STDs Expert Forum
Your guidance for long standing issues, please!
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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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Your guidance for long standing issues, please!

Male 49 yrs un-circumcised, had unprotected vaginal sex , m/m kiss, foolishly (sexually active wmn) 2.5 yrs ago on trip to Asia. Not realizing risk, continued nrml sexual life with wife there after.
4 wks ltr online Std tests came –ve on  NG/CT NAA urine, and RPR, Hsv,Hiv on  blood. 6wks, some itching on penis glans (glands) (ignored).  At 2mo, 2 days of fever sore throat(pcp gave zithro). At 3mo left testicular pain(pcp gave levoquine 10days then ok).  At 5mo, both wife and I had itching and burning (tried monstat).
At 6mo- burning 2cm inside urethra afr passing urine. Uro did urine culture –ve, urine NAA for NG/CT, mcoplasm/UreaPlasma and hsv, -ve. tried 1 month doxy then ok.
12mo-acute lowerback and extended to hip joint, CT done, no urinal stones, prostate normal size. At 15mo,  urthra burning agn, penis pain.  Uro gave 2nd doxy for a month then ok. Occational WBCs and trace of bld at Uro visits.
At 21 mo, unexplained two rash bumps turned to 2 skin lesions on upper shoulder & neck and lymph node on back neck swelled. Pcp confirmed lymph swelling and gave Azithro.  2 pain sores of 10mm  formed with very thick black scab for a month long.
At 21mo, noticed excessive white discharge from my wife and a white dried like powdery coating in vagina
Now at 2 .5 yrs, morning found a gray cloudy watery discharge wetness from penis followed by clumpy sml thick light yellow/white discharge,  pcp confirmed puss cells in the urine, but urine is –ve for NG/CT NAA, -ve urine culture, -ve hsv. Seeing the pic of my discharge, Uro thought it is Trich and gave Flazyl.
Till now, cnst. mdrte lower mid back pain,  on off warm liquid filled sensation in urethra, some clr discharge (my foreskin covrs and extnd beyond glans (glands)),  intrmitnt mild/mdrte burning aftr passng  urine, one time thick discharge.
1.Does this expln trich
2. What bothers me most is unexplained  skin lesions, resem DGI pics. Is it DGI?
3. Givn all this what do you suggest from here,please
Welcome to the forum and thanks for your question.  Here are some general comments before I respond to your specific questions.

Your age:  STDs are quite uncommon beyond age 30.  The reasons aren't entirely clear. but probably they involve lower risk based on how and where people select partners; the nature of those partners; and immunity due to past infections.  Whatever the reasons, STDs are quite uncommon in people your age.

STD persistence:  It is rare for any STD to continue for more than a year after acquisition, other than the obvious ones like herpes, HPV, syphilis, HIV, none of which is consistent with the symptoms you describe.

Your specific symptoms:  Most are not consistent with any STD.  The only exception is the more recent urethral discharge, etc. However, this could easily be due to prostate gland problems, which are common at your age.  I doubt trichomonas explains the problem -- and if it does, probably it didn't originate with the distant past sexual exposure you have dscribed.  Om amu case, neither trichomonas nor any other STD causes "lower mid back pain,  on off warm liquid filled sensation in urethra, some clr discharge (my foreskin covrs and extnd beyond glans (glands)),  intrmitnt mild/mdrte burning aftr passng urine...".

For all those reasons, I am quite confident that neither your symptoms nor your wife's have anything at all to do with your sexual indiscretion 2.5 years ago.  DGI is not even a remote possibility, and I'm sure your skin lesions are unrelated to both your genital symptoms and your past sexual activities.

My advice is that you continue to work with your personal physician; that you ignore your past sexual exposures in relation to any of this; and stop worrying about STD.  That's clearly not the problem here.

I hope thse comments have been helpful.  Best wishes--  HHH, MD
Thank you so much for your guidance and truly believe your expertise.
While I was  on Flazyl 2 weeks back, the 3rd day I had a rash like red bites/redness  on the glans (glands) and disappear the next day. Also had burning  urine that time. My spouse who was also on the same medicine complained of the burning around 3rd and 4th day, later she is ok. After completing the flazyl for 10 days, a week back we had unprotected sex.
Yesterday and today I noticed a gooey like clear discharge from my penis 3hrs after the previous urination in the afternoon. Morning I had minor itch on my tip and foreskin and lots of sticky wetness around the foreskin when I woke up. My penis is sensitive and has minor pain. I am worried what to do next. I do not have the urologist appointment until next week. I can see my PCP but he is not sure what it might be. I would like your guidance what should we  look for. Thank you so much for your expert guidance and framework.
Broad-spectrum antibiotics like metronidazole (Flagyl) can trigger genital yeast infections, which might explain your symptoms (especially if you are uncircumcised) and your wife's as well.

Your discharge should be professionally evaluated. Aside from appearing after urination, is it sometimes triggered by bowel movements?  Either way, this suggests a prostate gland problem.  There's no special hurry; this doesn't sound at all serious and I'm sure no harm will come with delaying until you can get an appointment with the urologist.

