Confused over NGU, rash diagnosis

[Annonymous101]

Dear Doctor,

I’m a male in my 20’s. 3 months ago I spent the weekend with my recent partner, we were intimate performing  (unprotected) oral sex on each other.
I noticed several days, possibly a week or so, later that I was getting a slight burning sensation during and after urinating. I also noticed my penis opening/urethra seemed more red and sensitive.
The symptoms persisted and I started to notice a clear discharge (tiny amount) after urinating.

On my return home over a month later I visited a clinic. I was examined and told that it seemed like nothing to worry about. They tested for gonorrhea & chlamydia. Both came back negative. I was told it was likely a urethral irriation that would go away and wasn't sexually transmitted.

The symptoms seemed to fade but didn’t clear up. I then read-up on possible causes and noted possible HSV-1 from oral sex. I must admit ignorance as to how closely cold sores and genital herpes were linked. This worried me as my partner suffered with cold sores at times and looking at photos of the weekend in question she appears to have small sore on her lip - which would have been when she performed oral sex on me.

While bathing 7 weeks after the original encounter I noticed a small mark on my testicle - about 2mm by 1mm, slightly raised, red/pink, no pain or itching, slightly sensitive if scratched. No idea how long the mark had been there.
The mark was checked and I told they werent sure but it was likely a fungal rash/infection. I was told to use Clotrimazole cream. I used this but the mark seemed to look more prominent some days and less others regardless of using the cream.

It’s now been more than 3 months since the initial encounter (and the burning sensation beginning) and over 1 month since noticing the red mark. And still both the discomfort on urination is present and the small red/pink mark. I’m not sure if another mark is appearing next to the original which is worrying me further.

Thanks in advance for any help/advice.

[Edward W Hook, MD]

I think what your doctor told you makes good sense.  I see no need for additional testing for NGU.

The sort of follicular skin lesions you describe occur on the scrotum are not uncommon and can persist for long periods of time. they are not something to worry about.  

Further, I would not recommend HSV-1 testing for you.  If you find you have HSV-1 you would be like the 50% or so of the population who have HSV-1 but do not know it, much less know where their infection might be.  It would not solve you questions.  your symptoms are not suggestive of HSV-1.  EWH

[Annonymous101]

I managed to visit the clinic on Friday morning. I spoke to a nurse and expressed the want to see a Doctor.
A Doctor came in and looked at my notes and asked to examine me. She thinks the issue is a skin condition which effects the head/glands of the penis - she noted the skin seemed dry. This she said was likely to be causing the discomfort during urination as she could see my ureathra looked a little sore/inflamed.
I also pointed out the mark on my testicle, which she quickly looked at and said was nothing to worry about and was likely an just old hair follicle that was just irritated.

I did question the skin condition causing the discomfort when urinating, as it seemed a little odd to me, but it was confirmed she believed this was the cause. I've been perscribed a hydrocortisone oitment (1%) to use daily for the next few weeks.
I also asked if additional testing was needed but due to my previous results being negative I was told no.
I must admit I got a bit lost with all the information - the doctor was called in quite quickly and I didn't get around to specifically asking about NGU, silly I know.

My question is does this sound like a likely cause? I've more noticed the redness at the urethra opening more than anything such as dryness. The skin does sometimes seem dry but not sure if this has been the case for a long time.
It also seems odd timing that this condition came about after my encounter to cause the discomfort when urinating. Not sure if I am overthinking things.

Also is it worth also returning to specifically ask for an NGU test despite this diagnosis?

The red/pink mark is still there. Which seems like a long time for a hair follicle (6 weeks) but then seems a long time for anything else. I think I will try to accept the Doctors conclusion, it just seemed a very quick glance to make a diagnosis for the mark.

I still have the HSV-1 idea ringing around in my head. My question is this, if I were to test for it and find it. Would this likely be the cause of the burning? I'm not sure I even should test for it in this case?
Also if I did have HSV-1 antibodies and assuming the doctor is right about the mark and i therefore have no sores is there not really any way of telling if it were oral or genital? Sorry to bring up the HSV-1 idea again. Just something that still comes to my mind.

Thank you very much for your advice so far. It really has been greatly appreciated. I do apologise if my questions seem a bit erratic.

[Edward W Hook, MD]

As I said, t here is a distinction between NGU/NSU and I would indicate the you are worried about non-chlamydial NGU and that if it was not done, you would like to have a gram stain to look for increased numbers of urethral white blood cells.

Given that there was not gonorrhea or chlamydia present when tested and the fact that NGU following oral sex is thought to be due to introduction of normal oral bacteria into the urethra, I do not think she needs notification specifically.  

See above.  The check for NGU can be done while you are present in the clinic.  

Hope this helps clarify things.  EWH

[Annonymous101]

Thank you for your quick response it is very much appreciated.

With regards to the initial testing - they did take a swab of the slight discharge. I'm not sure if this was to test for NGU? They never mentioned if they tested for NGU/NSU.
When I return to the clinic is it an NGU/NSU swab test I should specifically ask for? Should I also ask for any other testing?
I will also get the mark looked at as you suggest.

My  recent partner had to move back to her home country in Europe. We remain close friends as we were previously. I wondered if I have NGU from the encounter should I inform her in case she has an oral infection she's unaware of? I don't want to worry her or make her feel accused without good reason.
(I should mention she is my second partner in the last 6 years - although I doubt this makes a difference any advice given).

I’ve been dating someone new recently (since my recent partner returned to her home country) but am very reluctant to become sexually close due to this confusion. This now seems to be straining any potential relationship between us (with it being holiday period she wants to be close etc) but I don't want to put her at risk. Although I was previously told it was nothing to worry about I am worried as symptoms have not gone away. Should I abstain from any sexual contact as I have been?

If you deem it useful I will post any diagnosis etc here after visiting the clinic. Unfortunaltey it appears I'll to have to wait until after the holidays.

Thank you very much for your reply and advice it is greatly appreciated. Any further advice will also be greatly appreciated.

[Edward W Hook, MD]

Welcome to our Forum. I'll answer the two different elements of your post- the burring you experienced beginning about a week after your encounter and then the more recent rash.

First the NGU which occurred soon after your encounter.  NGU following receipt of oral sex is almost never caused by chlamydia.  It is thought to result from the introduction of bacteria from the mouth into the urethra.  Whether or not it is a threat to a person's health beyond the local irritation and discharge is unknown and if untreated the problem can resolve without therapy.  NGU (or NSU in the UK) is best diagnosed by taking a swab from the urethra and staining the secretions obtained in this way for white blood cells.  Culture is typically not helpful.  Since your symptoms persist, I would suggest you seek testing at a local GUM clinic.  The tests are best performed if you have not urinated for at least an hour before the specimens are collected.  If you have NGU it is easily treated.  

As far as the lesions you noted 7 weeks following the encounter, this is most unlikely to be herpes.  HSV typically occurs 4-14 days following exposure an when it occurs there are typically small blisters which are present for up to 2-3 weeks.  The lesions you describe occurred later than would be expected for HSV and o not sound to have had a typical appearance.  I would ad that most exposures to partners with HSV, even if lesions are present, do not result in transmission of infection.

There are many process which can cause the sort of red mark you mention an most of them are not STDs.  If you visit a GUM clinic I would ask the clinician you see there to evaluate this mark as well.

I hope these comments are helpful. Please let us know how your visit to the clinic turns out.  EWH