[Question #9983] #9900 Follow up Advice

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27 months ago
Correction: on 4/10, I was provided a 45 day Cipro (not Doxy) which I am still on.

4/11-27: Dysuria improved but some itching & pelvic pain

4/28: Wife performed oral to completion. Next day she mentioned a sore throat. She has allergies, so it may not have been related. I am worried

4/28-5/4: Tip Itch, testicle pain, and clear discharge (few times). Sometimes it feels like there is discharge, but nothing comes out

5/5: Symptoms same. Urinalysis, PSA, Chla, Gon, Hep B-C, Syphilis, Trich, CBC, HIV, culture Ureaplasma app and Mycoplasma H. all normal/negative. There was no discharge at the appointment, so no culture/swab

5/6-5/16: Testicular pain worse and same discharge

5/18: Testicle pain & several rounds of discharge. Urine showed WBC 10+hpf.

Chla, Gon, Mgen, and Trich ordered & result on 5/22. On-call PCP provided empirical Azithro 1g but I am unsure which PCP listen

5/19: Pelvic CT and urine culture - results pending. Testicle pain decreased to previous tenderness.

Urologist is on 5/23.

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27 months ago
Apologies - I left off my questions!
    Does the Doxy/Cipro change your assessment?
    Do you think the continued discharge is a sign of STI? Worried my initial MGen test at 10 days was to soon
    Do you think I infected my wife? Get her tested/treated?
    Tests on 5/5 provide any solace that this isn’t something infectious?
    Recent leukocytes & discharge change your assessment?

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H. Hunter Handsfield, MD
27 months ago
Welcome back to the forum. This question arrived on my watch, but I reviewed your recent discussion with Dr. Hook. I agree with all he said. 

You present an unusual and diagnostically difficult situation. Despite the onset after a potentially risky sexual exposure, I agree with Dr. Hook that no known STD is likely responsible for your symptoms. And STDs are the only topic for this forum; while we sometimes advise about other genitourinary infections, we do not provide direct health care. Clearly you have some sort of lower urinary tract inflammation or infection, but all I can do is advise that you follow up with your urology appointment as scheduled. If that doesn't result in clear answers, an infectious diseases specialist might be able to help. 

"Does doxy/cipro change your assessment?" No, only that it tends to suggest no STD is present.

I doubt you have anything that could have infected your wife, but the situation is sufficiently complex that I cannot give you complete assurance on that aspect.

Most likely this is not infectious, or at least not an Std.

Leukocytes and discharge do not change my assessment.

I'm sorry we cannot provide the answers you seek, but thank you for your understanding we can't do much more from this distance. I'll be happy to comment further if you would like to report the outcome of your urologic evaluation. Good luck.

HHH, MD
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26 months ago
Follow-up post urologist...thank you in advance!

5/22: Pelvic CT ruled out stones and 5/19 urine came back normal and without growth which (I believe) was because I was instructed to do a mid-stream catch. I’d love your feedback on whether this was the correct approach. Strange that there would be WBCs on 5/18 but not on 5/19.

5/23: Should’ve taken last 2 doses of Cipro but I inadvertently took Azithromycin in the AM & PM (same color/shape).

In the afternoon, I saw the Urologist who suspects it is chronic bacterial prostatitis. Completed a DRE/massage urine culture which came in today (5/26) with no growth. At the time of the exam, he noted that a negative test might be due to the Azithromycin/Cipro. I’m expecting a follow-up call on May 30th to discuss next steps. May recommend more long term abx but I’m a bit nervous as I’ve been on 8 weeks now.
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26 months ago
Questions:
  • Can you provide more clarification (or reassure) what specific it is that makes you think no known STD is likely responsible for my symptoms. Sorry if this is repetitive!
  • Immediately after the Azithromycin, I started to feel better but now on D3 the pelvic pain, itching, minor dysuria, and urgency have returned. I’ll observe this over the next 4 days but if the Azithromycin resolves my symptoms, is it possible to say this is urethritis? If it were idiopathic urethritis, have you ever seen it not resolve after Doxy and Azithromycin? Any other abx worth trying?
  • When you say ‘this is not infectious, or at least not an Std’, do you mean this is not a traditional STD (still NGU), or like a bacterial infection (non-STI ones)?
  • What are your thoughts on retesting the EPS urine after the AZ has left my system? I feel like this could be something viral perhaps.
  • How likely is it that HPV could be causing this?When I look inside my urethra with a flashlight, I notice minor texture changes/bumps on the inside. I am worried this could be subclinical/clinical warts causing my symptoms. Urologist didn’t feel there was anything wrong inside but we could scope it in the future.
  • If you were me, would you feel comfortable having unprotected (oral or vaginal) sex with your wife or would you abstain?

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26 months ago
Apologies for the extra comment Dr. HHH, I just wanted to note that my list of symptoms in question #2 still includes discharge which feels to be worsening.
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H. Hunter Handsfield, MD
26 months ago
Let me start by acknowledging your symptoms, which strike me as real and significant. I wish better answers were available.

Looking back at your original discussion with Dr. Hook, I agree that the most likely explanation is simply bad luck in timing of the oral sex event -- which happened to occur just as your likely prostatitis was about to cause symptoms. I understand how frustrating this can be, and fully understand how the timing of the events certainly makes the oral sex event suspicious as the cause. However, there simply is no evidence for any STD acquired by an oral sex exposure to cause the symptoms and problems you now have. However, if you have not been tested for two STDs -- trichomonas and Mycoplasma genitalium -- that should be done. PCR tests for both are available. However, neither of these causes oral infection and hence rarely if ever acquired by oral sex; if positive, you would have to address other sexual sources, including your wife.

