Discharge

24 year old Male. Chlamydia at age 20. I have been tested for HIV, Chlamydia, Gonorrhea and Syphilis many times over the years. Always negative. A blood test revealed I am positive for Herpes 1&2, but I have never had visible symptoms. In the last 3 months I have been to the doc 3 times because of a clear discharge and slight burning when I pee. The Dr. diagnosed me with non-infectious urethritis and cured me with doxy. It reoccurred 3 weeks later. The second time she diagnosed me with UTI. Cirpo cured it this time. It's back again. I am pending another urine test before she gives me more treatment. Let me make it clear I do NOT have an STD per her diagnosis and neither does my gf. She also referred me to an urologist. When I pee in the morning the stream is weak (spraying and coming out in ribbon like form), but corrects itself after I'm a little more awake and often mid stream.. My Gf has a milky discharge, and has had for it years (before meeting me). She was diagnosed with bacterial vaginosis 6 months ago at the STD clinic and has no history of STDs. We are monogamous.

My questions are:
1. Do you think I have a urethral stricture? This terrifies me.
2. Are my UTI/uretrhitis infections coming from her bacterial vaginosis?
3. What are the chances I have prostatis?
4. Could I have herpes in my urethera cuases these symptoms?

I have a Urology appointment Wednesday. I am worried they will try to give me a cystopsopy. I have read about this procedure and concluded it makes matters worse. I am I wrong?

Thanks for your help.

[H. Hunter Handsfield, M.D.]

Persistent or recurrent urethritis after an initial episode of nongonococcal urethritis (NGU) is a difficult and vexing problem for patients and doctors alike, but it isn't dangerous.  To answer your questions one by one:

1) I doubt urethral stricture, a rare condition that to my knowledge has never been clearly shown to be due to past chlamydia or nongonococcal urethritis (NGU).  However, the urologist probably will take a more detailed history about your symptoms and measure your urine flow before proceeding to cystoscopy.  But if you do have impaired flow (which could be due to things other than stricture, such as genital warts inside the urethra), cystoscopy isn't such a big deal (see below).

2) No male counterpart of BV is known, but conceivably could occur.  Using condoms consistently for 2-3 months might be wise.  Presumably her BV has been treated, by the way; although recurrences are common, most cases can be controlled.  Also, trichomoniasis could be a cause of your symptoms, and is often confused with BV.

3) Many doctors fall back to a presumed diagnosis of prostatitis in cases like yours, but actual prostate infection probably is uncommon.  But somewhere along the line, prolonged antibiotic therapy (3-4 weeks), which is indicated for prostatitis, should be part of your management if urethritis continues.

4) Although I doubt you have intra-urethral herpes, it is a slight possibility.  Usually the dominant symptom would be prominent pain with little or no discharge.  But see the closing paragraph below.

5) Cystoscopy is no big deal; not something you would do for hoots, but little pain or discomfort with proper anesthesia.  (I have had it myself.)  It wouldn't make your problem worse.

Assuming there is no overt evidence of urethral obstruction and cystoscopy isn't immediately necessary, I would do the following: 1) Examine both you and your partner to confirm her diagnosis of BV and treat her again, if necessary; and to make sure she doesn't have trichomoniasis.  2) Treat with metronidazole (Flagyl) for a week--as recommended by CDC as the first step in treating NGU that persists or recurs.  3) If symptoms continue, treat with 3-4 weeks of doxycycline or with a quinolone antibiotic (probably levofloxacin, convenient once-daily dosage).  If urethritis persists or recurs after all that, then it may be wise to reconfirm your HSV blood test result (see several previous strings on this forum about HSV blood tests) and perhaps culture for HSV from your urethra when your urethritis is active.  And maybe then cystoscopy.

It sounds complex and will take some time--but the likelihood that something really serious or dangerous is going on is extremely low.

Good luck--  HHH, MD