Let me know the outcome after you have been professionally evaluated.  But I won't have anything more to offer until then.
Thank you very much for your guidance doctor. I went and saw a urologist this week.He checked my urine and clearly said that I had WBCs in it. I also showed my discharge wetness surrounding foreskin and he agrees that. He also did quick ultra to check prostrate, which is normal size. He said he is clueless. Only thing he wants to make sure is AFB culture in the morning urine which I gave. I doubt I have that because my blood test few months back was negative.
Apart from one time morning white discharge as noted above a month back, still today I am noticing clear discharge and making my foreskin wet and kind of sticky (my foreskin extends beyond my glans (glands) and closes like a ballon neck). Some times stinging feeling in the tip of urethra, burning on glans (glands), sensitive penis and minor pain. Previously, I have single bump of 1mm comes and disappear once a month on the same spot. Just to complete, I had been having  milder lower mid back pain from a year. My Qs now:

1. Now I am so confused and frustrated, what are my next steps. I am worried about my  discharge. Your guidance in this regards will be most valuable to find some solution.
2. Assuming I have HPV in my urethra (based on the history of bumps on the glans (glands)), does this cause clear discharge from urethra?
3. My previous PCP looked for micoplasma hominis culture, but based on your readings, that should be genitalium. should I test for that and treat that.
4. Finally if you were my treating doctor, what would you suggest for my next steps?

I really value and salute your enormous excellence in this field and appreciate your expert guidance. Thank you so much.

Thanks for the follow-up.  I don't have much personal experience evaluating patients in your circumstances; when we have patients with this sort of problem in the STD clinic, we refer them urology.  To your specific questions:

1) I'm a little surprised your urologist only did a rectal examination to assess your prostate.  The usual approach would be a "3 glass" urinalysis:  the initial half once of urine, a midstream specimen, and a specimen after massaging the prostate.  If prostate massage produces fluid, that also is examined for WBC.  The number of WBC in the 3 or 4 samples can help localize the problem to the urethra, prostate, or bladder.  You might discuss this with your urologist, and if he seems uncertain about this approach, perhaps you need to see a different one.  You have no recognized STD and I am confident the present problem is unrelated to your sexual exposure in Asia 2+ years ago.

And although I said trichomonas is unlikely, I gather you only had one try of treatment with metronidazole (Flagyl).  Metronidazole isn't always effective; sometimes higher doses or treatment with tinidazole (Tindamax) works better.  So you could talk to your doctor about a repeat trich test (be sure it's the Gen-Probe company's Aptima trich test), or another trial of treatment.  Also, maybe a trial of treatment with moxifloxacin (Avelox), which is recommended for persistent NGU that may be caused by Mycoplasma genitalium.  (Actual testing for M gen is still a research tool, not commercially available in most places.)  But don't get your hopes up about either of these appraoches; I doubt they will make any difference.  Whatever is going on, I doubt it is any STD or other infection from your sexual encounter over 2 years ago.

2) HPV is not a possible explanation for the symptoms you have.  Even if you were to test positive in your urethra for HPV, I would say the same thing -- an asymptomatic HPV infection plus some other cause for your continuing symptoms.

3) M. hominis is not known to cause urethritis.  As noted above, M. genitalium can do so.

4) I would refer you to a urologist, and I would expect him or her to undertake the sorts of evaluation I have suggested above.
Thank you so much doctor  for your kind help and guidance. I will certainly followup up with my Urologist for the 3 glass suggestion. I have few clarifications based on your answers.
1. You suggested to take Gen-probe Aptima trich test? Should I take urethra swab or morning fist catch urine?, which is most accurate?
2. If I were to take another round of trich treatment what dose and period of trinidazole should I try? should my wife be given as well?
3. Again If I try moxifloxacin, what is the standard treatment for this like, dosage and period (should my wife be treated as well, incase)
4. I am not very clear from your answer for point 3, "-- an asymptomatic HPV infection plus some other cause for your continuing symptoms". Please clarify me if HPV can cause this
5. One last question, if any fungal could be a cause for my symptoms because my suger levels recently gone up (a1c test = 6.0)

Thanks you so much for your kind hearted support.
1) Urine is preferred.
2) On reflection, I would modify my advice:  get tested for trich, but not treated.  If the test is positive (which I doubt it will be), then both you and your wife will need to be treated.  As for specific doses of either tinidazole or metronidazole, these should be up to your (and perhaps your wife's) doctors.
3) Specific dose and duration of this also will have to be up to the doctor prescribing the drug.  Online experts are not substitutes for direct care.
4) Even if you tested positive for HPV, it would not mean it is the cause of your symptoms.  HPV isn't an issue for you.
5) Fungal urethritis or prostatitis are uncommon, but I cannot say with 100% certainty you don't have it.

That will have to end this thread.  Take care and good luck.
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University of Washington
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