Penis: bacterial infection/sores and not STD?

[annwantstoknow]

Can a man have two relatively large open sores on his penis and it not be an STD?

His ex-wife had herpes before they dated. From what I see on your site, it was probably a type 1 breakout; she never had breakouts during their 9 yr marriage. Divorced 5 years. No girlfriends.

Six months into monogamous relationship with me: we have sex at the tail end of my period and it feels a little grainy to him (in areas that did not later develop sores). I had no symptoms but had self-treated successfully for a yeast infection 3 weeks prior (diflucan). The day before my period started, I got lymph nodes in my neck (sore) that took several days to go down, no other symptoms.



Day after we had that slightly granular feeling sex, he felt some tingling when urinating, and wondered if he'd irritated his urethra with soap. Two days later the tip of his penis looked red and sore. A day after that, two sores appeared, one on the top of his shaft and one on the other side, not folliculitis. These sores looked big...the red circle about the size of a dime, with an open wet area in the middle. The area around the urethra still looked quite red.



His doctor diagnosed herpes just based on visual inspection (no culture done...grr). Put him on Famvir. Did bloodwork: Herpes AB (Type 1&2) IgM (I know what you think of that), Herpes Simplex IgG, Herpes AB Type 2 IgG. All negative. BF started to get a discharge. Doc put him on single dose Zithromax. Couple days later, things looked a lot better (ten days from start of symtoms). Then all clear.



Four days into his symptoms, I got a thick white discharge, my doc saw clue cells, put me on Flagyl. Chlamydia test negative. No signs of STD.



No problems since all that except that BF complains of chafing on each side of the underside of his shaft during intercourse fairly often. No sign of yeast, though, and normal otherwise.



So my doctor told me today that it is extremely unlikely that the symptoms I describe in my BF would NOT be an STD. She said it would be "awfully unusual" if it weren't (though she said maybe if his immune system was lowered and he was "susceptible". He did get shingles on his waist 5 months prior). But my BF claims complete faithfulness. He's a quiet geek type, healthy, no meds, 41 yrs old. These sores looked pretty nasty, seriously. We are NOT talking about a couple pimples. Is it possible for a man (good hygiene, circumcized, hadn't changed soaps, no spermicide or other irritants) to develop an infection like this out of nowhere? How is it possible? We do have some trust issues, and this is something that concerns me. If there is a way he could get something like this nonsexually, I'd be relieved. I'm going to ask him to see if he can get a HerpeSelect test, but if his wife had type 1, then he's probably clear. Thank you.

[H. Hunter Handsfield, M.D.]

The occurrence of genital sores always suggests herpes; it is the most common overall cause of genital ulceration, even when the lesions don't look like classical herpes.  That a physician thought the lesions looked like herpes on examination further increases that possibility.  The best bet is that it in fact is herpes, but not recurrence of his past infection; more likely you have HSV-2 and this was his first infection.  That would explain the negative blood test--not enough time had passed for it to become positive.  If it indeed was intial herpes, then he caught it from you (assuming your belief is accurate that he doesn't have other partners).



On the other hand, it is likely he didn't have the right kind of herpes blood test; we know for sure the IgM results are not helpful, but it is likely the IgG result also is unreliable.  (All IgM HSV tests are unreliable; an IgG test may be reliable or not, depending on what test was done.)



Herpes also can cause vaginal discharge, but it sounds like more than herpes apparently is going on.  Although herpes might have caused your discharge, that's not the best bet; and his urethral discharge sounds like nongonococcal urethritis (NGU).



And there are genital ulcer problems that aren't herpes or STD.  For example, if your partner takes any medications, conceivably he developed a "fixed drug eruption", which is a localized allergic reaction that sometimes involves the penis.  But this is very speculative.



Suggestions:  1) As you already are planning, your BF needs to have a proper HSV serology (e.g., the HerpeSelect test); if negative for HSV-2, it should be repeated after 2-3 months.  2) You need an HSV-2 HerpeSelect test; I won't be surprised if it is positive.  3) To be safe, both of you need syphilis blood tests if not yet done. 4) Perhaps most important, if either of you develops another genital sore, see a provider within 24 hr and insist on a viral culture for HSV, including virus type if the result is positive.



Good luck--  HHH, MD

[annwantstoknow]

I should add that he and I don't see the same doctor. I've seen two different docs at my practice, and both of them refused to do a herpes test on me, saying that a blood test on a woman in the absence of symptoms is meaningless...a positive result might just mean I've been exposed and formed antibodies. I've never had herpes symptoms that I know of nor slept with anyone who has.

[H. Hunter Handsfield, M.D.]

Your doctors are wrong.  There is no such thing as a test showing "exposure" that is distinct from actual infection.  You need a type-specific HSV-2 test.  Either insist your doctor send the test or find another doctor; your two docs' misunderstanding of herpes diagnosis shows they aren't up to speed on STDs and HSV.



HHH, MD

[annwantstoknow]

The only drugs this guy takes are: a baby aspirin, a multivitamin, and an Alpha Lipoic Acid capsule, which supposedly helps him prevent sinus headaches. He has no medical issues and has no prescriptions. Looking up genital ulcers on the web, I see: "Even after complete diagnostic evaluation, at least 25% of patients who have genital ulcers have no laboratory-confirmed diagnosis." So this incident may remain a mystery.



As I understand it, I can carry HSV-2 and have never had symptoms, right? (If I am actually the source of the herpes)



NGU: that is urethritis if gonorrhea has been ruled out. If he had gonorrhea or NGU, would his single dose of Zithromax have wiped it out? Would my course of Flagyl have wiped it out in me? I see that NGU can present in females as excess discharge, like I had.



