Persistent Urethritis and Testicular Pain

[aaa2006]

Hello Doctors. First, I wanted to thank you so much for all your help thus far. Dr. Handsfield's reassurance has been tremendously helpful in keeping calm.

It's been almost 2 months since my first protected sex exposure and I am still having pain in urination (on a scale of 1 to 10, I would say the pain is about 2 or 3) and pain in left testicle and perhaps epididymis that has recently gone up to a level 4 or 5 on the pain scale. I had trouble sleeping last night because of the pain.

Here are the medications I have take so far:
- May 28 - 250mg of Rocephin (injection) and 2g of Azithromycin (single dose)
- June 16 - One week of Doxycycline - 100mg tablets (twice per day)
- July 12 - 2g of Metronidazole (single dose)

I have been to a couple of urologists and every time I provide my urine sample they're unable to find any WBC. However, last night, I decided to get the AZO test strips, and with all three test strips provided, the result was clearly positive for Leukocytes.

1. What tests should I ask my urologist to do?
2. What should my next course of treatment be? Is it Cipro?
3. Is persistent UTI common?
4. Can stress play a role in my symptoms?

Thanks

[Edward W Hook, MD]

This will be the last answer.  

1.  There is a world renown textbook on STDs edited by Holmes et al entitled Sexually Transmitted Diseases.  There is an entire chapter on prostatitis which, when read carefully outlines the controversies related to the causes of prostatitis.  It may confuse you.

2.  Bacterial prostatitis is curable but can take repeated therapy to accomplish cure. You need to get yourself a good urologist and commit to working with them.

This ends this thread.  You have no reason to worry about STD.  Hopefully at some point you will come to believe this.  EWH

[aaa2006]

Thanks so much Dr. Hook. I am really confused about the cause of my bacterial prostatitis. Most of the online sources indicate that bacteria like Chlamydia, Mycoplasma, Urea-plasma, Gonorrhea, etc. can indeed cause infection in the prostate - especially for men under the age of 35. (http://www.nlm.nih.gov/medlineplus/ency/article/000519.htm). My semen culture was negative - but unfortunately, it did not include bacteria like Chlamydia, Mycoplasma, and Urea-plasma. What's really worrying me is the result of the semen analysis. It looks like my sperm count and sperm motility are both low -  I am now extremely depressed. I have completed 14 days of Levaquin with very minor improvement and just started a course of Augmentin. My urologist said that after treatment that my sperm count/motility should be normal again.

1. Can you point me to articles or reports that rule out STD's as the cause of prostatitis?
2. I know that this is not the urology forum, but from your experience, is bacterial prostatitis curable? How long does it take? As you can imagine, I am entering an extreme state of depression.

Thanks

[Edward W Hook, MD]

Prostatits is not an STD. while I do not doubt that you ahve prostatitis if the urologist says so, that you got it following the sexual encounter you describe is coincidence, nothing more.  EWH

[aaa2006]

Hey Dr. Hook. I just came back from the urologist's office and I was diagnosed with prostatitis. The prostate exam confirmed that I have an inflamed prostate and I was prescribed Levaquin for 14 days.

I guess I did end up catching a bacterial infection from my encounter - but not Chlamydia or Gonorrhea. I just hope that my prostatitis infection resolves - as I have read about severe cases in which the prostate had to be removed to relieve the patient from the agonizing pain.

[aaa2006]

Thanks so much Dr. Hook. I appreciate all your help. I hope my symptoms will just fade away as I try to relax and work with my counselor.

[Edward W Hook, MD]

Sorry, I forgot to comment on your HSV test.  You are correct that a blood test at 23 days is not conclusive however testing at that time would detect over half of infections and in the absence of other reasons to think this might be herpes, is storng evidence that this is not HSV.  EWH

[Edward W Hook, MD]

Herpes really would not appear to be a consideration here.  Herpes does not cause testicular pain or pain on urination unless lesions are present. Furthermore, even the initial outbreaks of HSV last less than 3 weeks and it sounds to me as though your pain has been present for longer than that.

HSV can cause WBCs in the urine, typically it also causes lesions which you do not describe.

I really see no reason or potential benefit from a trial of valacyclovir. There really is little to suggest HSV in what you have described. EWH

[aaa2006]

Dr. Hook. Thanks so much for quick and detailed response. I actually started seeing a counselor - my next session is on Friday.

The problem is that I am definitely encountering these physical symptoms - i.e. I don't that it's just in mind.

I just have a couple of follow up questions:
1. Is it possible that my symptoms are caused by HSV-2?
2. Would an HSV-2 infection cause WBC to appear in urine?
3. Should I try to take Valtrex and see if my symptoms subside?

My last test for HSV I/II was at 23 days after the exposure - so the negative result is not conclusive.

Thanks again for all your help.

[Edward W Hook, MD]

As you know, Dr. Handsfield and I share the forum.  You got me this time so I will try to alleviate your concerns.  FYI, the reason we share the forum is because we have worked together for nearly 30 years and while our verbiage styles vary, we have never disagreed on management strategies or advice to clients.

Pain is a very subjective symptoms and can be profoundly influenced by one's state of mind, including guilt, shame and anxiety, all of which I sense may be contributing to excessive vigilance on your part, as well as possibly repeated self-examination.  As Dr. Handsfield has told you, you had what amounts to a NO RISK exposure and need to put it behind you.  You have been tested and (unnecessarily) treated for STDs.  Furthermore, given the choice between a microscopic examination performed in a doctor's office and the AZO strips you mention ( I am not familiar with these but all such strip tests typically have false positive tests as an important limitation to their use), you should believe what the doctors have told you.

My honest advice is to seek counseling help to move forward rather than repeatedly seeking medical care.  If you persist in seeking care, this will sooner or later lead you to a doctor who will perform unneeded tests and procedures out of frustration or provide you with unneeded therapy "just in case"  (which can really be translated as "I don't think you have anything but maybe if I treat you you'll stop worrying", an approach which is common and not in your best interest).  Thus, in answer to your specific questions:

1.  I see no need for further testing
2.  I would not treat you unless there was objective evidence that you need it- a positive culture or visible WBCs
3.  No, not in 26 YO men.  It is rare
4.  Absolutely.

I hope my comments will be helpful to you. EWH