That said, evolving scientific data in the past couple of decades has shown that there are myriads of bacteria, viruses, and perhaps other classes of microscopic life (the group called archaea (or archaeans), for example, which cannot be grown in the laboratory and are not detected by any standard lab method, at least none yet known. Could something like this reside in someone's oral cavity and cause symptoms like yours? This is entirely unknown -- we're in the realm of speculation only.

Another possibility is that your problem started as a sexually acquired nongonococcal urethritis (NGU). Following oral sex, some NGU probably is the urethra responding to entirely normal oral bacteria, but ones which happen to cause an inflammatory response. Such forms of NGU are generally considered harmless; and although treated with azithromycin or doxycycline when diagnosed, they probably clear up without treatment. Whether this form of NGU should be considered an STD is a matter of professional uncertainty and debate; it isn't caused by any known STD bacteria or virus. However, it is plausible that some such infections might trigger subsequent nonspecific inflammation that explains symptoms like yours. As a sort of similar example, the condition called reactive arthritis occurs as an immunologic reaction following various infections, but is not due to infection per se. Could such a process occur in the genital tract and result in prostatitis? This has not been documented or, to my knowledge, even studied. But there's no way to prove it can't happen. If it does, antibiotics are not likely to help:  they only treat infections, not other kinds of inflammation. In any case, no STD is known to cause the combination of symptoms you now have, whereas prostatitis frequently does so.

Those comments address these questions in general terms. As for your explicit questions:

"Any other antibiotics worth trying?" Various antibiotics (e.g. Bactrim®, ciprofloxacin or related drugs) often are used in prostatitis and may be worth a try -- something to discuss with your urologist.

In the off chance testing for trichomonas or M. genitalium were positive, specific antibiotics are needed in each case (metronidazole and doxycycline+moxifloxacin, respectively).

I see no value in testing expressed prostatic secretions (EPS) for STDs, but your urologist may wish to do this to check for non-STD causes of prostatitis, if not yet done.

HPV does not cause inflammation at all. It is not a plausible explanation for your symptoms.

Finally, many urologists believe that nonspecific prostatitis benefits from sexual activity, and I see no realistic chance you have anything that could harm your wife. If I were you, I would follow my urologist's advice -- but I see no reason you cannot safely have unprotected sex with your wife.
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26 months ago
What Sx specifically rules out STDs? I am a bit hung up still. My urethra itching, urgency, dysuria, and wbc could be NGU, right? At that time, tested (-) for Chla, Gon, MGen, Trich.

Over weeks exp minor discharge and increased testicular & pelvic pain. Tested (-) for HIV, Hep, Syph, Myco/Urea cultures. Possible I had NGU & Epididymis? Today, feeling urethral itch & testicular pain but these Sx vary. E.g. testicles hurt more, minor discharge, other times pelvic pain, etc.

Wife noted a sore throat after performing oral, week later had a cold sore ( hasn't occurred in years), and another on 5/26. Worried I infected her.

Taken Doxy, Cipro (2x), & Zpack 1g on May 23. Should have addressed NGU right?  Any tests to rule out STI? Urine/semen/culture? Any final recommendations?
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26 months ago
A quick thank you Dr. HHH for all your support. I understand my case is very odd but I am just very worried about infecting my wife. I've obviously had a lapse in judgement which I hope doesn't have last implications on my wife and children's life's. Any final clarification you can provide is appreciated and I do apologize for an redundancy in my questions as I just want to be as sure as possible.
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H. Hunter Handsfield, MD
26 months ago
Thanks for the thanks. I'm glad to have helped. However, you are seriously overthinking everything. You're putting two and two together and coming up with nine! Like many, you misunderstand NGU symptoms, which do not include urgency, nor dysuria in absence of discharge. ("Minor discharge" that isn't observed by a health professional and that doesn't have WBCs microscopically doesn't count.) (As it happens, Dr. Hook was the senior investigator on one of the main research studies that documented absence of these symptoms in NGU and gonorrhea.) Such symptoms originate in the bladder, not urethra.

I don't recall you describing any symptoms that suggest epididymitis; minor testicular pain doesn't count, only severe pain associated with testicular enlargement and marked tenderness. And none of the STDs that cause urethritis cause sore throat:  almost all gonorrhea or chlamydia in the oral cavity is entirely without symptoms, and the same probably is true for other (largely unknown) causes of urethritis. And yes those treatments would have resolved all known cases of sexually acquired urethritis. (Interestingly, research 30+ years ago reported that sore throat occurs with increased frequency in persons who perform oral sex but could find no STD or other infectious explanation.)

I am confident that many of your continuing (probably most and maybe all of them) have primarily psychological origins -- something to discuss frankly with your urologist. (I'm not a believer in anxiety creating symptoms out of the blue. But for sure it commonly magnifies minor symptoms or normal body sensations that otherwise would be ignored or not even noticed.)

I have no other recommendations. And that concludes this thread, which will need to be your last on these issues. The forum has a policy against repeated questions on the same topic, which may be deleted without reply and without refund of the posting fee. This forum has delivered as much as it can in regard to your concerns, and repeated answers aren't going to be helpful. In addition, such questions have reduced educational value for other users, one of the forum's main goals. Thank you for your understanding. I do hope the discussions have been of some help to you. If you remain concerned, I suggest you go back and carefully re-read both threads. Best wishes.
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