[Question #9476] Assessment of last 11 days and possible causes

32 months ago

Hi,

Please read the following and answer my questions:

- Previous to the following events, I have periodically engaged in unprotected oral and protected sex with a sex worker.. say once every two months. My last comprehensive STD test was last winter, negative.

- 11 days ago, I had unprotected oral with a sex worker

- 2 days ago (Noon to be precise) I had unprotected oral and protected condom sex with a sex worker

- 1 day ago at night, I noticed some small amount of discharge from my penis but thought nothing of it

- Today during the evening, I saw increased discharge from my penis, more of a burning and urgency to pee, the slightest mild sore throat, and red/pink urine, which appeared to be Gonorrhea/Chlamydia symptoms, at which point I immediately went to the doctor, took a urine culture test for Gonorrhea and Chlamydia, and took the recommended treatment for Gonorrhea (Ceftriaxone shot 250mg and 1g azithromycin orally)

My questions as I await the urine culture test:

- The onset of my symptoms seem particularly fast if it was the encounter of 2 days ago that caused it.. is that possible? And if it was, seems like it would almost have to be Gonorrhea then? But would the urine culture successfully diagnose that, given the short testing window? I'm worried that the results will be negative and I'll be left to wonder what happened..

- Any material chance that it is the encounter of 11 days ago that caused my symptoms? Based on what I've read, it seems unlikely given the incubation period and symptoms would indicate Chlamydia, yet the fact that I only received oral makes it less likely.

- Is there any material possibility that it was say, an episode of Chlamydia from 3 months ago and that it just took this long to manifest symptoms? I want to understand how far back I should try to trace this in the event that it comes back positive for Chlamydia

Thank you.

Edward W. Hook M.D.

32 months ago

Welcome to the Forum. Thanks for your questions. I assume that the oral sex you refer to is RECEIPT of oral sex. With that assumption, I will address your questions:

The symptoms you describe certainly are suggestive of a sexually acquired urethritis. The most common causes of urethritis following oral sex are either gonorrhea or non-chlamydial non-gonococcal urethritis (NGU). If your symptoms are due to either of these problems, the treatment you took is almost certainly be curative. As you which of the encounters you described led to your symptoms, either of the encounters could have been the cause. The two day interval is more compatible with a gonorrhea infection while 11 days is more suggestive of NGU. If your infection is due to gonorrhea, the results of your urine test should be positive.

Chlamydia following receipt of oral sex is very, very rare. If your test for gonorrhea is negative, I would expect your symptoms to be due to non-chlamydial NGU which most often occurs when oral bacteria from a [artner's mouth get into the urethra to cause irritation. If this is the case, the treatment you received would be likely to cure it.

It would be most unusual for the symptoms of chlamydia to take three months to develop. It is far more likely that these symptoms are related to your encounters 11 or 2 days earlier.

I hope that this information is helpful. If there are further questions or any part of my response is unclear, please use your up to two follow-ups for clarification. EWH

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32 months ago

Thank you for confirming my suspicion that Chlamydia is by far the least likely cause of the symptoms, of the potential options (if any other possibility not previously stated please let me know)

Somehow the possibility of an NGU slipped my mind up until now, follow up question:

- Are there any symptoms that would point more so to an NGU or Gonorrhea or are they virtually identical? In addition to my previous listed symptoms my discharge was clear and sometimes slightly milky, and foul smelling, if that changes anything

- When the urine culture result comes out though, as I understand what you said, that will be the definitive way to interpret whether it is definitive Gonorrhea (positive) versus highly probably NGU (negative). In the case that it is NGU, when is it safe to practice sex again,? I don't think health services where I live push for a test of cure for NGU..

32 months ago

And for clarity yes, this is concerning receipt of oral sex and condom protected sex from the POV of a male engaging female sex workers

Edward W. Hook M.D.

32 months ago

Thanks for the clarification related to your exposures.

While there are generalizations regarding the symptoms of NGU vs gonorrhea (the onset of symptoms for NGU tends to take longer, symptoms tend to be somewhat milder and the discharge is more typically clear vs obviously purulent/pussy) there is much overlap. The best indicator of what is going on will be the results of your urine test. If gonorrhea is there, it should be detected. If it is not there, then this is most likely NGU.

After the therapy you have had, most experts would not recommend a test of cure. The cure rates with the ceftriaxone/azithromycin you took are very, very high and if the symptoms resolve (possibly even before your test results are back) then it is safe to presume you're cured. While the standard recommendations are to wait a week until resuming sex, biologically and practically, you would not be infectious by about day 4 after treatment.

Hope this helps- you have one follow-up remaining. EWH

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32 months ago

As a final follow up concerning NGU, is there a correlation between (my) specific symptoms or situations, such as plentiful discharge, foul smell, red urine, or unprotected oral only, that would make the probability of certain, potentially more severe/impactful NGU types greater such as Mgen for example?

To elaborate: I ask because I have had non serious 'tingly' feelings and burning pee post-sexual encounters a few times, but I also assume this could have been non-material NGUs that went away after a few days and I never took any attention or special action.

In contrast to that line of thinking, regarding my last 2 days where I experienced more severe symptoms than I ever have in my life, assuming that NGU ended up being my diagnosis, would any specific or more severe or even perhaps more persistent strains be likely as a result of my specific symptoms and case, and if so, could you please specify which? For what it's worth I feel much better one day following the antibiotics treatment, almost normal...

Thank you for everything you guys do here, it is a great service to the world to have your level of expertise and candor.

Edward W. Hook M.D.

32 months ago

Mycoplasma genitalium is an occasional cause of persistent/recurrent NGU. Current recommendations are to not test for M. genitalium unless initial treatment (such as you have had) fails. There are no specific associations with certain organisms which make the symptoms of NGU more or less severe- in general NGU symptoms tend to be milder than those of gonorrhea but,as explained above, there is much variability.

"tingling" or other noteworthy but transient symptoms following sex are rarely STIs. The symptoms of STIs tend to persist and/or get worse for at least several days or until treatment. OTOH, when persons are looking for symptoms, there is a tendency to notice what are otherwise normal sensations. These sorts of things may be perceived as transient burning or tingling in particular but do not persist. They may be a manifestation of retained genital secretions following sex as well.

I worry that you are getting ahead of things. I suggest you wait for your test results and see how you respond to the therapy you have already received. Once you have that information, you can take appropriate steps.

As you know, this will complete this thread. I hope that your symptoms have resolved with therapy. EWH

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