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Strange recurrent urethral sensation
I am a 36-year old gay male who experiences a strange urethral sensation (somewhat “tingling” in nature) from time to time. It’s not painful or even that bothersome, I’ve never seen secretions, and I can only recall a few times when there was a slight stinging sensation with urination (not with ejaculation).
~9 months ago, my PCP took a urine sample. I think his inability to find elevated WBCs led him to suggest that HSV may be the underlying cause (rather than gonorrhea/chlamydia). I also mentioned to him my concerns that the force of my ejaculation had declined substantially in only a few months. I’m not getting any younger, but the change was dramatic. He gave me a brief rectal exam (normal) and suggested I try quercetin (I did not). The urethral sensations have returned periodically since then. They are definitely real, not imagined. As symptoms are mild and I just get on with life, it’s difficult to define the duration and frequency. Two weeks ago, I tested neg for gonorrhea, chlamydia, syphilis, hep c, and HIV.
As ≥25% of MSM in NYC carry HSV2, it’s not unlikely that I (or indeed any of us) carry the virus. But I feel the psychological burden of such a diagnosis, unless absolutely necessary (ie, symptoms strongly suggestive of herpetic urethritis) outweighs the benefits. I’d therefore prefer not to get tested for HSV without eliminating other causes; however, I also don’t want to expose my partner to risk.
Questions:-
1. Is “urethritis” accurate to describe these symptoms?
2. Do normal levels of WBCs in a urine sample conclusively eliminate a bacterial and strongly indicate a viral etiology? (I read somewhere that this is not always accurate)
3. Might mycoplasma genitalium be involved (apparently ~15-25% NGU cases)? If so, would a course of azithromycin help?
4. Given the absence of external lesions and pain, could this be herpetic urethritis and is herpes testing warranted?
5. Could CPPS/other non-infective etiology be involved?
Thanks!
~9 months ago, my PCP took a urine sample. I think his inability to find elevated WBCs led him to suggest that HSV may be the underlying cause (rather than gonorrhea/chlamydia). I also mentioned to him my concerns that the force of my ejaculation had declined substantially in only a few months. I’m not getting any younger, but the change was dramatic. He gave me a brief rectal exam (normal) and suggested I try quercetin (I did not). The urethral sensations have returned periodically since then. They are definitely real, not imagined. As symptoms are mild and I just get on with life, it’s difficult to define the duration and frequency. Two weeks ago, I tested neg for gonorrhea, chlamydia, syphilis, hep c, and HIV.
As ≥25% of MSM in NYC carry HSV2, it’s not unlikely that I (or indeed any of us) carry the virus. But I feel the psychological burden of such a diagnosis, unless absolutely necessary (ie, symptoms strongly suggestive of herpetic urethritis) outweighs the benefits. I’d therefore prefer not to get tested for HSV without eliminating other causes; however, I also don’t want to expose my partner to risk.
Questions:-
1. Is “urethritis” accurate to describe these symptoms?
2. Do normal levels of WBCs in a urine sample conclusively eliminate a bacterial and strongly indicate a viral etiology? (I read somewhere that this is not always accurate)
3. Might mycoplasma genitalium be involved (apparently ~15-25% NGU cases)? If so, would a course of azithromycin help?
4. Given the absence of external lesions and pain, could this be herpetic urethritis and is herpes testing warranted?
5. Could CPPS/other non-infective etiology be involved?
Thanks!
MEDICAL PROFESSIONAL
Welcome to the forum. Your question came in while I happened to be on the forum. Most users shouldn't expect immediate replies! And thanks for obviously reading other threads with issues like yours (as indicated especially by question 5).
Your symptoms are really not suggestive of any STD, and certainly not genital herpes. As has apparently been the case for you, when we see patients with such problems in the STD clinic, we usually find nothing wrong at all. Your last question suggests you won't be surprised when I say that the most common explanation seems to be he that anxiety or other stresses have led to a heightened awareness of normal body sensations, or of minor symptoms that don't indicate anything wrong.
As for herpes, both the minor nature of your symptoms and their pattern are wrong. HSV doesn't cause the relatively frequent (nearly continuous?) symptoms that it seems you have. And herpetic urethritis typically is severe, with major pain on urination -- not just a minor tingle or itch. (Over the years, I've had a couple of patients who described herpetic urethritis as the worst pain they ever experienced.) And herpetic urethritis would produce WBCs.
To the specific questions:
1,2) This symptom does not suggest urethritis of any kind and normal WBCs reliably exclude urethritis of any cause, whether bacterial or viral.
3) Since you have no apparent urethritis, M. genitalium is an unlikely cause of your symptoms.
4) As discussed above, I'm confident this isn't herpes. If you want even more security about HSV-2, you could have a blood test. As you point out, merely on a statistical basis there's probably a 25% chance of a positive result, something you might want to know regardless of your symptoms. But if positive, it wouldn't explain anything; in that event, I would conclude that you have asymptomatic HSV-2 plus unexplained penile tingling.
