Testing and curing questions

[spacy]

The last 5 months or so have been constant hell for me, filled with anxiety. And its just getting worse. I'm a married 32 y/o male that has messed up a couple of times and is so afraid of losing what's most important to me. Last Oct, I had brief unprotected sex with another woman. I freaked, and tested negative for stds, and so did the other woman.  In Feb. I was put on 10 days of doxy for a sinus infection.  After 3 days of it, I received unprotected oral from yet another woman.

Late March of April I started seeing signs of what I thought was urethritis: occasional discomfort with urinating and clear sticky fluid (mucus?) present only when milking my penis. I had 3 (yes 3) negative swabs for chlamydia. But still also received 2g zithromax and 7 days of doxy.  Things seemed to be ok for a few weeks until the end of may, when milking my penis (I do this a lot out of anxiety) the fluid changed from clear to sometimes cloudy.  Went to another place, but they wouldn't test me again, but gave me 1 month of levaquin. Things seemed to be fine for a while again until a couple of weeks ago when I noticed that sometimes my urine would be split when I started urination. No pain or discomfort and no visible discharge.  Though there is still clear mucus-like stuff there if I milk it.  The stream is not split in the mornings like I would expect, but usually only after sitting for a while, where my penis may be resting on my scrotum.

Went to my doc.  He said there is always some mucus in the urethra.  He did a DRE and said my prostate felt "boggy" and put me on 3 weeks of cipro.  I am almost 2 weeks into it and the split stream thing is still there from time to time. Again, usually after sitting and/or having my legs crossed.  Can split streams normall occur and I just am noticing more? I have been to him dealing with prostatitis in the past and he thinks its back.

1.The split stream thing bugs me, but am I reading too much into it?

2.I have not had any sexual contact at all with anyone, including my wife since the oral in march.  I'm worried about false negatives on the ct swab. Should 3 negatives since last exposure be statistically good enough?  Is there even the slightest chance with the 3 negatives and all the antibiotics?  I've had the 2 main antibiotics, and one of the second choices.

3. Any ideas what I can do or what is going on?  Is it anxiety making me notice normal things more?  Could something make me produce more  mucus that normal?  Please help, I feel like nervous hell.

Most of the time I'm convinced its not ct.  It seems too far fetched to have 3 negative tests and 3 of the best antibiotics for it and still have it.  But then I always wonder, is it possible?  Its the first thing in my head when I wake up in the morning.  How can I put it behind me?

[spacy]

Thank you very much Dr. H.  But perhaps I wasn't totally clear on the treatment I have received in my panic during writing.

The first place I got swab tested was the county health department.  She said the test was only for ct, came back negative.

Next, a week or so later, I went to planned parenthood for another swab test.  This one was for, I believe, both ct and gc.  It was also negative.  While I was there, she did another swab and looked at it under a microscope.  She told me she only saw epithelial cells, no wbcs, no trich.

After that I went to a walk-in doc, who also services the local college.  He suspected nothing was going on, but swab tested me once more anyway.  This was for both ct and gc, and also came back negative.  He gave me 2g of azithromycin anyway, which I took all at one time.  Your response indicated that I either left that out initially, or you didn't see it.

A week or two later, still feeling paranoid, I went to the local low-income clinic.  She didn't think any further testing was necessary, but still gave me 7 days of doxycycline twice a day, and 2 grams of metronidazole to be taken all at once.  I know I didn't mention the metronidazole in the first posting, and I apologize.  I took the metronidazole after the doxy was completed as she suggested.

Everything seemed to be fine for a while, but then I began milking my penis repeatedly, like a lot, throughout the day to check and make sure there was nothing there.  After a couple of weeks of this, I began to notice the presence of mucus, which eventually began to become cloudy.  Still no pain or spontaneous discharge.

Went back to the walk-in clinic where I got the azithromycin.  A different doctor was on that day,  I told him all I had undergone.  Also asked about prostatitis, which I had dealt with a couple of times in the past.  He said I was too young for prostatitis.  I'm 32.  He said persistent/recurrent urethritis and said there was nothing he could do and sent me off.

A couple of days later (this is now early June and this all started in April) I went to yet another walk-in place. He heard my story, but what he could milk out was clear that day.  Did a dre, said it felt normal.  Said he noticed slight flaking around urethra and offered 30 days of levaquin.  I took it all and kept my hands off and everything seemed fine.

About 3 or so weeks ago (2 or 3 weeks after finishing the levaquin) I first noticed the split stream.  I didn't really worry at first, until it happened a couple of more times.  Its always very brief and only happens a couple of times during the day.  Always a very small amount of clear mucus like fluid upon milking.

Went to my family doctor, who did a dre and said it felt boggy.  He is the one who diagnosed prostatitis a few years ago.  The first time I had a definite clear thick discharge, negative std tests.  Cleared with levaquin, though it has flared a couple of times since then.  Since my initial diagnosis, I have almost always had a small amount of totally clear slightly stcky fluid that I can milk out.  Sometimes more than others.  But never the split stream...that I've noticed.  Hr said there is always some mucus present and I just make more, and notice it more because my urethral opening is lower than most...closer to what he called the resevoir.  He gave me three weeks of cipro.  Almost 2 weeks and no real change yet.

