Dr. Handsfield: Follow-up after 3 doctor consultations

[PilotMan390]

As a recap, I developed urethritis consisting of a clear discharge, no or very mild dysuria.  I called PCP and took azithromycin with no effect, then went to a clinic for more testing.  Urinalysis was negative for everything, chlamydia/gonorrhea swab test negative but high WBC count and a small amount of blood in swab test.

Next was given doxycycline and ciprofloxacin, both for a full 7 days.  At about day 8 after new treatment, symptoms seemed to have gotten better with no discharge, lasted about 13 days. (New Development) =>On the 16th was hit with a very large degree of mucous discharge and I had painful urination (nothing extreme).

I called PCP again and this time was given erythromycin for a week and metronizadole.  On Sat/Sun 18th/19th i had yellowish purulent discharge in the morning. but after taking the new antibiotics, the symptoms began to clear up as discharge went from yellow, to milky, to clear again and a week later discharge is basically over with but i still have dysuria.  For one day during erythromycin treatment i did have a soar groin and a constant uncomfortable pain at the head of my penis the next day, but both went away in a day.  I have not had unprotected sex since mid september.  

If symptoms come back for the third time, would a longer course of antibiotics be recommended?  What would you do if you were my doctor?  How long can this recurring condition potentially last?

Could checking for discharge continually cause persisting dysuria even though the infection is eradicated?

Is there a possibility this could be caused by herpetic urethritis, since symptoms came and then left again after a latent period?  I've read that typically burning on urination is excruciating and that you have not witnessed herpetic urethritis with discharge.  Could i have a "mild" case then in your opinion?  My first doctor was too busy to talk more than 2 minutes (clinic) and I know more about this than my PCP...literally. Its sad.

[PilotMan390]

Thanks Dr. Hook...i'll discuss all these items with the doctor i've been seeing and update the forum if need be with any results or lack thereof.  Regards.

[Edward W Hook, MD]

Brief answers:

1.  Prostate.  I would just raise the question as to whether, given the poor response. there might be prostate involvement.
2.  I would use the drug you had the best response to.  It sounds like that might be doxycycline
3.  She's probably OK but you don't want to leave any stone unturned, do you?
4.  No, I would only treat her for a week
5.  No, I doubt that there is anything in particular wrong with you or your immune system, nor is your situation suggestive of any other STD.
EWH

[PilotMan390]

Dr. Hook,  Thank you for your very thorough response...between you and Dr. Handsfield I've gotten more information online than 3 discussions with my doctors.

To answer your question, no, I have not had a prostate exam and have not discussed it with my doctor, but i can...anything in particular that i should address apart from what you've told me above and i've described on my own?

You recommend 3 weeks of treatment, is there any particular drug that you feel is best given my circumstances?  as you know, i've now tried 4 different antibiotics :(

I have had sex with a new partner since i thought i was "clear" after the second round of antibiotics (doxycycline) and had no discharge for over a week.  It was about 5 days after the encounter with her that i got the copious discharge and dysuria for the first time (however, she has gotten a full panel of clean STD tests about 3 weeks prior to me (verified) with no sex besides me since then, so since I had sex with her only once before the recurrent symptoms I think it would be highly unlikely that she would have passed anything new on to me...don't you?  

Also, if i go on three weeks of therapy, do you think its a good idea that she does as well?  or would a shorter regimen of say a week be better for her?

And, not to sound like i'm fishing, but besides what we've discussed thus far, including prostate involvement, is there any other STD, or affliction that you feel may be causal?  imparied immune system, etc?  i'm actually in great shape besides this persisting problem.  I'm curious as to what sort of testing can be done if the prostate were involved...Thanks again for the very thorough response...you seem to have really thought about it well.  I'm glad you both are out there helping guys like me with few answers and persisting problems.

[Edward W Hook, MD]

Dr. Handsfield and I share the forum.  You got me.  FYI, the reason we share the forum is because we have worked together for nearly 30 years and while our verbiage styles vary, we have never disagreed on management strategies or advice to clients.  I've read both your current note and your past exchange with Dr. Handsfield.  Before I answer your specific questions, a few observations and a question.

Observations.   Your urethritis is not "behaving" like typical STD-associated urethritis.  Treatment with the medications you have received (azithromycin, doxycycline, ciprofloxacin and flagyl) would have cured virtually all typical STDs.  In addition, the fact that the problem you have is antibiotic responsive but does not completely go away and stay away following treatment raises three major possibilities - that it is not due to infection (some antibiotics have anti-inflammatory effect beyond their antimicrobial activity), that your treatment to date has not been long enough (this would suggest, as mentioned by Dr. Handsfield that there may be prostate involvement), or that you have been re-infected.   A final, most unlikely possibility is that you have infection with something that is resistant to the antibiotics you've taken - this is unlikely given your at least partial Reponses.  I find myself wondering about your prostate.  Has the doctor done a prostate exam?  the treatment for prostatitis is different from the treatment for urethritis.

This leads me to my question.  As this has gone on, have you continued to be sexually active and, if so, has  your partner been treated. If not, re-infection may be part of the problem.

Now for your questions:

Duration of treatment.  If the symptoms improve again, I would use a prolonged course of antibiotics - three weeks rather than 7 days.

Could repeated self examination lead to persistent discharge? Yes, without a doubt, particularly if you are "thorough" in your examination.  .  

Is this herpetic urethritis. Unlikely.  No lesions and the pain of HSV urethritis is typically considerable.

A final suggestion.  AS also mentioned by Dr, Handsfield, it sounds as though the STD doctor you saw was quite knowledgeable.  You are now in the realm where there are no studies to guide what to do next - your problem is too rare.  You doctor however does sound knowledge able.  there may be some trial and error involved but I would suggest you stick with him.  Hope this helps EWH