NGU, Gonorrhea or swab trauma?

[greentea79]

Hello Doctors, my thanks in advance for your response and everything else you do here. I am a 31 y/o male who is in a long-term relationship.

After going through a rough patch in this relationship I hooked up with a girl in a club and received oral sex (18 days ago). About 4 days later (2 weeks ago) i then met a girl in a club who I took back to a hotel. She seemed educated and from the upper-middle classes. I put on a condom and proceeded to have vaginal intercourse with her. Upon completion i pulled out and noticed that there was no semen in the top of the condom, and on closer inspection could tell it had ripped at the top. The girl freaked out a bit, and so did I. It didn't look like my penis head was that exposed. She told me she was clean and that her father is a doctor.

4 days ago i decided to go and get tested. The doctor took a swab from my urethra and also a urine test, and tested for chlamydia and NSU. He said they don't test for gonorrhea unless there are symptoms. Fast forward to the day after the test, and I started to feel a tingling in my penis head that feels almost like it is burning. It is not always there, but seems to be whenever I am thinking about it. Then last night, (2 weeks after exposure), I noticed what seems to be a slight discharge from my urethra. It wasn't yellow, but clear and sticky. This morning it was there again, but only slightly. I plan to get HIV tested in 2-3 weeks.

So, my questions are:

1. As the swab was very painful and conducted with a metal instrument (not a q-tip), could that trauma have caused a reaction that now manifests as a type of NGU?

2. What is the likelihood my symptoms are gonorrhea, that the chlamydia test was inaccurate, or that this is another case of genitally-focused anxiety? I have ultimately been feeling extremely guilty about this whole thing...

Thanks again,

b

[greentea79]

thanks doctor, the only reason i posted was because i had the combo test 4 days earlier than you recommended. i will now move forward as you recommend. thanks again

[Edward W Hook, MD]

1. time for you to believe the test results and move forward.
2.  No need for further testing of any sort.
3.  OK at this time to resume unportetected sex with your regualr partner.

Take care.  EWH

[greentea79]

Hi Doctor, just posting results. I went back and had 'test of cure' evaluation after 1 week, and the result was negative for gonorrhea and chlamydia. partner had a full panel and was negative for everything. I also had a combo hiv test at 24 days post exposure (I know this is not the 28 days you recommended but my anxiety got the better of me as my doc wouldn't be available for another week after that date), and just got results that are negative. So: 1. How definitive do you think this result is after 24 days? 2. Do you recommend any follow-up testing at the end of the 3 month window, also for other stds? 3. When do you think it would be ok to resume unprotected sex with my partner?

Thanks a lot for your final help on this.

[Edward W Hook, MD]

Yes, althought the cefixime will probably work, I would suggest you go back and be re-tested. this is called a "test of cure" evaluation.  If your partner was tested and is infected, she should be re-tested. Simialrly, if she was not tested, she should be.  You can both go for repeat testing 2 weeks after your treatment.

HIV testing will provide reliable results at 4 weeks after the exposure if you are tested with a combinaton HIV p24 antigen/HIV antibody test.  If the testing is performed with a test that only tests for antibodies, results will be reliable at 8 weeks after the exposure.  EWH

[greentea79]

i am being treated with cefixime, not cipro. i was diagnosed with a swab and urine test. the discharge did not get worse - in fact it seemed to have pretty much disappeared, but i went back anyway. will it be sufficient to go back in a week to see if the cefixime has worked, before having to take the shot? if it works on me will it presumably have worked on my partner? also, when is the soonest time i can test for hiv, and what is the test that will be effective earliest? thanks

[Edward W Hook, MD]

I'm glad you got re-evaluated.  How was the gonorrhea diagnosed? Did the discharge continue or worsen?

Ciprofloxacin is no longer recommended for gonorrhea therapy and, more recently, the U.S. CDC has modified its recommendations so that an injection (intramusclarly) of ceftriaxone (250 mg) and a single 1.0 gram dose of azithromycin are the preferred recommendation even over the combination of cefixime and azithromycin.  Thus, the cipro MIGHT cure your infection but the ceftriaxone/azithromycin therapy is preferred if possible.  Cefixime plus azithromycin is probably almost as effective but of late gonorrhea has become more resistant to this combination.  If you and your partner are treated with ceftriaxone/azithromycin it should cure pharyngeal gonorrhea if present.

