Herpetic Urethritis?

[goingnuts505]

Hello Dr:
I'm a male, 31, and I had a brief (20-30 sec) unprotected oral sex in May - afterwards found out she had a sore throat.  
30 days later noticed a dribble of clear mucoid-type discharge after urinating. My mind turned to the oral sex.  I had no pain on urination nor did I notice this happen again.  June 14, swabbed (ouch) for gonorrhea and chlamydia. Treated with Suprax & Azithro? After the swab, felt a bit of lingering pain in urethra for about a week or two - nothing excruciating.  Upon neg results 25th - irritation subsided. July - sex with condom 1x - no symptoms that month.
On August 7th, I noticed irritation again and kept looking inside urethra to make sure I didn't see any changes.  I did this often during month of Aug. Looked normal though seemed a bit red.  It also seemed to be 'sticky' when prying the urethra open as opposed to how it is after urination.  Urethra does appear to have a whitish, shiny hugh with flashlight.

Aug 7-Present - Irritation off and on throught day.  Urine showed trace of blood but everything else was fine. First urinalysis had the same. Dr. said was normal.

Sept 12, noticed small bubbles in urine - dipped toilet paper in and lifted out and saw clear mucus hanging from the paper! Have psoriasis on the head and part of shaft of penis that causes small plaques but I have not noticed any change in this skin, or any blistering ever. The pain seems to wax and wane and it's never painful during urination only a mild ''irritation'' afterwards. It's aggravated by sitting and mainly irritation at the tip of penis. Also noticed itching my scrotum in the night more. prostate was checked by digital rectal exam - 'fine'.  
1. Does this sound like herpetic urethritis?
2. What do the lesions for herpetic urethritis look like?
3. Would anything show in urine tests to indicate hsv? WBC, Leukocytes
4. If not HSV then what the heck is it?
5. Could all the 'self exam' have caused all this? Cause blood in urine?

Thank you!

[H. Hunter Handsfield, M.D.]

Any shampoo or soap in the urethra is very irritating, resulting in painful urination for a day or two.  But I'm not aware that psoriasis ever involves the urethra, so I doubt that is the explanation.  Your dermatologist should know for sure.

Having a little completely clear mucus in the urethra from time to time is not abnormal, especially if you notice it mostly in the morning (it could be pre-ejaculate fluid related to normal nocturnal erections) or during bowel movements (prostate secretions being squeezed out by straining and from feces passing over the prostate gland).  You might discuss these possibilities with your doctor.

In any case, it seems to me it is time for you to move on, secure in the knowledge you have nothing that you caught from the oral sex event, nothing that can ever harm you, and nothing that can be transmitted to a sex partner.

[goingnuts505]

Thank you so much for your prompt and informative reply.  

If I may ask:

If this doesn't clear up shortly, what path should I take and what other possible issues could this be?  Seeing that a number of physicians including now you think this is not an infection - yet it is still symptomatic... I'm pushing for a referral to a urologist but my physician is reluctant at this point.  (strange?)

Also, I had used a tea tree oil shampoo on the area one day and it burned like fire for a few seconds.  Is it possible that it caused some lasting effect?  I know it's unlikely but just wondering..

Could this have anything to do with my skin condition (psoriasis)? I know it's not your expertise, but is it probable/possible?

Thank you so much for putting my mind at ease..

[H. Hunter Handsfield, M.D.]

Welcome to the STD forum.  Bottom line:  I doubt you have urethritis at all, and surely you don't have herpetic urethritis.  To the specific questions:

1) No, this doesn't sound like herpes.  HSV uncommonly causes urethritis alone; usually there is obvious evidence of herpes skin lesions on the penis at the same time as urethritis symptoms.   Also, HSV urethritis doesn't show up a month later; 3-5 days is typical.

2) Herpetic urethritis typically causes more severe symptoms than you describe, with serious pain on urination.  (Some of my patients have described it as the the most painful thing they ever experienced.)  And usually there would be obvious penile blisters/sores, or open sores visible in the urethral opening.

3) HSV urethritis would show WBC, but so would any other urethral inflammation.

4) Your symptoms are consistent with garden variety nongonococcal urethritis (NGU), but lack of response to the antibiotics is good evidence against it.  So is the month delay in symptoms; NGU usually has an incubation period of 7-14 days.  Given the lack of response to antibiotics and the late onset of symptoms, my guess is that you don't have any infection at all -- and your symptoms probably have nothing at all to do with your oral sex encounter.  Also, a completely clear discharge usually is not caused by an infection anyway.

5) Self exam?  If you are vigorously massaging your penis to look for discharge, it might be the cause of mucus.  I have never heard of this causing bleeding, but I suppose it is possible.

Whatever is going on, there is nothing to suggest anything serious. I doubt you have anything you caugt from the oral sex event, or that could ever cause any kind of important health problem, or that could ever harm a future sex partner.  My advice is to keep your hands off and sit tight for a few weeks.  Probably the symptoms will clear up.  This doesn't sound like anything to worry about.  But of course continue to work with your personal health care provider if you remain concerned about it.

Regards--  HHH, MD