Gonorrhea-like symptoms several months after possible exposure

[dumdum1000]

I had unprotected oral sex and protected vaginal sex with a sexworker in October 2008.  This is my only sexual encounter outside of my marriage.  I had shaved my genitalia a few days earlier and may have had one or two small nicks on my penis.  In February 2009 I experienced gonorrhea-like symptoms (penile tingling, milky discharge) for several days.  I had no symptoms before this. I had a comprehensive STD test and all came back negative and symptoms recided.  Now at the end of March I am experiencing similar symptoms.  I am going in for another STD test but have several questions:

1.  Is it typical for symptoms to not manifest for 3-4 months from exposure?
2.  Is it common for gonorrhea/chlamdyia to be transmitted via oral sex (female to male)?
3.  Is it possible that I have an NGU since my first STD tests came back negative?
4.  Can gonorrhea/chlamydia symptoms manifest episodically?
5.  Is it really possible to contract an NGU non-sexually (looking for a reasonable cover story here)?
6.  If this is a NGU and not gonorrhea/chlamydia, does my wife need to be treated?

THANKS!

[Edward W Hook, MD]

Your situation and circumstance is unusual in many ways.  While gonorrhea can occur following receipt of oral sex, it is not common.  Similarly, it is uncommon for the symptoms of gonorrhea to occur after so long.   Finally, if you had gonorrhea, it would be uncommon for your tests to be negative.  I will preliminarily answer your questions below but I also have several questions for you.  these include:

1.  Were you treated when you had symptoms in February?  With what?  Did you improve with treatment?
2.  Was your wife treated after you had the onset of symptoms
3.  Were you tested before you were treated or after you had started treatment?
4.  Have you taken any other antibiotics between your October exposure and now?
5.  When you are sexually active with your wife, does she perform oral sex on you?
6.  Do you have any other health problems?

As for your current questions:

1.  No, it is uncommon.
2.  For all practical purposes, chlamydia is not transmitted by oral sex.  Gonorrhea and NGU can follow oral sex however.  We see a fair amount of it.
3.  Possibly, I will answer further when I hear answers to the questions above.
4.   No, not following treatment
5.  Yes.  More on this after your answers
6.  Yes, it is best to err on the safe side.

Loooking forward to your answers to my questions.  EWH

[dumdum1000]

Thank you very much.  Here are answers to your follow-up questions

1. No treatment in February. I did not seek as STD tests were all negative.  After those results my symptoms receded and I chalked it up to pyscho-somatic manifestations of guilt.
2.  Wife was not treated.
3.  Again, no treatment.  I did provide the urine sample in the morning however.  I had urinated upon waking at home and provided the sample approximately one hour later.  not sure if that has any bearing.
4. No antibiotics
5. Wife performs oral sex rarely and not that I can recall during sex since October which has been infrequent (less than 6 times).
6.  Generally healthy.  I have had a urine leaking issue for the past year at the end of uniration.  Have to shake vigorously and wait several seconds to make sure I have fully drained.  PCP checked prostrate and found negligible enlargement.

[Edward W Hook, MD]

Thanks for the follow-up.  Several additional comments based on your situation.

You tests have proved that you do not have gonorrhea.  It is not normal however to have penile discharge.  I presume your doctor say increased numbers of white blood cells present either in a swab test or in your urine.  If so, then you have NGU.  NGU should be treated.  While some NGU is caused by chlamydia, some is not.  No matter what is casuing it, to be safe, both you and your wife should bbe treated., either with azithromycin as a singe 1.0 gram dose or with doxycycline 100 mg twice daily for a week. EWH

[dumdum1000]

Thank you.  One final question if I might.  nonsexual sources of NGU are possible, correct?

I have read that UTIs, prostate infections, catheterization, and foreskin issues can result in NGUs.  Only the first two could be applicable to me.  Saying a UTI can cause an NGU seems to me like one is saying the same thing twice, an infection is an infection.  I know male UTIs are uncommon, but they do happen.  Might a prostate infection also explain my leaking issue over time such that these symptoms are actually not related to my October indiscretion?

