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STDs (Expert Forum)
Continuous urethral symptoms
Answered by
University of Washington
Seattle - WA
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This forum is limited to questions about STDs other than HIV/AIDS. For questions about HIV prevention, or if you have general questions about safe sex (e.g., condoms, how to protect yourself from HIV and STDs), please visit the HIV Prevention and Safe Sex Forum
Some of the most common types of questions concern the risk of HIV or STD after a particular sexual exposure, and about symptoms that might or might not be due to HIV. If your question is along these lines, please visit the HIV Prevention and Safe Sex Forum.
Continuous urethral symptoms
by stillHurting, Jun 15, 2007 12:00AM
30 M
4/3 heterosexual sex w/ friend (not regular partner), unprotected.
4/14 Urethritis symptoms � discharge, slight dysuria, meatus swollen
4/15 Urinalysis - leukocytes +1. Discharge. Empirically treated 1g azithromycin + 400mg cipro. Regular partner 1g azithromycin.
4/18 GC NAAT negative. Not sure sample was FVU.
4/27 sex with regular partner
4/30 test negative GC hepb hepc hiv syphilis hsv1 hsv2
4/30 5/1 5/2 urgency to urinate
5/7 urinalysis - negative
5/24 burning on penis, urethral opening reddened
5/29 hsv1 hsv2 IgG hiv hepc, trich PCR swab, urine culture (from FVU) negative
Wet mount:
Epithelial cells: few
wbc: moderate
rbc: few
trichomonas: none
clue cells: none
yeast: none
bacteria: 2+
Urethral swab VERY painful, caused bleeding. Pain on urination.
5/30 Urinalysis non-hemolyzed trace blood.
5/31 7d doxy, 2g Flagyl (not gotten 5/29 results) 1 fluconazole
Burning sensation (almost unbearable) until 6/4, continues today. Corona glandis swelling. No discharge. No dysuria. Meatus redness.
Questions:
1) 4/18 false negative? DNA still detectable after antibiotics?
2) 4/30 too soon after antibiotics? Reinfection on 4/27?
3) Chlamydial IgM useful?
4) Symptoms from urethral swab on 5/29? Bleeding seen from this?
5) Wet mount results suggest bacterial urethritis?
6) HSV, what % of people with a first outbreak, do not see sores.
7) Leukocyte esterase + with HSV urethritis ?
8) Abstaining from sex. Take other tests?
4/3 heterosexual sex w/ friend (not regular partner), unprotected.
4/14 Urethritis symptoms � discharge, slight dysuria, meatus swollen
4/15 Urinalysis - leukocytes +1. Discharge. Empirically treated 1g azithromycin + 400mg cipro. Regular partner 1g azithromycin.
4/18 GC NAAT negative. Not sure sample was FVU.
4/27 sex with regular partner
4/30 test negative GC hepb hepc hiv syphilis hsv1 hsv2
4/30 5/1 5/2 urgency to urinate
5/7 urinalysis - negative
5/24 burning on penis, urethral opening reddened
5/29 hsv1 hsv2 IgG hiv hepc, trich PCR swab, urine culture (from FVU) negative
Wet mount:
Epithelial cells: few
wbc: moderate
rbc: few
trichomonas: none
clue cells: none
yeast: none
bacteria: 2+
Urethral swab VERY painful, caused bleeding. Pain on urination.
5/30 Urinalysis non-hemolyzed trace blood.
5/31 7d doxy, 2g Flagyl (not gotten 5/29 results) 1 fluconazole
Burning sensation (almost unbearable) until 6/4, continues today. Corona glandis swelling. No discharge. No dysuria. Meatus redness.
Questions:
1) 4/18 false negative? DNA still detectable after antibiotics?
2) 4/30 too soon after antibiotics? Reinfection on 4/27?
3) Chlamydial IgM useful?
4) Symptoms from urethral swab on 5/29? Bleeding seen from this?
5) Wet mount results suggest bacterial urethritis?
6) HSV, what % of people with a first outbreak, do not see sores.
7) Leukocyte esterase + with HSV urethritis ?
8) Abstaining from sex. Take other tests?
Doctor's Answer
by H. Hunter Handsfield, M.D., Jun 15, 2007 12:00AM
, Jun 15, 2007 12:00AM
Some of your terminology suggests you are a health professional, yes? If not and you need terminology clarification my response, let me know.
First, visible bacteria on a urethral smear is meaningless; plenty of bacteria are seen normally on gram stained smears in completely normal people. Only leukocytes matter, but I don't know how to interpret 'moderate' WBC in urine. The severe dysuria following an endourethral swab doesn't suggest much more than trauma from the swab. You started with nonchlamydial NGU, but since everything else is completely negative, and in view of the treatments you have had, you can be sure there is no ongoing STD at this time, and probably no other infection.
