Advice please

[hfb20]

Thank you so much docs. I reviewed many posts and understand this is tough to diagnose online:

Timeline:
After 2 weeks get pain behind left testicle, gon/chl neg; given 1.5g Azith;
Pain less in week 3, greater + swelling week 4. Doc says ultrasound small varicocele

Pain/swelling persist; substantial discharge when defecating and post ejaculatory discharge – test neg week 6 (gon/chl/hep/syph/hiv/hsv2); pos hsv1

Week 7 pain/swelling increase. 2 weeks doxy then 3 weeks cipro with 1 week metrodinazole no help.

Week 13 – docs say maybe mental, no more test or treatment. Develop burn at tip of penis.

Week 14 – develop strong perineum pain

Note – Was healthy, late 20s, received oral

Symptoms now week 16:
swelling in scrotum, behind left testicle. When tight, left testicle bulges. Scrotum full overall now. When loose, can see/feel swollen veins behind left testicle and some above. Pain when sitting or epid. touched in spots

Very uncomfortable perineum pain when sitting and walking – this pain often worst.

Burn at tip of penis much of the day.

Excessive discharge when defecating several times per week – keeps coming if strain (some clear, some cloudy, some thick semen like) – some burn in urethra after; at least some clear every time, some clear discharge with urine too

ejaculatory issues (weird discharge after, occasional burning, sometimes no semen)

Questions:
Can you think of anything that would cause this?  originally thought mental – not now.

Any additional tests or treatments?

Is this chronic problem because not treated properly?

With epid infection, can scrotum hang loose or always tight/swollen? Could self examination make it worse?

Could infection spread to prostate?

Any other suggestions – what can be done? If I could know that it wasn’t harmful or transmissible, I could deal with it. However, it seems implausible that this just happened randomly. Never any issues before…now been 4 months and getting worse – thanks so much.

[H. Hunter Handsfield, M.D.]

7 days moxifloxacin (Avelox) generally is considered sufficient -- but I recommend you follow your doctor's advice.  If s/he prescribe more than a week, that's what you should do.

If you have not seen a urologist, that would be a logical step to evaluate your continuing symptoms.  As already discussed, however, you can be confident that it's not an STD problem.  Therefore, there is nothing more this forum can offer.  But this shouldn't be a big worry for you.  The discomfort is one thing, but such problems rarely are due to anything serious -- no cancer, no infertility, nothing that can harm a partner.

Good luck--  HHH, MD

[hfb20]

Hi Dr.,

I completed 7 days of Avelox with no big change in symptoms - is this enough treatment or should I have 10 days or more?

Also - I had another clean urine microscope exam. Can wbc be present on gram stain but not in urine? I had urinalysis clean many times, which seems odd.

Finally, you mentioned that this may be prostate related or something else. Should I look that direction at this point given the meds I've tried and can that cause the urethritis? I'm not sure where to go from here as these symptoms are driving me crazy.

Sorry about all of the follow up, I promise to stop here- but I can't shake these symptoms (scrotum swelling,pain behind left testicle, perineum pain, discomfort in urethra, discharge with urine/defacating). Thank you again for all of your help.

[hfb20]

Thank you so much Dr., I appreciate your help. I don't have any other questions, but I will follow up in the future if anything new occurs regarding tests/treatment going forward.

Thank you for providing this forum.

[H. Hunter Handsfield, M.D.]

"Inflammation" by gram stain simply means that white blood cells were observed in your urethral secretions.  While initial NGU (i.e. the first episode, before any treatment) is virtually always sexually acquired, the genesis of recurrnent or long-persisting NGU is not well understood.  Some cases may be inflammation without infection.  Also, there is overlap between NGU and prostatitis -- and this may still be primarily a prostate problem, entirely unrelated to STD.

Your doctors are following the standard approach, i.e. re-treat with doxycycline, especially some time has passed since your previous episode (e.g. several weeks or more).  Otherwise, it might have been best to try azithromycin, with or without metronidazole (which treats trichomonas -- not a common cause of this problem but worth a try).  Subsequent efforts could include moxifloxacin (trade name Avelox), to cover Mycoplasma genitalium, which is a possible cause in this situation.

However, you may find that no antibiotics are helpful, if the problem is noninfectious.  But the good news is that this sort of problem is not believed to be harmful in the long run, either to you or your sex partner(s).

I think those comments answer all three of your questions.  Good luck with it.

[hfb20]

Thank you Dr. Handsfield, I appreciate your advice and it certainly helps. I have some new info to add.

I went to a scheduled appt. today and a gram stain found inflammation. They diagnosed NGU. They said it can be from many things and prescribed doxy, but I can't imagine this will help as I had doxy before. They said the scrotum looked pretty swollen, but understand from your response that this may be something else.

I have a few related questions:
1) What could cause the inflammation test result at this point? Is this still related to the original event or could something else cause this test result now?

2) Would you advise using this treatment? I already had it plus other treatment.

3) Do you have any other thoughts about what is going on here? How can inflammation in the urethra still be here? I am quite worried.

Thank you so much for your help!

[H. Hunter Handsfield, M.D.]

Welcome to the forum.

Your symptoms are nonspecific -- i.e. they don't point strongly to any particular problem.  The only STD related condition that could cause testicular pain and swelling is epididymitis (testicular infection), and the only STDs known to cause it are chlamydia and gonorrhea.  With those tests being negative, sexually acquried epididymitis has been definitively ruled out.  Further, real epididymitis is a much more dramatic, inflamed condition than you have described.

Some of your symptoms could indicate prostatitis, but that's not a sexually tranmsitted condition.  Discharge of fluid with bowel movements is not in itself abnormal, although frequent occurrence sometimes can be associated with prostatitis (see http://www.medhelp.org/posts/show/859854).  But for most of your symptoms, I'm inclined to agree with your doctor(s) at week 13, as well as your own initial impression:  that your symptoms are primarily psychological in origin.

You can be entirely certain your problems are not due to any STD, and certainly receiving oral sex is not a likely source of any infection that could cause all this.  But that's as far as I can go. This is strictly an STD forum, not a venue to resolve non-STD genital symptoms and problems.  But I hope some of these perspectives have been helpful.

Regards--  HHH, MD