mystery urethritis

[RPVpmvj]

Hello,

unprotected oral/protected vaginal sex with high risk stanger.

~7 days later, dysuria at onset of urinating, but subsides over duration of urinating.
no obvious discharge, but subtle clear dribbling.
lymph nodes on right side of groin moderately swollen/tender.

~3 days after onset of these symptoms, negative test for chlamydia/gonorrhea.
asked doc about other "minor" organisms. doc replied: "“minor” organisms that can cause urethritis and are sexually transmitted like mycoplasma genitalum are picked up by the screening test."
so negative for everything covered by this screening test.
doc described meatitis as "impressive".

over these past few days since doc visit, urethritis seems to have worsened, meatitis is more obvious.
couple lymph nodes on right groin became severely swollen/tender. now seem to be subsiding somewhat but still swollen/tender.

dysuria is no longer sharp at onset of urination, subsiding throughout.
dysuria is now constant (perhaps even worsening) throughout urination.
urine streams to the left when pressure low.
subtle clear dribbling, perhaps slightly more viscous than urine, remains.

pain is near urethral opening, does not go deeper than head of penis. sensitive to touch (shaking of penis after urination, rubbing against pants, etc.).
sometimes pain in head of penis even when not urinating.

today-- 3rd day since doc visit-- symptoms seem steady, not particularly improving. not particularly worsening either other than aching type pain following urination and even random other times.

no noticeable external lesions.


what could this be?? what should i do??

[Edward W Hook, MD]

Welcome to the Forum.  I'll try to help.  The timing and symptoms you describe certainly seem to raise the possibility of urethritis.  I am not sure what sort of "screening" test your doctor did.  Was it on a specimen obtained using a swab or in a urine specimen?  If it was a urine specimen, was it in a first void specimen or midstream?  From your history, i would expect there to be signs of inflammation present- white blood cells at least if a swab test was taken.  

It is also not clear to me from your question whether you have received any treatment or not.  Even though the gonorrhea and chlamydia tests are negative, I would worry about other organisms- perhaps Mycoplasma genitalium or trichomonas.  An outside possibility is that this is herpes urethritis but that is very uncommon without external lesions as well.  

At the very least, given your continuing symptoms, you need further evaluation-optimally by an experienced clinician who can do additional tests.

I hope this is helpful.  I may have further comments based on your answers to my questions. EWH

[RPVpmvj]

After urethra swab last week, doctor's email today: "HSV culture is positive for type 1. The treatment should clear the infection."

[Edward W Hook, MD]

Yes, the New Orleans Helath Department's Delgado STD Clinic is superb.  EWH

[RPVpmvj]

Ok. How do I go about finding one of those? Do you by any chance know of anyone in New Orleans?

[Edward W Hook, MD]

I think you need to see a more knowledgable clinician who can perform some of the tests I suggest earlier, as well as consider other causes of your symptoms. EWH

[RPVpmvj]

I took the 1000mg Azithromycin & 400mg Cefixime Saturday around 3pm.

The only thing I really noticed was a significant increase in the dribbling type discharge over the next 12 hours or so. I don't know if this is maybe a good sign, the result of whatever's in there being killed, or maybe a bad sign of worsening infection or something.

Saturday night through Sunday night dysuria remained but perhaps improved slightly.

However, this morning's first urination was just about as painful as ever.

This is all I've noticed...

[Edward W Hook, MD]

I'm afraid your experience indicates that the health care providers you have seen are not well versed or perhaps equipped to evaluate and care for persons with possible STIs.  It sounds like the tests they performed included a urine test for gonorrhea and chlamydia (very accurate, the results will be reliable) and a urinalysis which is a general test for clues to kidney, bladder and penile problems but will be unlikely to help sort this issue out.  They then treated you with pretty good therapy which will cover gonorrhea, chlamydia and NGU.  I suspect there is a good chance that the treatment will help- if it does not, you need to see someone who can do the tests I originally suggested- a swab test from the penis for herpes and to look at under the microscope.  

You are correct and more up to date than the providers who you saw regarding treatment of urethritis.  For about a year and a half the CDC has not recommended cefixime, suggesting instead use of a small shot of a drug called ceftriaxone.

