Persistent NGU? Stricture? Something else? What to do?

[Flagstaff_Fella]

Still dealing w/issues after unprotected oral + sloppy protected encounter w/2 sex pros on 5/20/07:
• 6/18: 1st spontaneous discharge after urination, crystallized stain in shorts
• 6/21–8/03: Spont dischrg persists after urination, rarely cloudy. Swollen penis on first 2/3rds starting at base, spilt/spraying urine, dull aching pain behind pubic hair, feeling like can’t empty bladder. Symptoms better in morn.  Pain/Distract = Mod to High. Trtment: 1) Azith + Cipro 2) Doxy 3) Metronidazole
• 8/04–10/14: Spon dischrg replaced w/clear, stringy/stretchy fluid post urination when penis irritated/swollen. Resembles superglue & stretches 2ft from tip of penis. Large amnts prior to ejac (slimy like astroglide but don’t think its precum). Wet ejac appears clearer/snottier & dry ejac has shiny,crystallized look. Ejac doesn’t shoot out w/same force. Still some swelling, urine split/spraying most after erections but better. Stream shaky @bottom, but full. Tested NEG f/everything except HSV1 (high IgM).

1) Moxiflox (Avelox) prescribed on 8/03. W/symptoms still there (but getting better) take it or wait more? Risks?
2) What is the clear, superglue-like fluid? Discharge?
3) My penile swelling seems unique. Can swelling occur from inflamed urethra? or is “swollen penis” more assoc w/something else?
4) My leading theory is STRICTURE b/c of swelling & split urine. Likely/Unlikely?
5) Can persistent NGU last 4 mos or would it have resolved on its own by now? Just residual inflam?
6) Prostatitis: If my NGU was caused by mycoplasma or ureaplasma couldn’t these pathogens move up my urethra to prostate? Uro won’t sample prostate fluid so how 2 rule out?
7) Does HSV1+ result (with high IgM of 7) mean anything?  How test f/HSV1 in urethra?  Likely or unlikely to cause probs?
8) Masturbation: How often f/people with NGU? Does body need time to heal?
9) Cystoscopy? 10/29 appt. Based on improving yet persistent symptoms, yes or no? More harm than good?
10) When can I resume unprotected sex?

[H. Hunter Handsfield, M.D.]

Sorry, I really cannot help much.  If we had a patient like you in the STD clinic, we would have referred him out to a urologist long ago, and I have little direct experience with patients with your sort of complaints.  Whatever is going on, and whether or not the problem started with an STD like NGU, that's not the problem now.  You may or may not have persistent inflammation of the urethra or prostate--but if you do, after the antibiotic treatmetns you have had, it cannot be due to any continuing inflammation.  Presumably you are under the care of a urologist (nobody else would suggest or schedule cystoscopy); s/he is the best person to respond to your questions.  Or, if uncertain about his or her expertise, ask for referral for a second opinion.

Addressing those specific questions that I can respond to:

4)  HSV IgM testing never is useful, whether positive or negative.  (Search this forum for "herpes diagnosis" and "IgM" for many discussions about it.)  In any case, there is nothing in your story that suggests an HSV infection could be responsible for your symptoms.

10) Since you cannot have a transmissible STD, I see no reason that you cannot resume unprotected sex, without danger to you or a partner.  But you should also check with your urologist about this.

Sorry I can't be more helpful.  Best wishes--- HHH, MD

[Flagstaff_Fella]

I appreciate your response but it doesn't help me much at all.  My urologist (Stanford grad) and PHP are very uninformed and my HMO won't let me seek outside help.  For example, I had to convince my PHP to give me a type-specific Herpes test after he assured me there was none.  The urologist had never heard the terms "adenovirus" and refused to test me for mycoplasma & ureaplasma.  Isn't there anything else you can provide to any of the other questions? Let me refine them.

1) I'm sure what I have started with NC-NGU.  Do you ever see cases of NGU producing symptoms that include swelling of the penis (first 2/3rds) and splitting & spraying of the urine stream?  Is this usually something else?

2) You say I cannot have a transmissible STD.  Why is this exactly?  How can you be sure this stretchy glue-like fluid coming from my penis is not infectious?  Do you have any guess or idea as to what this might be?

3) I've read the studies, both past and ongoing that show Moxifloxacin can address persistent NGU if Azithromycin + Ciproflaxcin (single dose), Doxycycline & Metronidazole have all failed.  I just don't want to pump my body full of another antibiotic if unneccessary.

4) Would persistent NGU resolve on its own by now? (4 months after first symptoms)

[H. Hunter Handsfield, M.D.]

I reassured you nothing dangerous is going on.  Sorry you don't find that useful, but I can't help that. The science is the science; I'm only the messenger.

1, 2) Persistent symptoms don't necessarily mean continuing infection.  When several antibiotics don't work--especially after 2 or more drugs of different classes each with its own with activity against a broad range of bacteria--the usual reason is that an infection is not the cause, not that something resistant to all the antibiotics.

3) There is no reason to believe moxifloxacin would be any more effective than ciprofloxacin; they are active against pretty much the same bacteria.  Anyway, you tried moxi and it hasn't worked!  Why would you think more would help??  

4) I don't know that you have persistent NGU.  Most likely not.  But PNGU probably usually clears up in several months, and it's probably harmless anyway.

Accept the reassurance and move on.  I won't have any further comments.

[Flagstaff_Fella]

Thanks for the response and the answers. I truly do appreciate you taking the time. Just to clarify, I was prescribed Moxi but never actually took it because my urologist had prescribed Levaquin but I convinced my PHP to prescrip Moxi instead.  After reading about the harmful effects of too many antibiotics I opted against the Moxi until I got an answer from you.  I would have clarified this more if I wasn't limited to 2,000 characters when writing my note.  Just an FYI... I've been waiting for months to write this note (in hopes I'd finally get some better answers) and it took me a long time to truncate my message to the 2,000 character limit.

So no thoughts at all about the clear, stretchy glue-like fluid?  You've seen this type of fluid before?  This was my biggest concern of all the things that have gone on with my body because it has been there since the symptoms got worse and won't go away.  Thanks again.

[monkeyflower]

Clear, stretchy, glue-like, Astroglide-like fluid when you're aroused sure sounds like pre-ejaculate to me... :-)

[H. Hunter Handsfield, M.D.]

Levofloxacin (Levaquin) and moxifloxacin are pretty much equivalent and not much different from ciprofloxacin.  (See the "floxacin" in all of them?  That's a clue to their similarities.)  There is little chance either would work better than the other.

The "sticky" fluid dishcarge doesn't change my overall assessment.  If anything, it sounds benign:  "clear" usually means no infection and nothing serious.  If there were significant infection, the discharge would normally be more like pus or at least cloudy, not clear.  Whether or not that symptom bothers you most, in itself it doesn't suggest a particular diagnosis and does not suggest a serious health problem.

It sounds like you were pinning unrealistic hopes on my opinion.  It is rare that online advice provider can do better than a personal health care provider.  As I said in my original reply, I don't even take care of patients with this sort of problem--I refer them to urologists.

[H. Hunter Handsfield, M.D.]

For an ongoing dialog, please use the STD support forum.  Thanks.