Oral Sex Painful Urination Perhaps NGU

[MiniB]

The facts start back 10-14 days with 2 episodes of receiving oral sex from escorts. Approximately 6 days following the 2nd event I developed severe burning with urination and an itch inside the head of my penis. Urine flow is strong, however, it initially sprays in multiple directions. In the beginning I didn't have discharge

I am currently on an extended business and leisure trip with friends and colleagues. One person is a physician and I confided in him for guidance. He told me that STD from oral is unlikely yet it does happen. He also said my symptoms are consistent with a urethitis ranging from gonorrhea to NGU to non sexual bacteria. He prescribed a single 400mg dose of Suprax and two 500mg doses of Cipro. He then suggested a one week course of Doxycycline Hyclate or Avon(sp?). He told me the Suprax/Cipro would treat potential gonorrhea and  Doxycycline would cover NGU and other non sexual bacteria. I have a weeks supply of Cipro, however, he told me it wasn't necessary
I took the Suprax and Cipro last night. In the middle of the night I went to urinate and noticed a clear substance covering my opening. It was very slight, however, could be described as a clear perhaps sticky discharge. It has not returned today. I am still experiencing painful burning urination. I need to start the Doxycycline Hyclate and/or Avon today.
My concerns:
1. What is the likely cause of my urethritis, perhaps gonorrhea, NGU or other reason
2. Whether my treatment is appropriate for gonorrhea, NGU and other bacterial causes. Should I take the Doxy and/or Avon
3. When can I expect improvement with my symptoms
4. I steadfastly use condoms for vaginal intercourse. When can I resume this activity
5. As a general rule are condoms an effective means of preventing bacterial STD transmission for both men and women
6. When I complete the course of antibiotics am I still at a risk of infecting others with condom protected intercourse
  
Your time and courtesy are appreciated

[H. Hunter Handsfield, M.D.]

I agree this is suspicious for reactive arthritis.  However, it is equally likely your urethritis was caused by adenovirus, which is responsible for ~5% of NGU, especially when acquired by oral sex; and adenovirus most commonly causes head colds with conjunctivitis.  Since RA is rare and adenovirus common, the latter seems a better bet.  However, if the back pain becomes severe and/or you develop other sore, inflamed joints (not just aching), then RA would be a more serious consideration.

If your symptoms persist, stop relying on your doctor friend and get proper profesional care from a primary care physician (family or internal medicine); or if joint problems become prominent, perhaps directly from a rheumatologist.

In the event you really have RA, most cases are transient and mild.  A minority can become chronic or recurrent, but serious disability -- e.g. ongoing arthritis -- is the exception.

That's as far as this thread can go.  Take care.

[MiniB]

What a difference a day can make

I was thrilled at the prospect of moving forward from this incident. Last night I was talking to my friend and mentioned I had a red inflamed eye, and low back pain. He told me it sounds like the unfortunate beginning of Reactive Arthritis. He explained the condition and the relationship with NGU. I spent most of the night without sleep researching the condition. I am now terrified. It appears this might only be the start of very serious and perhaps life long symptoms including risk to my skin, genitals, lungs and heart

I don't understand and need guidance. I tend to ignore minor aches and pains and remain active. Now I feel much is at risk. Should I now anticipate the condition to spread and include skin ulcers and inflamation in numerous other body parts. Can it remain mild and resolve on its own.

I should note that I am also fighting off a head cold, however, I have no past history of pink eye with colds

Please share your guidance and information

All this from a stupid indiscretion

[H. Hunter Handsfield, M.D.]

1) Treatment beyond 7 days is not necessary.

2) Normally NGU patients are not reexamined if symptoms clear up and do not recur.  However, there is a modest chance of relapse, which occurs in ~20% of patients.  If your symptoms recur, return to your doctor or clinic.

3) Condom-protected sex is fine for now, and it would be best to continue to use condoms for another 1-2 weeks.  Not because there is particular risk of harm to your partner, but if you are unlucky and have recurrent symptoms, if you have consistently used condoms you and your doctor will be confident you were not reinfected.

4) Excellent question -- but unfortunately no answer.  Whether persons who acquire NGU by oral sex have increased risk for future episodes simply isn't known and has never been studied.  My guess is not; or if there is any such effect, it is still infrequent.

Thanks for the thanks about the forum.

[MiniB]

I complied with your instructions. I took the 7 day course of Doxycycline with the last dose tonight. I am now 2 days symptom free.

The fact based information you shared was of tremendous assistance in permitting me to make educated treatment decisions. To the extent the purpose of this forum is to assist with patient understanding you certainly succeeded on multiple levels. I am most grateful.

Perhaps you will permit this follow up inquiry related to the completition of the medication

1. Should I renew the Doxy for an additional 7 days
2. Can I consider myself recovered and/or do I require medical testing for confirmation
3. Can I resume condom protected intercourse without exposing my partner. For how long are condoms required
4. Moving forward am I predisposed to NGU from receiving oral sex or was this merely chance occurrence. In other words is oral sex more risky for me given my history

Once again please accept my gratitude for the information and assistance

[MiniB]

I am 2 days on Doxycycline with no improvement of the painful urination symptoms. It burns in the shaft and head when I urinate

I believe you have commented elsewhere on this board that painful urination isn't typical with NGU and more common with a prostate infection

Am I on the wrong track with my treatment. Do I need to start over or perhaps be more patient with the current treatment

I will continue to follow your instructions and report back only when the antibiotic therapy is complete. Thanks for your time and consideration

[H. Hunter Handsfield, M.D.]