I apologize for the long post.  I wanted to clarify the treatment I have had (esp the azithromycin and metronidazole) and the past diagnosis of prostatitis. I'm not sure why prostatitis, if that's what it is, would flare up after the levaquin which has always helped it in the past. And its never caused this split stream.  Though its only once or twice a day and never first thing in the morning.  Maybe I sit too much now and its sweat?  The whole underside of my penis will feel sweaty or moist after sitting, though no visible disharge, nor does it look wet. I would gladly pay another $10 if you would respond again.  Does the additional information/clarity change anything?  Should I still worry about trich after the metronidazole?  Thanks so much for everything.

[H. Hunter Handsfield, M.D.]

Only speculation exists about non-infectious immunologic reactions causing urethritis.  What is known is that in a disease called Reiter's syndrome (a kind of arthritis plus various combinations of urethritis, skin rash, and/or eye inflammation [conjunctivitis etc]), the urethritis sometimes appears to be non-infectious.  Since the other manifestations of Reiter's are immunologic in origin, there is speculation the urethritis may be the same.  The other piece of soft evidence is the lack of consistent response to antibiotics that would be expected to clear most infections.

So the question is whether some cases of persistent/recurrent NGU alone, without Reiter's syndrome, sometimes might have an immunologic origin.  If it can happen in the one case, why not the other?  But that's as far as it goes.  There are no clear data to conclude that it does or doesn't explain some cases.

If not yet done, your providers should prescribe metronidazole for a week or so; and if still persistent, perhaps azithromycin.  Most experts would have tried the azithromycin before giving either levofloxacin or ciprofloxacin.  Levo and cipro are very similar; with rare exceptions, either should be equally effective [or equally ineffective] as the other.

Thanks for the thanks--  HHH, MD

[spacy]

You told a previous person:

"it may be an immunological reaction, i.e. no infection at all. (Personally, I favor the immunological explanation, but the data are not clear.) A third possibility is that it is a physiologic event, i.e. exaggertion of normal urethral mucus production"

I am looking for information on those possibilities, but can't seem to find anything.  Can you explain those a little more?  I understand if you can't or don't have time.  Because I really shouldn't have anything left in me after all those treatments.  But then I read about cipro can lead to persistent chlamydial infections.  I'm on 500mg 2 times a day for 3 weeks.  Though I imagine you will probably tell me it doesn't matter anyway since I tested negative and my previous treatments.  I also can't understand why prostatitis would flare up after 1 month of levaquin (which I used in the past to treat it).

I don't know what it would take, but if I could know for sure that 3 negative tests can't be wrong and that its also not possible to have it after my 1st three antibiotics it would probably help.  I just want to stop paying and paying for my stupid mistakes.  I won't bore you by promising never to slip again, but the level of anxiety it causes me sure isn't worth it.

I thank you for everything you do here for everyone, as well as myself

[H. Hunter Handsfield, M.D.]

After the treatment you have had, there is zero chance that chlamydia explains your continuing symptoms.  But you probably have persistent/recurrent nongonococcal urethritis (NGU) or perhaps prostatitis.  A very small amount of completely clear mucus (i.e., not cloudy at all) may be normal in the urethra, but not cloudy.  If you haven't yet seen a urologist to assess persistent NGU or prostatitis, that would be a logical next step; or an infectious diseases specialist.  Many people with symptoms like yours in fact have nothing wrong, only anxiety magnifying normal body sensations.  However, anxiety won't cause abnormal discharge/mucus or a split urine stream.  Further, doxycycline and levofloxacin (Levaquin) are not the only and necessarily the best antibiotics for this condition.  Somewhere along the line, you should be treated for possible trichomoniasis (metronidazole or tinidazole) and azithromycin.

To answer your specific questions:

1.  See above.  I think you have ongoing urethritis or perhaps prostatitis.  You need to be evaluated for them, and you should have a culture test for trichomonas, if not yet done.

2.  Except for occasional cases of trichomoniasis, persistent/recurrent NGU or prostatitis usually is not caused by anything known to cause harm in sex partners; probably you can safely have sex with your wife.  However, it might be a good idea to use condoms until your further evaluation is complete, just to be super safe and to avoid confusion if your symptoms persist after still more treatment, and until you have a negative culture for trichomonas.

3.  Next steps depend on a careful evaluation for urethritis/prostatitis, and also on exactly which antibiotics yo The cause(s) of persistent/recurrent NGU aren't known.  It may not be an infection at all, by the way; it is possible that some cases like your are caused by an aberrant immune response, not an infectious organism.  No serious harm has ever been documented:  no infertility, no cancer, no disease in partners once trichomoniasis is excluded.  So don't be frightened about any dangerous outcome.

Good luck--  HHH, MD