The rash on your neck could be a drug allergy-I'd ask your doctor.  EWH

[greentea79]

hi doctor. well i got tested and the doctor found gonorrhea. he initially prescribed cipro over 7 days, for me and my partner, but i then showed him a post of dr. Handsfield which stated that cefixime with azithromycin is more effective, and just as effective as the IV shot. Will this treatment be effective? i am also worried about having passed the gonorrhea to my partner via oral sex, even though i was asymptomatic at that time.

i have also got a rash on my neck, which is like lots of raised red bumps. could this be anything related?  

your advice would be very welcome. as you can imagine this is very difficult for me.

[Edward W Hook, MD]

Thanks for your clarifications.  The average time for the appearance of gonorrhea symptoms is about 3days.

It sounds like you we're well evaluated and I think your plan to go back to where you were evaluated and talk to the doctor is the proper thing to do.  My impression is that your anxiety may be getting to you but discussing it with the doctor is the right way to resolve this.  EWH

[greentea79]

Hello Dr Hook, thanks for your quick reply.

Answering your question - I was tested in an international health clinic by a western doctor. I received the results of the NSU and Chlamydia test about 2 hours after they were taken (urine sample and swab).

An update on my situation - Today I have not had as much (if any) discharge as was noticed last night. The tingling/numb pain in the head of my penis has been less constant. However, I am still extremely worried about passing on anything to my girlfriend, whom I have unprotected sex with regularly.

Any more input from you will be very appreciated. I plan on going for further testing on monday when the doctor I already saw is back on duty, but I also would like to know your opinion of what these symptoms could be caused by.

I probably should add that I have experienced pretty intense psychosomatic manifestations before. I get a rash on my arm when stressed, and have had an outbreak of small red spots over my pubic area which was not caused by any detectable disease, and which I now put down to simple worry and anxiety. As for my discharge last night, it was similar to 'precum' - sticky but not really yellow, and not too much. So, your comments about the possibility that this is anxiety-related is certainly helpful.

Could you also please tell me what is the average time you have seen gonorrhea symptoms appear after exposure, and what is the upper outlier of that time period? What should I be vigilant for at this point?

Thanks again

[Edward W Hook, MD]

Welcome to our Forum.  I'll try to help.  Let's first provide some perspective and then I'll address your questions.  As you'll see, in some instances you may wish to seek additional information from the doctor who evaluated you 4 days ago.

Your exposures include both a single episode or oral sex and vaginal sex in which your condom failed.  Overall, the risk from these two encounters is low. Most people do not have STDs, most exposures to infected partners do not lead to infection, and the reaction of your partner to the broken condom by your partner suggests that she, like you is concerned about STDs.  These are all good. Further and even more importantly, you did the right thing by getting tested.  At the time you were tested, you can anticipate reliable results from your tests.  

I presume you have not gotten all of your tests results back yet or they are negative and will presume that when they come back, they will be negative.  If this is the case, this is strong evidence that you were not infected.  Even if you were not tested for gonorrhea, if gonorrhea had been present the tests for NSU, which look for signs of inflammation, likely would have been positive and thus provided evidence of infection which would lead to treatment.  

There are several unusual aspects of your story which make me ask questions which may allow me to comment further.  Where were you tested?  Do you know what kind of tests were performed?  Do you have any results yet?

In answer to your questions:

1. As the swab was very painful and conducted with a metal instrument (not a q-tip), could that trauma have caused a reaction that now manifests as a type of NGU?

Urethral specimen collection is typically uncomfortable and more so if the clinician doing so does not regularly collect specimens of this sort.  Residual discomfort, particularly on voiding is not unusual but typically resolves entirely in the day or two after specimen collection.  In some settings rather than use a swab, health care providers use small wire loops to collect specimens, particularly outside of the U.S. and Western Europe where virtually all testing is now carried out using tests which provide small swabs for specimen collection.  This may have been what was used.  Can you tell me if the doctor collected one specimen or two?   If you are still having discomfort and it has not improved more than two days after specimen collection this is unusual and may warrant further evaluation.

2. What is the likelihood my symptoms are gonorrhea, that the chlamydia test was inaccurate, or that this is another case of genitally-focused anxiety? I have ultimately been feeling extremely guilty about this whole thing...

Depending on what test was performed and their results it is unlikely that tests are incorrect but the answers to the questions I asked above will be helpful.  Anxiety may be contributing to this and indeed it is not unusual for men to have a small amount of urethral discharge which can be detected if one looks closely for it.    Further guilt can certainly make us more aware of genital sensations which would not be noticed otherwise.  

I will comment a bit more when I hear your replies to my questions.  EWH