptoms start, they don't get better (like in my case) without treatment...

Also, you mentioned that with my earlier June exposure "there is a possibility of chlamydial NGU as well." Here I'm confused again, not only in relation to what I've read within this website about it, but also with regard to our previous interactions on this matter. First of all, it was my understanding that chlamydia is inefficiently spread through fellatio. My vaginal sex with this girl was protected, and I believed that condoms would protect again vaginal acquisition of it (if they don't break). Last, but not least, I've always read in this forum that if no discharge appears within about 10 days from the risky exposure, one can go ahead and safely resume unprotected sex with one's regular partner. In my case, I had no symptoms whatsoever for over 30 days since the June exposure. Therefore, couldn't I have safely resumed unprotected sex after that incident?

Anyway, I'll still go ahead and do the testing you prescribed. I've found a local STD clinic where to get them. Interestingly, they will all be urine tests, with a note on the provider's website that " penile swabs are rarely performed these days because equally sensitive urine tests are available."

I'll come back for my last follow-up when the tests are ready.

Many thanks again!

Edward W. Hook M.D.

36 months ago

I’m not sure why you didn’t ask these questions earlier.

Most typically after the symptoms of STI’s appear, they remain present or worsen. That your symptoms did not reappear suggest this may not be in STI but without testing you cannot be sure and I would advise you not to take the risk given your history of recent exposures.

Thank you for the additional information regarding your June encounter. Your original post did not state the sites of exposure and so I presume it was unprotected general contact. If it was only receipt of oral sex then chlamydial infection is less likely.

Regarding sex with your regular partner, our answers are specific to the information provided by the client. Chlamydia can be asymptomatic in men for long periods of time. On the other hand if they’re on the exposure is oral sex and 10 days has passed since an unprotected encounter the presence of an STI is unlikely.

With the additional information you have provided the possibility that your infection was due to your June encounter is less likely. Nonetheless, given the circumstance and description of your recent symptoms, my advice would be that in order to be on the safe side testing is the appropriate approach. I look forward to hearing your results. EWH

---

36 months ago

Hi Dr. Hook,

So I finally got the test results back. Luckily, no chlamydia or gonorrhea (or Trichomonas) were found in the urine sample, but only two slightly unusual things: a small amount of Leuk Est (not specified) and the "White Blood Cells Urine" result amounted to 6 (Ref Range 0-5). The physician assistant I spoke to today told me that these denote a UTI, so I have been prescribed Ciprofloxacin 500 Mg (for five days I believe).

Symptoms-wise, I didn't have any noticeable discomfort or discharge Tue and Wed, but this morning I did notice something 'wettish' coming from the urethra (upon milking it), and I've felt something more of a burning sensation. So, my symptoms have been on and off so to speak.

1) Based on this, do I really have UTI or NGU? What would be the difference anyway (symptoms-wise), and does it even matter for me to know which one of the two caused my urethral discomfort exactly?

2) Since I have no history of previous UTIs, can we then assumed that my symptoms were indeed triggered by the unprotected oral encounter some 10 days ago?

3) Based on your experience, do you think Ciprofloxacin 500 Mg will solve my current symptoms (i.e. some occasional urethral burning on urination and 'wettish' feeling in the urethra), or my symptoms could get worse? Would you have prescribed a different treatment?

4) Since I tested negative to chlamydia, gonorrhea and trichomonas, is NGU or UTI contagious to one's regular sexual partner? (I thought to have read somewhere that either one shouldn't pose risks of transmission like other STDs).

5) Should unprotected sex be totally discontinued until the symptoms go totally away?

6) What do you think of the overall level of accuracy of these urine tests taken 6 days after the risky encounter? In other words, can I really assume I'm negative to chlamydia and gonorrhea?

In any case, I don't think I'll take the same risk again of receiving unprotected oral from partners I don't know well. It's just too much headache dealing with the possibility of "silent" bacterial infections, "asymptomatic" carriers and so on and so forth. For some reason, based on our previous exchanges on this website (and other old answers I've browsed), I seemed to have come to the conclusion that oral sex (namely receptive fellatio) isn't so risky after all. Also, which is even more important, even the assumption that no symptoms for 10 days following a risky exposure means one can move on, all of a sudden seems to crumble.

Many thanks once again...

36 months ago

Small correction: the Ciprofloxacin 500 Mg is to be taken twice daily.

Edward W. Hook M.D.

36 months ago

As you know, we provide of the three responses to each client’s questions. This will be the final response, following which this thread will be closed without further responses. I don’t believe you mentioned your age but in men under the age of 40, UTIs are quite unusual and the presence of white blood cells in your urine specimen manifest as a positive leukocyte esterase and slightly elevated leukocytes is totally compatible with Nonchlamydial NGU. This process is not uncommon following receipt of unprotected oral sex is a reflection of the introduction of oral bacteria into the urethra during oral sex. Experts debate whether or not it needs to be treated and there are no data that none chlamydial NGU poses a risk to sexual partners of persons with this syndrome. In response to your specific questions:

1. See my comments above. I remain skeptical that this represents a UTI but the distinction in your circumstance, with negative tests for gonorrhea and chlamydia is unimportant.

2. That would be my opinion.

3. I think that the ciprofloxacin therapy you have received is fine.

4. There is no evidence that your infection, whether it is non-chlamydial NGU or a UTI, represents any sort of threat do your regular partner or is a reason to abstain from unprotected sexual contact.

5. No, I see no reason to abstain from unprotected sex with your regular partner.

6. I would have great confidence in your test results ruling out the possibility of gonorrhea, chlamydia, or trichomoniasis.

Take care. EWH

---

36 months ago

Thank you. Much appreciated.

Edward W. Hook M.D.

36 months ago

You’re welcome. EWH ---