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Recurrent NSU
Hello,
I'm a 31 old gay male. Ten days after unprotected anal sex with my partner I had a slight yellow discharge (three months ago).
Went to the ER, where I was given a single shot Cefepime i.m. (if remember correctly the name) and 1g Azythromicin. I had to give a urine sample. Prostate was normal according to Doctor. A week later I was referred to a control visit with an STD specialist. She said that urine test "didn't show a lot" and prescribed Fucidin cream for remaining irritated entrance of urethra. During the weeks after I had a stinging pain while urinating.
Three weeks later, I had strong yellow discharge. Doctor took a smear test of mouth, anus and of discharge / urethra. My partner and I got treated both with a single-shot cefixime/azythromicine in case there was a ping-pong infection. It turned out that there were no chlamydia or gonoccola bacteria present. They found Klebsiella and "some streptococcus". Was treated with 10 days of Amoxcillin+Clavulanic acid as antibiogram showed that amoxicillin was effective.
After that slight pain at the tip of the glans continued. Due to the antibiotics I had a yeast infection of the glans. Took first creams and was then prescribed 1 week of Itroconazole which was effective.
Two weeks without any symptons, except for some soreness of the glans and slightly swollen entry of the opening of the urethra. A couple of days I had a little colorless/clear but sticky discharge. Glans felt slightly swollen. When signs got more intense I went to see my GP who has prescribed me now 10 days of moxifloxacin. Am now on my second day. Symptoms have somewhat improved.
NB: only protected sex in between these symptoms.
My question would be: how likely is it that there would be still any bacteria left to bother me after this treatment? After all the antibiotics I have taken (or am taking right now). I wonder if I just have a recurrent inflammation? What to do if symptoms persist?
I'm a 31 old gay male. Ten days after unprotected anal sex with my partner I had a slight yellow discharge (three months ago).
Went to the ER, where I was given a single shot Cefepime i.m. (if remember correctly the name) and 1g Azythromicin. I had to give a urine sample. Prostate was normal according to Doctor. A week later I was referred to a control visit with an STD specialist. She said that urine test "didn't show a lot" and prescribed Fucidin cream for remaining irritated entrance of urethra. During the weeks after I had a stinging pain while urinating.
Three weeks later, I had strong yellow discharge. Doctor took a smear test of mouth, anus and of discharge / urethra. My partner and I got treated both with a single-shot cefixime/azythromicine in case there was a ping-pong infection. It turned out that there were no chlamydia or gonoccola bacteria present. They found Klebsiella and "some streptococcus". Was treated with 10 days of Amoxcillin+Clavulanic acid as antibiogram showed that amoxicillin was effective.
After that slight pain at the tip of the glans continued. Due to the antibiotics I had a yeast infection of the glans. Took first creams and was then prescribed 1 week of Itroconazole which was effective.
Two weeks without any symptons, except for some soreness of the glans and slightly swollen entry of the opening of the urethra. A couple of days I had a little colorless/clear but sticky discharge. Glans felt slightly swollen. When signs got more intense I went to see my GP who has prescribed me now 10 days of moxifloxacin. Am now on my second day. Symptoms have somewhat improved.
NB: only protected sex in between these symptoms.
My question would be: how likely is it that there would be still any bacteria left to bother me after this treatment? After all the antibiotics I have taken (or am taking right now). I wonder if I just have a recurrent inflammation? What to do if symptoms persist?
MEDICAL PROFESSIONAL
Welcome to the forum. Thanks for your question.
First, so there is no confusion on terminology: nongonoccal urethritis (NGU) and nonspecific urethritis (NSU) are the same thing. NGU is the usual term in North America (and the one I will use in my reply), NSU in the UK and many commonwealth nations.
Second, your symptoms are somewhat more suggestive of gonorrhea than NGU, especially during the second episode 3 weeks later ("strong yellow discharge"). What lab tests were done each time? Does "no chlamydia or gonococcal [infection]" mean microscopically or by a urine or urethral swab test? It also isn't clear to me whether your partner was teated and treated after the first episode, and if so what his tests showed and what treatment he received.
Pending more information, I'll assume the diagnosis was correct, i.e. you had NGU (NSU) both times and neither gonorrhea nor chlamydia during either episode. Your treatment was proper both times, and obviously intended to cover all three likely causes -- gonorrhea, chlamydia, NGU. (Cefipime has not been studied much against gonorrhea, but in a large enough dose should work well.)
Recurrent NGU is a common problem, especially when NGU isn't due to chlamydia, and often a frustrating one for patients and their doctors alike. The specific causes usually aren't known. The sorts of bacteria found in your urine (or urethra) aren't abnormal in men with or without urethritis, and I doubt they have anything to do with your symptoms.
When there has been sexual exposure between episodes, it can be difficult or impossible to distinguish re-infection from relapse. For the first recurrent episode of NGU, the usual approach (recommended by CDC in the US) is if azithromycin was used first time, to use doxycycline the second, and vice versa; and to also treat with metronidazole or tinidazole in case of trichomonas. However, the last probably isn't necessary in men whose only partners are other men; male to male trichomonas is probably rare if it occurs at all.
Herpes is a potential cause of recurrent urethritis, perhaps especially when there is substantial redness and swelling of the urethra -- which it seems you may have. This is another issue for you to discuss with your doctors.
Unfortunately, NGU and its treatment, and especially recurrent NGU, have been systematically studied only in heterosexual men, with few if any studies in MSM. Accordingly, it is difficult to give definitive guidance in cases like yours. I would suggest you discuss all these issues with your doctors, preferably the STD specialist -- then follow her advice.