5) I don't think I would classify this as CPPS, which usually has a component of pelvic or testicular pain (as the name itself implies) and often urinary urgency or frequency, which you don't mention. But as my comments above suggest, it's possible this is indeed part of the spectrum of genitally focused anxiety, which is often part and parcel of CPPS.
The bottom line is that I really don't think you should be worried about this, and I see no clear need for any further medical evaluation. But if you remain unconvinced or if the symptoms worsen, consider seeing a urologist. If you do, I recommend you print out this thread -- it might be a good framework for discussion with the doc.
I hope this has been helpful. Best regards and stay safe-- HHH, MD
Your symptoms are really not suggestive of any STD, and certainly not genital herpes. As has apparently been the case for you, when we see patients with such problems in the STD clinic, we usually find nothing wrong at all. Your last question suggests you won't be surprised when I say that the most common explanation seems to be he that anxiety or other stresses have led to a heightened awareness of normal body sensations, or of minor symptoms that don't indicate anything wrong.
As for herpes, both the minor nature of your symptoms and their pattern are wrong. HSV doesn't cause the relatively frequent (nearly continuous?) symptoms that it seems you have. And herpetic urethritis typically is severe, with major pain on urination -- not just a minor tingle or itch. (Over the years, I've had a couple of patients who described herpetic urethritis as the worst pain they ever experienced.) And herpetic urethritis would produce WBCs.
To the specific questions:
1,2) This symptom does not suggest urethritis of any kind and normal WBCs reliably exclude urethritis of any cause, whether bacterial or viral.
3) Since you have no apparent urethritis, M. genitalium is an unlikely cause of your symptoms.
4) As discussed above, I'm confident this isn't herpes. If you want even more security about HSV-2, you could have a blood test. As you point out, merely on a statistical basis there's probably a 25% chance of a positive result, something you might want to know regardless of your symptoms. But if positive, it wouldn't explain anything; in that event, I would conclude that you have asymptomatic HSV-2 plus unexplained penile tingling.
5) I don't think I would classify this as CPPS, which usually has a component of pelvic or testicular pain (as the name itself implies) and often urinary urgency or frequency, which you don't mention. But as my comments above suggest, it's possible this is indeed part of the spectrum of genitally focused anxiety, which is often part and parcel of CPPS.
The bottom line is that I really don't think you should be worried about this, and I see no clear need for any further medical evaluation. But if you remain unconvinced or if the symptoms worsen, consider seeing a urologist. If you do, I recommend you print out this thread -- it might be a good framework for discussion with the doc.
I hope this has been helpful. Best regards and stay safe-- HHH, MD
MEDICAL PROFESSIONAL
With this additional information, a prostate problem -- whether CPPS or true prostatitis -- seems quite plausible. A urologist will be able to work it out. In the meantime, don't lose a lot of sleep over this. These conditions are generally inconveniences, not serious health threats. The reason for a urology evaluation is to make sure you aren't the rare person (especially at your age) with a more serious prostate problem -- but most likely you have nothing that will ever seriously harm you or a sex partner. And almost certainly no STD.
Thanks so much for your detailed response to my questions! It's gone a long way towards providing me with reassurance (on the herpes issue in particular). I know you can't engage in endless back and forth (I promise this will be my final comment!), but I just want to respond to your follow-up questions:
- You ask if my symptoms are "relatively frequent (nearly continuous?)", I would say they maybe occur every 2-3 months, but I don't always notice precisely when they begin and end (wish I'd kept some kind of a diary).
- "pelvic or testicular pain" - perhaps at times there is a feeling of testicular heaviness. Right now, I feel aches between testes and leg (inguinal lymph nodes?) and on my leg.
Last year, around the time I was first concerned about ejaculation force, for a time urine flow was somewhat abnormal. No frequent urges, but there was definitely a kind of post-void dribbling (thankfully now gone). Would these 2 issues (reduced ejaculation force and previous voiding concern) suggest I might benefit from a closer look at my prostate?
- You ask if my symptoms are "relatively frequent (nearly continuous?)", I would say they maybe occur every 2-3 months, but I don't always notice precisely when they begin and end (wish I'd kept some kind of a diary).
- "pelvic or testicular pain" - perhaps at times there is a feeling of testicular heaviness. Right now, I feel aches between testes and leg (inguinal lymph nodes?) and on my leg.
Last year, around the time I was first concerned about ejaculation force, for a time urine flow was somewhat abnormal. No frequent urges, but there was definitely a kind of post-void dribbling (thankfully now gone). Would these 2 issues (reduced ejaculation force and previous voiding concern) suggest I might benefit from a closer look at my prostate?
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Herpes spreads by oral, vaginal and anal sex.
Herpes sores blister, then burst, scab and heal.
STIs are the most common cause of genital sores.
Millions of people are diagnosed with STDs in the U.S. each year.
STDs can't be transmitted by casual contact, like hugging or touching.
Syphilis is an STD that is transmitted by oral, genital and anal sex.
