Urethritis Confusion

[NYCBoy]

I am a gay male. 1 month ago I performed and received oral sex with another male, unprotected. About 5 days later I noticed some mild anal itching (which promptly went away) and some testicular discomfort. 11 days after the encounter I was tested for gonorrhea and chlamydia. Both tests were negative.

Later that week I felt some slight pain at the tip of my penis and the testicular discomfort continued. I was tested again for both and both were negative, but I was prescribed 2g of zithromax. The symptoms never got better, but also did not get initially worse.

Almost 2 weeks later, and 29 days after the unprotected oral sex, I noticed a very mild clear/white discharge on the inside of my underwear, but never dripping from my penis. I went to the doctor again. This time he prescribed doxycycline for the next 7 days. The cultures have not come back from this test.

I am in a relationship and have had unprotected sex with my boyfriend in the meantime, but he is completely asymptomatic and has not had sex with any other partners. My tests have all been negative and my symptoms have been mild, so we resumed sex after each negative test.

Here are my questions:

1) Is it possible that I had/have one of these STDs, but was still testing negative?

2) If it is not an STD, do you have any ideas what it might be?

3) Is it possible that doxycycline will catch things that the zithromax did not.

4) Is is possible to have one of these STD is one location (i.e. penis, anus) and not the other, or do they all areas of possible sexual intercourse?

Thanks

[H. Hunter Handsfield, M.D.]

Of course there was no way to acquire an anal STD by mutual oral sex. If you had an anal/rectal infection, it had to predate the exposure you describe in your question.  The urethral symptoms suggest nongonococcal urethritis (NGU), for which the cause is not known for sure in 70% of cases and therefore STD tests show up negative.  Sometimes NGU probably is due to normal oral bacteria. So even if you had it, you might have picked it up from your regular partner.

1) You don't say what sites (urethra? rectum? throat?) were tested, but you can rely on the negative results.

2) See above re NGU.  I have no guess about the cause of your anal symptoms.  The most common cause of localized anal irritation is called pruritus ani--but that fancy names literally means itchy anus, and it says nothing about the cause.  
Any number of minor conditions, as well as STDs (e.g., herpes) can do it.  I cannot even guess; seeing a provider is the only way to sort it out.

3) No, doxy and azithromycin pretty much cover the same bacteria.

4) You only catch STDs at the site of sexual exposure.  You cannot get a rectal STD by oral or genital exposure, for example.

Most likely all is well, but follow up with your health care provider if symptoms persist or you remain concerned.

HHH, MD

[NYCBoy]

Is there any reason that you can think of that the azithromycin would not have eliminated this bacteria?

I forgot to mention that the testicular pain became markedly worse (though still not extreme) around the time that I noticed the discharge. My concern right now is that I completed a cycle of antibiotics, but the symptoms only increased.

(Also, because it wasn't clear...I had urethral/anal/oral cultures and the first test and a urethral swab for the second. The second and third tests I was told there was "inflammation", but at least the second test still came back negative.)

[H. Hunter Handsfield, M.D.]

There are several possible reasons azithromycin might not have worked. Maybe you had a virus, which no antibiotic can affect.  Maybe some organism resistant to it.  Whatever the reason, 10% of the time either azithromycin or doxycycline doesn't work completely, then the opposite drug is used.  The main thing for you to know is that except for gonorrhea and chlamydia, probably no serious health outcome results from this sort of problem. It's a pretty minor deal with few or no long term consequences for your health.

See the last sentence of my reply above.  I have nothing else to add.

[NYCBoy]

It has been a week since my post. I have completed my doxycycline, but the symptoms have not lessened at all. There is still quite noticeable pain in my testicles and a very mild burning when I urinate. All of my most recent tests have come back negative.

If this is a virus, what could it be? All the research that I have done on my symptoms indicates a bacteria, but these antibiotics have not made any change.

I realize that at this point it is not a cause for serious concern, but the symptoms persist with no end in sight and I just don't know what to do about it. I've been to the doctor 3 times, and clearly something is off. I don't want to overreact to this, but I also want to this pain to go away.

[H. Hunter Handsfield, M.D.]

No virus causes symptoms that persist this long.  And if it were a bacteria, the symptoms would have cleared up on doxycycline.  Something else entirely explains your symptoms.  Definitely no STD explains it.  Sorry I cannot be of more help.