STDs Expert Forum
Recurrent Urethritis
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The STD Forum is intended only for questions and support pertaining to sexually transmitted diseases other than HIV/AIDS, including chlamydia, gonorrhea, syphilis, human papillomavirus, genital warts, trichomonas, other vaginal infections, nongonoccal urethritis (NGU), cervicitis, molluscum contagiosum, chancroid, and pelvic inflammatory disease (PID). All questions will be answered by H. Hunter Handsfield, M.D. or Edward W Hook, MD.

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Recurrent Urethritis

Hello Doctor--

I'm a 42yo gay male.  My sexual practices are limited to unprotected oral (giving and getting) and protected anal sex in which I'm the top.  In the past 13 months I've had 3 bouts of urethritis.  Always starts with a day of very low urine output, followed by a generalized discomfort at the tip of my penis for 2 days or so, then progresses to stinging at the end of urination, then an off-white discharge.  Downright pain at the tip of my penis after a day of bending and squatting for work, with my penis pressing against my underwear.  Saw my PCP the first two times; he cultured by urethral swab (ouch) and treated me with Rocephin IM and Z-Pak by mouth.  Cultures came back negative for gonorrhea and chlamydia first time.  Second time I was surprised that it came back pos for gonorrhea.  The doctor stressed that unprotected oral sex was likely the culprit.  My symptoms disappeared soon after treatment, and I told both my partners who went to be tested (they claim) and turned out negative.  They say they were checked for both urethral AND oral gonorrhea.

It all started again the other day, and frankly I was too embarrassed to return to my PCP for fear he'll be judgmental that I'm continuing to have unprotected oral sex or think I'm having anal intercourse without protection.  I am not, and I inspect the condom afterwards to make sure no break has occured.  I went to an urgent care clinic where my midstream urine specimen was negative.  Doc indicated this meant I do not have a urinary tract infection and that an STD is the obvious cause.  Results of that urethral swab are pending.  He put me on Levaquin 500mg x 7 days.  Discharge gone, urinary stinging all but gone, but still have generalized discomfort after 4 doses.

Questions:
1.  I've read your posts that chlamydia is almost never from an oral source.  How about gonorrhea?  Partners are without symptoms and claim to test negative.

2.  If this current process is neither gonorrhea nor chlamydia, is there any other likely explanation?

3.  Is it possible this is a flare-up from an unresolved prior infection?  If so, what would exacerbate it?

4.  Is this regimen of Levaquin sufficient if it turns out to be G or C?

5.  Do any of my symptoms indicate a chronic prostate infection/inflammation?  Nobody's checked my prostate.  I've never heard that discharge is associated w/prostate infection.

6.  Could rubbing my penis unprotected against the exterior anus of my partner before putting on a condom for penetration infect me with gonorrhea or chlamydia?

7.  Is it remotely possible my symptoms are a reaction to the spermicide in condoms?

8.  Are some guys just more susceptible to others' normal mouth bacteria?

Since I came out at 19, I've had more episodes of this than anyone I know.  All have been negative for GC except the one last Sep.  It's driving me nuts, and the attitude of judgmental docs makes seeking answers very difficult.  Thank you very much.
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I'll try to help. Your question is a good opportunity for another primer on urethritis, oral sex, and related issues.

Your doc is right; oral sex often results in nongonocccal urethritis (NGU) or gonorrhea.  Otherwise normal bacteria from the mouth apparently can sometimes cause inflammation in the urethra.  Overall, about 30-40% of NGU is due to chlamydia; for the most part, the specific causes of the remainder are unknown. Other known causes include a bacteria called Mycoplasma genitalium, and a few cases are caused by herpes and other viruses.  But the specific causes are pretty much unknown for around half of all cases of NGU.

Gonorrhea certainly can be acquired by fellatio, and is particuarly common in gay men. Chlamydia rarely infects the throat and mouth, and therefore NGU from oral sex is rarely if ever caused by chlamydia.

Gonorrhea testing of the throat is imprecise and many cases are easily missed with starndard testing.  Their negative tests do not prove your partners were not infected.  They should have been treated against gonorrhea, based on exposure to you and regardless of their test results.

Recurrent NGU is a common and vexing problem, for both patients and their providers; it almost never is due to chlamydia.  However, I cannot tell whether your recurrent problem represents recurrences or new infections.  At leat one episode, the gonorrhea, was a new infection; gonorrhea treatment failure is rare.

It isn't clear that all NGU recurrences mean infection, or just inflammation/irritation.  In any case, recurrent NGU appears not to be dangerous in any way.  There is no evidence it ever leads to urethral stricture, epididymitis, infertility, or any other complication in men, and no evidence that it causes disease of any kind in a person's sex partners.

You would be wiser to stick with a single provider, preferably your PCP.  It sounds like he is pretty knowledgeable about STDs, and therefore will understand the issues about recurrent NGU--and thus will understand it doesn't imply you are being untruthful about your safe sex practices.

That answers several of your questions.  To the others:

4) Levaquin is active against chlamydia and gonorrhea, but at this time you probably have neither of those.  The drug also is active against most NGU of unknown cause.

5) Theoretically, your symptoms could reflect prostatitis.  But that is a grossly over-diagnosed condition; it is a "wastebasket" diagnosis, that is a name many providers attach to otherwise unexplained urethral discharge, including recurrent NGU.  True prostatitis probably is not a common explanation.

6) Non-penetrating penile-anal contact carries a very low risk, but I cannot say it is zero.

7) I doubt spermicide is a cause.  But you should stop using condoms with spermicide.  Nonoxynol-9 and other spermicides tend to increase STD/HIV risk, not decrease it.

8) Conceivably some people's urethras indeed are more susceptible to symptoms from oral bacteria.  This has never been studied.

The last thing I will add is that you might consider using condoms, even for oral sex, for several months.  Perhaps you are in a cycle that might be broken if you stopped allowing the potential for urethral infection. In addition, although the risk of catching HIV is low, in the presence of urethritis your risk undoubtedly is higher than it otherwise would be.  You should be sure you know your partners are HIV negative, especially if you continue to have unprotected exposures.

Good luck-- HHH, MD
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Thank you, Doctor, for the very well-written clear explanation.  I feel a little better.  Am I understanding correctly that symptoms--including discharge--can be caused by inflammation/irritation without any bacterial cause?  I'll take your advice re. sticking with my PCP and condoms for oral sex for a few months.
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