Need opinion on NGU

[infected_1]

Hi Doctor

I'm a male, married with kids, I have HVS-1
History:

Initial Event - Had unprotected oral sex and then protected (with a condom) vaginal sex with a woman I don't know very well.

Day 2 - Had unprotected vaginal sex with my wife.  I recall the urge to frequently urinate on this day.

Day 5 - I begin to notice a discharge from my penis.  It was thin and clear but would dry to a yellowish color in my underwear.  When I would check my penis there was no discharge evident, even  with milking, but as the day went on I could feel my underwear were wet and spotted.  

Day 6 - I give a urine sample to the lab where they perform a NAAT test to check for gonorrhea and Chlamydia
Day 7 - The test results are negative for both gonorrhea and chlamydia

Day 8 - My GP takes a urine sample and examines it for elevated WBC's, which is negative. I'm given  250 mg Ceftriaxone and a 10 day  prescription of Doxy

Day 14 - 7 days completed of the Doxy treatment.  I returned to my GP for a check up because I'm still experiencing a sharp/ stinging pain in my urethra that lasts a few seconds. The tip of my penis at the opening is sensitive and it causes discomfort when it rubs against my underwear.  I still have the frequent urge to urinate.

Symptoms:

Prior to antibiotic treatment -  Frequent urge to urinate, clear discharge that dried yellow in underwear,

After 7 days of antibiotic treatment - Frequent urge to urinate, periodic sharp/ stinging pain in the urethra that lasts a few seconds, discomfort at tip of penis when it rubs against my underpants.

Questions:

1. Assuming this is NCNGU, what is the likelihood I could have passed this onto my wife based on th facts above

2. If a person contracts NCNGU, how soon after exposure are they contagious and able to pass it on to another person?

3. When will it be safe to resume sex with my wife?

7. If symptoms do not resolve what do you suggest?  

Thank you

[H. Hunter Handsfield, M.D.]

This not an issue that any STD expert can resolve -- even in person, let alone impersonally or online.

"f I can't get well, there is really nothing left for me" is a nonsense line.  YOU HAVE SYMPTOMS, NOT DISEASE.  YOU HAVE NOTHING THAT WILL EVER HARM YOU OR A SEX PARTNER.

This thread is over, and I ask that you not post a new question about it on this forum.  There is nothing more we can do.  Nobody should ever, in any circumstance, look for definitive answers to health problems by online searching or forums.  I suggest you stop trying.

[infected_1]

Doctor,

I know I've probably tried your patience and exhausted this thread but please read on, I'm in serious trouble.

Treatment:

250 mg Ceftriaxone
Doxy (10 days)
1g oral azithro
Moxifloxacin (8 days)
Cipo (1 - 500mg tab)
250 mg Ceftriaxone
Gentamicin (80 mg)
Erythromycin (7 days)
Bactrim (14 days)

I'm still having frequent urge to urinate and discharge.  Urologist did a CYSTOURETHROSCOPY and said it's not a urological problem and sent me back to my GP.  My GP says there is nothing left for him to do after all the treatment.  I'm in uncharted territory here Doc and everyone has given up on me.  My wife (soon to be x-wife) has said she doesn't have any symptoms but was treated anyway.  

It's been 3.5 months post exposure and as a leading STD expert, I need your input desperately.  It's a matter of life or death for me.  I've lost my family and now it appears I've lost my health as well.  If I can't get well, there is really nothing left for me.  Can you please give me your thoughts on what this could be and what direction you think I should start looking in in terms of treatment, etc.  Do you feel I'm still contagious with the discharge (it still dries to a yellowish color in my under pants).  Please, any input would be much appreciated.  

[H. Hunter Handsfield, M.D.]

No apology necessary; and of course I understand your concern.  Your situation is a daily one for any STD professional.  Good luck.

[infected_1]

Doctor,

I want to apologize for being so freaked out.  I hope you can understand the predicament I was in.  I discussed this with my wife and she went to get checked out and treated.  Thank you for your advice.  

[H. Hunter Handsfield, M.D.]