The anal fingering is irrelevant.  There is no anatomic connection from the rectum to the prostate; they are anatomically close only, but you cannot get a prostate infection that way.

At this point, I agree we should wind up the conversation for now.  Bring me up to speed after you have completed treatment.

[MiniB]

You are straight forward, informative, reliable and damn fast

The oral did include digit insertion to rectum. I previously didn't think it important. Thus the prostatitis concern. Shall we still consider it NGU and take the Doxycycline or now consider prostatitis

I will continue to share your comments with my friend and travelling associate

With your permission I will reach back out next week

[H. Hunter Handsfield, M.D.]

I disagree with your friend's advice about ofloxacin.  Tell him there are no data available, and little or no clinical experience, on its efficacy for NGU acquired by oral sex.  There are good data for doxycycline.  If there was a serious concern about prostatitis, ofloxacin might be a good choice -- but prostatitis is not a realistic consideration based on your symptoms and the timing of onset with the oral sex exposure.  And anal itching is not a prostate gland symptom.  And yes, the lack of very prompt improvement tends to argue against gonorrhea.

[MiniB]

I can't adequately express my appreciation for the time you spent sharing knowledge and information. I am benefiting from your advice and guidance.

My friend is encouraging that I switch from the Doxycycline to the Ofloxacin. I have taken 3 doses of Doxycycline to this point. He suggest the Ofloxacin is a broader range antibiotic and might be better if the source is a non-sexual bacteria and otherwise equally effective as Doxycycline. He feels given my age(40) Ofloxacin is the preferred choice

Does the presence of increased anal itching suggest inflamed prostate as the cause rather than oral induced bacteria and would this change the treatment. The painful urination continues and my emotions aren't great, however, I am determined to remain objective. I need to make a firm decision on medication today.  Doxycycline, Ofloxacin or perhaps both. I kindly request your view given this additional information.

Slightly unrelated, does the lack of symptom improvement 2 days post Suprax indicate gonorrhea wasn't the cause.

I think it best that I refrain from posting further until I have completed a full course of one or both of the antibiotics. I request permission to report back when that is completed.

I again appreciate your time

[H. Hunter Handsfield, M.D.]

There was no signficant risk to your partner.  The reason for avoiding sex for a while is that NGU sometimes persists or recurs despite standard treatment.  When that happens, it can be difficult to distinguish persistent infection from the possibility of a new infection.  Avoiding sex entirely for a while precludes the latter possibility.  With a condom, there's always the theoretical possibility of unrecognized condom failure.

[MiniB]

I can't ask for a more comprehensive and informative response

One follow up regarding condom use. I will follow your instructions regarding no intercourse until completition of medication and symptom free.
I did have condom protected intercourse between the oral exposure and the onset of my symptoms. Given the entire encounter was condom protected and there was no oral genital contact is it reasonable and appropriate to conclude I didn't expose that partner.

Your time is most appreciated

[H. Hunter Handsfield, M.D.]

Oh, ofloxacin.  It's also one of the recommended NGU drugs, but as a second line option after doxycycline or azithromycin.  Doxy would be more appropriate.

[H. Hunter Handsfield, M.D.]

Welcome to the forum.

Your doctor friend was on exactly the right track; I agree word for word with "STD from oral is unlikely yet it does happen" and that your "symptoms are consistent with a urethitis ranging from gonorrhea to NGU to non sexual bacteria."  I would add that gonorrhea is less likely than the other possibilities; gonorrhea symptoms usually start sooner, e.g. 2-5 days.

His treatment recommendations also were appropriate.  Arguably it was overkill to use both cefixime (Suprax) and ciprofloxacin to cover gonorrhea, but it wouldn't do any harm.  My guess is that "avon" is azithromycin (trade name Zithromax); and indeed doxycycline for 7 days or azithromycin 1.0 g (single dose) are the two treatments of choice for NGU.  (It is clear your doctor friend is very knowledgeable about STDs.  It also may be significant that he didn't mention chlamydia as a possibility; it seems he knows that chlamydia is rarely acquried by oral sex, but many (most?) doctors don't understand this.)

1) The exact cause of NGU usually cannot be known.  Many (most?) cases from oral exposure may be due to entirely normal oral bacteria.  Another possibility, however, is adenovirus -- normally a cause of common colds and other respiratory infections, but also responsible for around 5% of NGU cases, especially from oral sex.  If it's adenovirus, the antibiotics will make no difference -- but it would clear up on its own in 1-2 weeks, so nothing to worry about.

2) See above; take the doxy or azithromycin.

3) The effect of treatment is not instantaneous.  Assuming bacterial NGU, the symptoms should start to improve in 2-3 days and clear up pretty much entirely by 7-10 days.  Longer if adenovirus, as noted above.

4) Even with condoms, I would recommend you not have vaginal sex for at least a week or until your symptoms have cleared up entirely.

5) Yes, condoms are virtually 100% protective against bacterial STDs and all causes of urethritis.

6) Once you have been treated and symptoms are gone, you can safely assume you no longer are infected and cannot transmit anything to your sex partner(s).

I hope this helps.  Best wishes--  HHH, MD

[MiniB]

Do you suggest I take the Doxycycline and/or the Oflox

[MiniB]

I apologize for the obvious typo

That should read Ofloxacin(sp?) Oflox(sp?) and not AVON