It seems as if he would have had to have gotten anything like that (NGU, gonorrhea) from someone else, though, right?



I think he and I will have to either go to the health department or planned parenthood to get these tests (like the HSV)...we both have clueless doctors. This incident actually took place 18 months ago...it's just that yesterday was my first chance to talk to my own doctor, which raised these questions. He has not had any sort of outbreak since then. I would think if he got HSV-2 from me and had an outbreak, that he would have had other outbreaks since then, right?



Do you know why he would be complaining so often about being "chafed" during intercourse now, when he never was at the start of our relationship? We use lube.



Thank you!!!

[H. Hunter Handsfield, M.D.]

The 25% rate of undiagnosed genital ulcers is true, but that statistic is based only on tests done from the lesions at the time of presentation; i.e., the studies did not include HSV blood tests either initially or later, and there were no follow-up visits to ask about recurrent outbreaks.  Many (most?) of the unknowns probably were herpes.  But as you suggest, if neither of you has had repeat genital lesions in 18 months, the likelihood it was herpes is lower.  Still I recommend you both have type-specific HSV-2 testing.  However, if both of you have positive results, you will never know for certain which of you brought the infection into the relationship.



Yes, you certainly could have HSV-2 infection, as indicated by a positive blood test, without ever noticing symptoms.  That is the normal outcome of genital herpes; more than half of all people with positive HSV-2 antibody tests have no recognized outbreaks.  But everybody with a positive test has active virus from time to time in the genital area--i.e., asymptomatic viral shedding--and can transmit the infection to previously uninfected sex partners.



As far as other STDs are concerned, it's all in the past and it simply will never be possible to figure out what was going on, who was infected first, etc.  Azithromycin isn't perfect against either gonorrhea or chlamydia, but it really doesn't matter; those infections almost always clear up on their own within a few months.



Sorry, I don't have any thoughts about "chafing" during sex; I'm an STD expert, not a sexologist.



Best wishes--  HHH, MD

[annwantstoknow]

To summarize the answer to my original question:

1) It could have been herpes. Proper blood tests will show.

2) If it was not herpes, and not a fixed drug eruption, then it was either an STD or something else. You said there are other causes for non-STD related genital ulcers. Are there any others you can mention?

Thank you!

[rocky123]

Hi - Syphilis is the other STD that causes genital sores.  That is why Dr. HHH said to make sure you get a blood test for syphilis.  In any case, please wait for his response as I am no doctor.



Good luck.

[H. Hunter Handsfield, M.D.]

1) Yes, it could have been herpes.  But at this point, blood tests may not prove it one way or another.  If negative for HSV-2, you can be pretty certain it wasn't herpes.  If positive, it it would support but not prove that herpes caused the episode you described; a positive blood test can't tell you when infection was acquired.



2) Don't fixate on fixed drug eruption; it was a wild stab.  Your partner's medication history doesn't support that.  In addition to herpes, the main sexually acquired genital ulcer diseases are syphilis and chancroid; the latter is very rare in the US.  There are many other non-STD possibilities, but individually each one is rare.  A dermatologist would be better at listing them that I could be.



HHH, MD

[annwantstoknow]

Do you have a preference between the HerpeSelect Elisa or Immunoblot? It looks like the Immunoblot will test for both 1 and 2 with a single test strip. It looks like it could be more expensive, though, so perhaps fewer labs would have it.



This seems like a good link for comparing tests:

http://www.ashastd.org/pdfs/blood_test.pdf



Ann

[H. Hunter Handsfield, M.D.]

Biologically, the HerpeSelect ELISA and immunoblot are the same test; they just different immunochemical tests to detect the antibody to HSV.  The choice as to which test is best is bascially a laboratory decision - which one will work best give the lab's experience, expertise, and other equipment and technologies available.  Don't worry about which system is used; the results are the same, and equally reliable whether positive or negative.



HHH, MD

[annwantstoknow]

I can't find the answer to this anywhere:

HSV-2 can lay dormant for even years, and suddenly erupt.

Can an HSV-1 infection of the genitals also lay dormant for years before making its one appearance?

[H. Hunter Handsfield, M.D.]

Not specifically studied for HSV-1, but undoubtedly it is rare--although I am sure it occurs once in a while.  Over 90% of people with genital HSV-1 infection have no recurrent outbreaks at all, or just 1 or 2 outbreaks in the next couple of years, then none.  Asymptomatic shedding also is uncommon.



When HSV-2 does this, the infection is not "dormant" between acquisition and the first recognized outbreak.  Almost everybody in fact has outbreaks from the very start; it's just that many of them are not symptomatic.  Therefore, STD/herpes experts would not use the term "dormant" in this context.  The infection is fully active, just not symptomatic.



HHH, MD

[GorgioArmani]

Im 19 yrs. and sexually active. my partener and i have been together for six months and rarely use condoms, i was a virgin into the relationship and my partner wasn't. she had multiple partners but, used protection with all of them and also recieved std and hiv tests during her medical check ups, tests were negative. into the relationship i discovered a tiny little pimple on my penis foreskin, (un circumsized penis. weird thing about it is that i have read about stds and symptons and how the disease grows upon time. my symptoms are none. i have had the little pimple but it doesnt burst,hurt, rash, sore up. when i urinate no pain and no pain while intercourse. I touch this pimple and no pain or burst neither does it look like it grows with yello or white fluid. the size of the pimple id say would be like a typing period ( . ) i was wondering if this would be any type of herpes or std or maybe just a regular acne pimple. i dont discharge out of my penis and i believe to have discoverd the pimple a month and a half ago. and it doesnt bother. neither my girl friend has any that appear like mine either in her mouth anal, or vaginal. just like to know what type of infections or pimples other than stds might this be? ,,,, thank you...

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