At this time, having been treated, you should see if the treatment helps.  If it is going to work there should be at least some improvement in 24-36 hours.  If still not helpful you need to see someone else.  Please let me know how you are in a day or so.  EWH

[RPVpmvj]

(Urination is now more painful than ever. 8-9 out of 10 I'd say.)

[RPVpmvj]

(so-- this screening test they used does not seem to test for any specific pathogens, just general signs of infection or something like that.)

[RPVpmvj]

Just returned from doctor. They reran same first void urine screen test that was negative Tuesday, this time it was positive for "a small amount of blood in urine (no red visible in urine) and some sort of elevated protein level? Also, I noticed some sort of white particulate matter in urine sample.

They also sent urine to be cultured and analyzed by PCR for chlamydia/gonorrhea, as well as cultured for "bacterial infection". I guess that means bacteria other than chlamydia/gonorrhea-- all she gave as a specific example was E. coli.

I'm going back to see the men's clinic doctor this Tuesday (same doctor I saw initially, this past Tuesday) for test results, follow up, etc.

In the meantime, the doctor today prophylactically prescribed 1000mg Azithromycin and 400mg Cefixime.

I see however that the CDC "no longer recommends oral drug for gonorrhea treatment"

http://www.cdc.gov/nchhstp/newsroom/2012/GCTx-Guidelines-PressRelease.html

They say, "This change leaves only one recommended drug proven effective for treating gonorrhea, the injectable antibiotic ceftriaxone."

Should I be concerned by this?

[Edward W Hook, MD]

Thanks for the update,  It does not change my assessment or advice however.  EWH

[RPVpmvj]

This morning the dribbling appeared cloudy for the first time.

So even though the last antibiotic was taken the day before this sexual contact, the antibiotic still could've had an effect preventing sexually transmitted bacterial infection?

I'm going back to student health center right now, hopefully they offer this swab/PCR testing.

[Edward W Hook, MD]

Thanks for the clarification.  All of the antibiotics you have taken make it unlikely that this is a bacterial STI.  I do think you need further evaluation and my bias is that you would be better served with swab tests than a urine test.  I am still a bit unsure as to what screening test was performed.  I would consider going to some one or a clinic which specialized in STI diagnosis.  

In evaluating this I would consider doing a swab test for herrpes PCR testing rather than a herpes blood test.

As far as this being a non-STI problem, that is certainly a possiblity and is beyond the scope of this Forum. Working thought this with your doctor would be the way to go.  

I do think you need to see your doctor again and would suggest you do so sooner than later.  EWH

[RPVpmvj]

Dr. Hook,

Thank you for the rapid response.

It was a first void urine specimen. All else I know about this test is that

-he said it was negative for chlamydia/gonorrhea
-when I asked about the sensitivity he seemed highly confident that this was not a false negative given ~10 days since contact
-his response to an email I later sent him asking about other "minor" organisms: " “minor” organisms that can cause urethritis and are sexually transmitted like mycoplasma genitalum are picked up by the screening test."

The meatus certainly appears inflamed. It is red, puffy/swollen, and painful. Nothing was swabbed though.

I have received no treatment, presumably because this screening test was negative across the board. He said drink plenty water and acidify urine by drinking cranberry juice, etc. in order to ease pain. He also said come back in a few weeks for herpes blood test for the same outside possibility you mentioned.

Also, the day before this risky sexual contact I had just finished a 7-day course of Levofloxacin for a respiratory infection. Directly before that I took a 10-day course of Amoxicillin/clavulanic acid and about a month before that 5-day Azithromycin, both also for the respiratory infection.
This may be paranoid, but the thought arose that perhaps residual Levofloxacin during/soon after risky sexual contact selected for something worse.

Anyway, symptoms are indeed continuing, if not worsening somewhat. I will go back to see him as soon as possible. Is there any scenario in which I should seek urgent care?


Additional tests could determine if this is something not-yet-detected that is treatable by antibiotics? Would the antibiotics I've taken recently affect this?

What about viruses other than herpes?
What about something else entirely / not sexually transmitted?

If it is something not treatable by antibiotics, what should I do? Is there anything I can do to help it generally in the meantime?


Thank you so much again.