My only other advice is to consider seeing a urologist.

kt84 is mistaken.  Having a vasectomy has no effect on discharge or other symptoms of urethritis.  Quite impossible, given the anatomy.

That's definitely all for this thread.  Sorry I can't help further.

[kt84]

I believe discharge does not occur or is different or restricted if you have a vasectomy. I am not saying a vasectomy means you will not get an STD, just that it affects your symptoms with discharge.

[infected_1]

Dr

I know you said this was the end of the post, but I believe I’m now in uncharted territory.  The Moxiflox is not working and I believe that was the last line of antibiotics prescribed for my condition based on your responses and research I’ve done.  My GP is not an expert on STD’s, as it was I who brought to his attention that we should give Moxiflox a try.  

1.  Is there any other line of antibiotic treatment once Moxiflox has failed
2.  Do you believe this is no longer an STD/ STI issue and maybe it’s urological?  

I appreciate any response you may have as I’m lost at this point and have no clue what the next course of treatment may be and my GP is stumped.  

[infected_1]

Doc

Thanks for your comments and help!

[H. Hunter Handsfield, M.D.]

The persisting abnormal discharge (as indicated by the underwear stains) suggests you NGU has not cleared up.  Your doctor apparently is quite knowledgeable about STDs, since he knew to prescribe moxifloxacin -- which is the CDC recommendation for NGU that persists after both doxy and azithromycin.  The chance it will cause significant toxicity is quite low.

Continue to follow your doctor's advice on this.  There's not much more I can do here.

[infected_1]

Doc

I have been examined again and had another UA done.  Everything was normal, however I still have the symptoms of sharp shooting pain the urethra and discharge.  Again, there is no discahrge to be see upon examination, but my underpants have a bunch of yellowish stains at the end of the day.  I've taken 10 days of doxy and took 1 g Azithro orally.  I'm now on Moxifloxacin for 14 days.  

What are your thoughts on my diagnosis of non chlamydia NGU after falure of Doxy and Azithro?  

Also, do you think the Moxiflox is necessary?  I'm terrified after reading all the potential side effects and reading reviews on-line.  Many people who have reviewed the drug seem to experience bad side effects.  I would rather not take it, but I do want to get better.  

Also, there has been no chance for reinfection as I've abstained from sex since my treatment started.  

[H. Hunter Handsfield, M.D.]

1) Probably safe once the discharge has been gone a few days, but still best to wait until all symptoms resolve; or if they continue, after you have been professionally reevaluated to check for persistent urethritis.  If and when you return for reevaluation, try to avoid urinating for several hours (preferably 4 or even 6 hours) before you are examined.  That's the best way to assure an accurate assessment of possible scant discharge or WBC in the urethra.  You may need to cut way back on fluid intake, or arrange a visit early in the morning, having held your urine overnight.

2) Single dose oral.

3) In general, nobody should go to a doctor and request a particular test.  Describe your symptoms and let the clinician decide.  If you're uncertain about his expertise in this area, you could print out this thread and discuss it with him.

Don't wait until you are reevaluated for your wife to be examined and treated.  The sooner the better on that.

That will do for the follow-up comments, unless and until you are examined and have more to report.

[infected_1]

Doc,

Thank you for your answers.  I have just a few more questions.

1.  When you said I should not have unprotected sex with my wife until symptoms clear up, did you mean all symptoms, even the urge to urinate?   It's not safe to assume that a full 10 days of doxy treatment cleared up any infection?  

2.  The azithromisyne treatment is a one time oral treatment or is that an injection?  How soon should it begin working?

3.  After I complete my 10 day treatment of Doxy, and I sitll have stinging pain and discomfort at the tip of my penis, should I request a swab test or do you feel it wouldn't be fruitful after Doxy treatment?  

I do apologize for the continuing questions, but it seems you answer spur more thought and in turn more questions.  Thank you for taking the time to answer.  

[H. Hunter Handsfield, M.D.]

You continue to ask intelligent and common-sense questions.  Unfortunately, the answers are not necessarily clear.