Perhaps I'll have more to say if you can fill in the gaps discussed above.
Best wishes- HHH, MD
First, so there is no confusion on terminology: nongonoccal urethritis (NGU) and nonspecific urethritis (NSU) are the same thing. NGU is the usual term in North America (and the one I will use in my reply), NSU in the UK and many commonwealth nations.
Second, your symptoms are somewhat more suggestive of gonorrhea than NGU, especially during the second episode 3 weeks later ("strong yellow discharge"). What lab tests were done each time? Does "no chlamydia or gonococcal [infection]" mean microscopically or by a urine or urethral swab test? It also isn't clear to me whether your partner was teated and treated after the first episode, and if so what his tests showed and what treatment he received.
Pending more information, I'll assume the diagnosis was correct, i.e. you had NGU (NSU) both times and neither gonorrhea nor chlamydia during either episode. Your treatment was proper both times, and obviously intended to cover all three likely causes -- gonorrhea, chlamydia, NGU. (Cefipime has not been studied much against gonorrhea, but in a large enough dose should work well.)
Recurrent NGU is a common problem, especially when NGU isn't due to chlamydia, and often a frustrating one for patients and their doctors alike. The specific causes usually aren't known. The sorts of bacteria found in your urine (or urethra) aren't abnormal in men with or without urethritis, and I doubt they have anything to do with your symptoms.
When there has been sexual exposure between episodes, it can be difficult or impossible to distinguish re-infection from relapse. For the first recurrent episode of NGU, the usual approach (recommended by CDC in the US) is if azithromycin was used first time, to use doxycycline the second, and vice versa; and to also treat with metronidazole or tinidazole in case of trichomonas. However, the last probably isn't necessary in men whose only partners are other men; male to male trichomonas is probably rare if it occurs at all.
Herpes is a potential cause of recurrent urethritis, perhaps especially when there is substantial redness and swelling of the urethra -- which it seems you may have. This is another issue for you to discuss with your doctors.
Unfortunately, NGU and its treatment, and especially recurrent NGU, have been systematically studied only in heterosexual men, with few if any studies in MSM. Accordingly, it is difficult to give definitive guidance in cases like yours. I would suggest you discuss all these issues with your doctors, preferably the STD specialist -- then follow her advice.
Perhaps I'll have more to say if you can fill in the gaps discussed above.
Best wishes- HHH, MD
Thank you very much!
MEDICAL PROFESSIONAL
Well, you're a better judge than I can be about whether your symptoms are wholly or partly psychological. If no abnormal discharge is visible and if a test for white blood cells in your urethra (or the first spurt of voided urie) is negative, then a psychological component is very likely.
In any case, don't be worried about the eventual outcome. Recurrent NGU is not known to be serious or to result in any long term health consequences either for affected men or their sex partners. You should look at all this as an inconvenience, not an important health threat.
I think this discussion has gone as far as can be useful for a distant online forum. You're clearly in the hands of a knowledgeable physician, and you have access to an STD clinic. I would advise you to follow their advice.
In any case, don't be worried about the eventual outcome. Recurrent NGU is not known to be serious or to result in any long term health consequences either for affected men or their sex partners. You should look at all this as an inconvenience, not an important health threat.
I think this discussion has gone as far as can be useful for a distant online forum. You're clearly in the hands of a knowledgeable physician, and you have access to an STD clinic. I would advise you to follow their advice.
Dear Dr Handsfield,
thank you very much for your response! I'd like to fill the gaps:
For the first episode only urine test was carried out. After the first episode my partner was neither treated or tested.
When I had my second episode, the doctor took a urethral, throat and anal swab test. While waiting for the results my partner and me were treated both with a single-shot of Cefixim/Azythromycin. He wasn't tested further. My urethral swab test showed Klebsiella and Streptococcus and was tested with an antibiogram (hence the amoxicillin prescription). No signs of gonorrhea for all three swab tests (anus/urethra/throat).
I see how difficult it is to distinguish relapse/re-infection. However, as far as my last episode is concerned, I didn't have sex for three weeks before (we live in a long-distance relationship). This time no test was carried out and I was put straight on moxifloxacin.
I am actually starting to wonder if there is also a psychological element involved, i.e. I'm quite under some job stress right now. I'm also afraid that there might be a "hidden" prostatitis causing the relapses. However, I don't have any problems beyond the symptoms I have described above.
Thank you again for your reply!
thank you very much for your response! I'd like to fill the gaps:
For the first episode only urine test was carried out. After the first episode my partner was neither treated or tested.
When I had my second episode, the doctor took a urethral, throat and anal swab test. While waiting for the results my partner and me were treated both with a single-shot of Cefixim/Azythromycin. He wasn't tested further. My urethral swab test showed Klebsiella and Streptococcus and was tested with an antibiogram (hence the amoxicillin prescription). No signs of gonorrhea for all three swab tests (anus/urethra/throat).
I see how difficult it is to distinguish relapse/re-infection. However, as far as my last episode is concerned, I didn't have sex for three weeks before (we live in a long-distance relationship). This time no test was carried out and I was put straight on moxifloxacin.
I am actually starting to wonder if there is also a psychological element involved, i.e. I'm quite under some job stress right now. I'm also afraid that there might be a "hidden" prostatitis causing the relapses. However, I don't have any problems beyond the symptoms I have described above.
Thank you again for your reply!
MEDICAL PROFESSIONAL
I should have said that it seems your doctors are up to speed on the latest recommendations. Although I didn't mention it above, moxifloxacin (to cover the possibility of infection with Mycoplasma genitalium) is exactly the usual expert recommendation for the second and later recurrences of NGU.
You are reading content posted in the STDs Forum
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