Thanks again.

[Edward W Hook, MD]

You are correct, things other than STD do cause NGU although sexual acquisiton of infection is most common.  The starting point of care however, no matter what the cause is for you and your GF to be treated.  Prostate infections can cause similar symptoms as can UTIs.  UTIs and NGU, in general are somewhat different however in terms of what causes them, whether or not partners are treated and other management issues, thus the disticntion is a real one and important to health care providers.  EWH

[dumdum1000]

OK -- so it appears that I have nonchlamydial NGU based on negative tests for chlamydia and gonorrhea but WBCs in my urine.  Was treated with 1g Zithromax.  I have read in other posts here that nonchlamydial NGU does not cause health problems in women.  Does that mean she cannot contract PID from nonchlamydial NGU or any other major health problem?  If that is true, then am I correct in assuming that my wife does not need treatment to address any health concerns for her per se but rather to prevent her from reinfecting me?  Is it safe to assume that if I was negative for chlamdyia and gonorrhea there is no way she could contract either from me?

Thanks again.

[Edward W Hook, MD]

If you are negative for chlamydia and gonorrhea then your wife cannot get them from you.

As for nonchlamydial NGU, there is no clear lik=nk between this problem and adverse health outcomes in women, mostly becasue it has not been studied very well.  Do you want to take the chance?  If at all possible, just to resolve all of this once and for all, I would hope that you could both be treated.   Remember, with non-chlamydial NGU, since we don't know what casues it, we don't know that it is an STD.  Rather than mess around, you'd both be served well to get treated.  EWH

[dumdum1000]

Thank you.  Your feeback has been unbelievably helpful  I have what I hope is one final question.  The instructions for Zithromax 1000mg for oral suspension call for dissolving in 2 oz. of water, consuming, adding an additional 2oz of water and consuming.  Can the 1000mg be dissolved in a larger volume of water or other liquids (nonalcholic) without diminishing its effectiveness?

Thanks again.

[MLWTR]

My apologies if I'm misinterpreting your words, but the tenor of your last posting sounds as if you may be considering giving Zithromax to your wife without her knowledge by dissolving it in some other liquid you will offer her to drink. I understand you may be unwilling to reveal your sexual indiscretion to her, but please rethink this course of action, if it was indeed your intention. Not only would it be highly unethical and unfair to your wife, it could also exposure to risk if she has any medication allergies or is taking any other medications with which the Zithromax might interact.

[Edward W Hook, MD]

Facts first.  The azithromycin can be suspeced in larger volumes of liquid.  The amounts specified are minimal amounts.

I also need to register my concern as well that tryig to sneak medication into your wife is not a good or ethical idea.  EWH

[dumdum1000]

I understand and appreciate deeply these comments.

[dumdum1000]

I had 1g Zithromax last thursday and symptoms lessened over first few days but are now re-emerging, raising concern that it is in fact gonorrhea despite the negative test for such in February.  My wife had 1g Zithromax this am (tough conversation) and is complaining of strep throat-like and flu-like symptoms (headache, joint pain).  Could those symptoms be the result of gonorrhea and will the Zithromax address adequately?  I understand such symptoms may be a sign of sphyillis which is unlikely given my exposure pathway (unprotected oral sex).

What is the probability of my February test being a false negative?

This forum has been unbelievably helpful.  Thank you!

[Edward W Hook, MD]

We have discussed this repeatedly and at this point I have little more to say other than to congratualte you on making sure that your wife was treated.  The symptoms you are expereincing are non-specific and are almost certainly not due to gonorrhea.  Between the large number of antibiotics you have taken and your negative tests it is simply beyond the realm of possibility that this is gonorrhea or, ofr that mattter any other STD, including syphilis.  I really ahve nothing more to say.  Your problem has reached a degree of complexity that it really should be address through face-to-face interactions with your own health care provider.  Take care.  EWH