Urine testing for WBC isn't helpful in diagnosing urethritis.  The way to accurately look for WBC in suspected urethritis is to microscopically examine material from a swab of the urethra itself.  Your symptoms of discharge, especially with yellow staining of underwear, is sufficient evidence to be certain you had urethritis.  The negative gonorrhea test confirms it was NGU.  (The negative chlamydia test was predictable.  Chlamydia is rarely if ever acquired by oral sex.)

Your experience with oral sex at home, but NGU after oral sex by another partner, probably is common.  The reason(s) are not known.  Perhaps the urethra becomes acclimated to the bacteria in a regular partner's mouth, but not to different strains carried by other people.  And there are at least occasional instances of NGU in monogamous couples, whether acquired by oral, vaginal, or anal sex.  Such infections probably do not "ping pong" back and forth between partners, but this too isn't known for sure; never studied.  Most of what we know about nonchlamydial NGU is based on the clinical experience of STD experts and common sense; there has little research, and almost none on transmission risks or adverse outcomes in affected men's partners.  As it happens, I have published on exactly this topic -- i.e. the frustration that many STD experts (and their patients) feel about the lack of knowledge and need for research about NGU (Handsfield HH, Sexually Transmitted Diseases 2011 Feb;38:70-3.)

Sorry the answers aren't clear, but that's the state of the art (and science).  Lacking certainty, and with at least a strong theoretical chance that partners could be harmed or that the initial patient could be reinfected, partner treatment is universally recommended.

[infected_1]

In addtion, why is it that bacteria from a new sex partners mouth will cause NGU but it's not likely that bacteria from a regular partner will cause NGU.  I've been with my wife for many years and recieve oral from her regularly, but never contracted NGU.  I addition, if you do catch it from your regular partner, is it possible to pass it back to her if left untreated?

[infected_1]

Doctor

Even with all my negative test, you still feel it's NGU?  Does the lack of elevated WBC's indicate there is no infection present?  

[infected_1]

Thank you for the answer.  You're correct, this is not what I was hoping to hear.  

[H. Hunter Handsfield, M.D.]

Welcome to the forum.  Thanks for a very clear description of the problem and questions.

The diagnosis of nonchlamydial NGU is clear and your symptoms typical except for slightly early onset (usally 7-10 days, but 5 days isn't rare).  You probably acquired it by the oral exposure, since vaginal was condom protected.  You were treated "by the book", covering both gonorrhea (ceftriaxone) and chlamydia plus the other largely unknown bacteria that cause NGU (doxycycline).

Your continuing symptoms don't worry me very much at this stage.  Your discharge apparently has cleared up, and it often takes quite a bit longer for other symptoms to completely resolve.  Your current symptoms are consistent at least in part with an anxiety component, especially the sense of urinary urgency and frequency.

However, nonchlamydial NGU persists or recurs in about 20% of men.  If your current symptoms continue more than a few more days, or if abnormal discharge reappears, you should return to your doctor for possible retreatment.  When doxycycline is used initially, repeat treatment with azithromycin is recommended.  Sometimes a drug against trichomonas is included (metronidazole or tinidazole), but trich is unlikely from oral sex.

Those comments respond to question 4.  To the others:

1,2) There are no data on infectiousness of nonchlamydial NGU, especially when acquired by oral sex.  However, based on experience with gonorrhea and chlamydia, it is assumed you could transmit the infection immediately after catching it.  Therefore, you should assume you exposed your wife, and she should be treated.  Some (most?) cases of NGU from oral sex may result from normal oral bacteria, which might not cause harm in a partner's gential tract.  However, we do not know this and the standard recommendation of all experts is that your wife needs examination and treatment.  I'm sure that's not what you wanted to hear, but I see no way around it.

3) You should avoid unprotected sex until your symptoms clear up -- or, if they persist, you have been retreated as suggested above.  And you should avoid unprotected sex until your wife has been treated -- otherwise you might be reinfected.  The actual risk of reinfection in this circumstance, i.e. NGU from oral sex, is not known -- but this is the standard recommendation for NGU management.

I hope this helps.  Best wishes--  HHH, MD