Symptoms consistent with continuing urethral irritation, with or without other evidence of urethritis, are quite common in this situation and the cause remains obscure. Psychological origins are often suspected, but that's probably too simplistic. Perhaps some cases reflect some sort of ongoing immunologic (non-infectious) reaction. Perhaps most important, there is no suspicion that any harm ever comes from it - i.e., not even anecdotal reports, let alone controlled studies - that is, no risk of long term harm, no infertility, and no harm to future sex partners, since there is nothing infectious to transmit. My routine advice to men in your situation is to just sit tight and do nothing, secure in the knowledge that nothing serious is going on and with the expectation that the symptoms will fade with time.
To your specific questions:
1) You can rely on the negative NAAT result.
2) No reason to suspect reinfection.
3) Chlamydia serology is useless in this situation, whether IgM or IgG.
4) In my personal experience, pain and bleeding after urethral swab might suggest that all is normal. Although that seems paradoxical, the increased mucus and/or overt discharge associated with urethritis seems to provide a measure of lubrication; the normal (drier) urethra might be more readily scraped raw by a swab. This is my clinical impression, not controlled data - but I'm pretty convinced, having passed thousands of urethral swabs over the years.
5) As noted above, bacteria on smear, without WBC, are meaningless.
6,7) Herpetic urethritis can occur without external lesions. But herpetic urethritis symptoms never last so long and the symptoms are always cyclical, with much longer asymptomatic than symptomatic periods. That said, valacyclovir and other antiherpetic drugs are benign, and you certainly could try a few days treatment without harm. But don't get your hopes up; I don't expect it would help.
8) I see no reason not to have sex, from the perspective of either your health or that of your partner.
I hope this helps. Best wishes-- HHH, MD
First, visible bacteria on a urethral smear is meaningless; plenty of bacteria are seen normally on gram stained smears in completely normal people. Only leukocytes matter, but I don't know how to interpret 'moderate' WBC in urine. The severe dysuria following an endourethral swab doesn't suggest much more than trauma from the swab. You started with nonchlamydial NGU, but since everything else is completely negative, and in view of the treatments you have had, you can be sure there is no ongoing STD at this time, and probably no other infection.
Symptoms consistent with continuing urethral irritation, with or without other evidence of urethritis, are quite common in this situation and the cause remains obscure. Psychological origins are often suspected, but that's probably too simplistic. Perhaps some cases reflect some sort of ongoing immunologic (non-infectious) reaction. Perhaps most important, there is no suspicion that any harm ever comes from it - i.e., not even anecdotal reports, let alone controlled studies - that is, no risk of long term harm, no infertility, and no harm to future sex partners, since there is nothing infectious to transmit. My routine advice to men in your situation is to just sit tight and do nothing, secure in the knowledge that nothing serious is going on and with the expectation that the symptoms will fade with time.
To your specific questions:
1) You can rely on the negative NAAT result.
2) No reason to suspect reinfection.
3) Chlamydia serology is useless in this situation, whether IgM or IgG.
4) In my personal experience, pain and bleeding after urethral swab might suggest that all is normal. Although that seems paradoxical, the increased mucus and/or overt discharge associated with urethritis seems to provide a measure of lubrication; the normal (drier) urethra might be more readily scraped raw by a swab. This is my clinical impression, not controlled data - but I'm pretty convinced, having passed thousands of urethral swabs over the years.
5) As noted above, bacteria on smear, without WBC, are meaningless.
6,7) Herpetic urethritis can occur without external lesions. But herpetic urethritis symptoms never last so long and the symptoms are always cyclical, with much longer asymptomatic than symptomatic periods. That said, valacyclovir and other antiherpetic drugs are benign, and you certainly could try a few days treatment without harm. But don't get your hopes up; I don't expect it would help.
8) I see no reason not to have sex, from the perspective of either your health or that of your partner.
I hope this helps. Best wishes-- HHH, MD
I took tests on 6/12 - Herpes Select HSV1 HSV2, HSV IgM, HIV Ab, Chlamydia Ab IgM, G/C NAAT. All negative. 6/15 POCKit HSV2, negative. The redness has lessened, but is still there, especially the corona glandis. No visible lesions.
However, today I noticed discharge again. Not much, but definitely there, and purulent. Some urethral discomfort, but no real dysuria.
So I am at a loss. I know it could still be HSV1 urethritis, as the test on 6/12 is still too soon to be sure. I feel with the POCKit test + HerpesSelect that HSV2 is quite unlikely (<10%), correct me if I am wrong. But HSV1 is only <30% at this time. Going by published seroconversion profiles.
Questions:
I am aware that HSV IgM does not mean recent infection, that there is great cross reactivity with HSV1 and HSV2, and also with other virii (VZV, CMV). But in my case, a negative HSV IgM is a good result? I know I have no HSV1 or HSV2 prior. My lack of dysuria is a good sign.
1) What is my next course of action? More antibiotics?
2) PCR test for Mycoplasma/Ureaplasma useful? http://www.labcorp.com/datasets/labcorp/html/chapter/mono/vm003300.htm
3)Should I have taken the Chlamydia IgG Ab test instead?
4)Gram stain useful for detecting non chlaymydial NGU? I am nervous about a second swab due to the pain involved.
5)Abstain from sex until situation more clear? Retreat partner?