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recurrent male urethral discomfort after sex
I'm a retired physician. I tried to help a friend "long distance," & now we both need your help.
"Sam" is 26, a heterosexual man with past hx of IV drug use, sober for 2 years. Tests for HIV have remained negative. He's had many sexual partners. Last summer in rural Maine he developed a milky penile discharge & dysuria a few days after sex with a new partner. Local care was not immediately available; I ended up calling in rx for Suprax 400 mgm plus Zithromax 1 gram, & he made an appt for follow-up.
His discharge cleared, but urethral discomfort remained. His partner was treated; no further contact occurred. The next week he saw an MD & was "tested" with neg results. Discomfort persisted. After 3 more weeks he called his physician, who advised waiting longer. "Sam" then called me. Since he met the criteria for "persistent urethritis" I treated him with 2 grams of Flagyl plus erythromycin 800 mgm QID X 7 days & advised him to seek additional consultation if symptoms persisted. Eventually he saw a urologist who rx'd long-term doxycycline.
So my friend's been on doxycycline since last fall. At one point, after rafting in a wetsuit, he developed perineal & perianal redness & itching, treated with 1 dose of Diflucan. His rash resolved. His urethral discomfort also significantly improved; he had only the faintest intermittent tingling.
He was abstinent until recently when he had (prolonged) sex with 2 new partners, separate encounters several weeks apart. Each time, the next day he experienced the same distal urethral discomfort (no discharge). Yesterday he visited a clinic & was tested for GC & chlamydia (results pending) & given Vantin & more doxycycline. At this point I can't believe he still could have a "routine" STD. Do you have any thoughts about his recurrent post-coital urethral symptoms? He says they also occur after receiving oral sex, when no condom is used, which seems to rule out latex allergy.
Thanks for your helpful expertise.
MEDICAL PROFESSIONAL
Thanks for the thanks. You're welcome.
As you well know, almost everybody who is told a set of symptoms may have a psychological origin (or influenced by emotional factors) disbelieves it at first. That said, I'm not making any diagnosis from a distance, and on further reflection I think he probably should follow through with a urologist. There's probably still a significant chance of prostatitis; and even if nothing is found, it will add to the evidence that nothing serious is wrong -- whether or not there is a psychogenic component. You (and he) might read up on the chronic pelvic pain syndrome, the new terminology for what used to be considered a form of noninfectious prostatitis. If you google CPPS (spelled out), start reading with the excellent Wikipedia article that will be near the top of the hit list; also see the information from the Stanford U. dept of urology. Perhaps "Sam" will see that most or all his symptoms are consistent with CPPS. (Which by the way, as the websites show, probalby has an important if not exclusively psychological component.)
As you well know, almost everybody who is told a set of symptoms may have a psychological origin (or influenced by emotional factors) disbelieves it at first. That said, I'm not making any diagnosis from a distance, and on further reflection I think he probably should follow through with a urologist. There's probably still a significant chance of prostatitis; and even if nothing is found, it will add to the evidence that nothing serious is wrong -- whether or not there is a psychogenic component. You (and he) might read up on the chronic pelvic pain syndrome, the new terminology for what used to be considered a form of noninfectious prostatitis. If you google CPPS (spelled out), start reading with the excellent Wikipedia article that will be near the top of the hit list; also see the information from the Stanford U. dept of urology. Perhaps "Sam" will see that most or all his symptoms are consistent with CPPS. (Which by the way, as the websites show, probalby has an important if not exclusively psychological component.)
MEDICAL PROFESSIONAL
One more comment: On closer read, I missed that he is only experiencing urethral discomfort, no discharge. That raises the possibility that the problem may be psychogenic, at least in part. Real urethritis usually causes noticeable discharge. If he hasn't been professionally professionally to evaluate for objective signs of urethritis, i.e. visible discharge, elevated PMNs on a urethral swab, etc, that should be done now. (Best early morning, with examination prior to first urination.) If urethritis cannot be documented I would lean even more toward the psychological explanation. In that event, urology evaluation might be considered optional.
MEDICAL PROFESSIONAL
Greetings, Colleague. I'll try to help. However, this situation is in a deeply gray zone of uncertainty.
It sounds pretty certain that your friend's problem started out as garden-variety nongonococcal urethritis (NGU), either chlamydial or nonchlamydial. Probably nonchlamydial, since chlamydial NGU has a much lower relapse/persistence frequency than those not associated with C. trachomatis.
Even with ideal management, the relapse rate is quite high for nonchlamydial NGU, and patients like your friends are very common in STD clinics -- and we are no better at managing them than you have been. When cases continue to recur despite the recommended regimens, all of which he has had, the most likely scenario is that no infection is responsible. Whether there is a component of prostate gland involvement remains a conundrum. There is lots of speculation about it, largely because the symptoms of prostatitis and persistent urethritis are essentially identical. However, the few studies on this topic were unable to establish a link between NGU and prostatitis. That said, post-coital exacerbation of symptom in your friend certainly is consistent with a prostate problem. And the association with non-genital sex suggests an endogenous origin, not repeated new infections.
There is at least one circumstance in which urethritis appears to have a non-infectious, presumably immunologic etiology. Men with nonsexually acquired reactive arthritis (formerly called Reiter's syndrome), e.g. triggered by campylobacter, shigella, or other inflamatory colitis often have NGU which presumably is immunologic in origin. It is logical to suppose there are other circumstances, and I can imagine such a problem being triggered by an initial infectious urethritis.
There has also been speculation that some such cases are due to Candida or other yeasts. This belief is more common in Europe than N. America, and STD clinics in the UK often try courses of antifungal therapy (e.g., oral fluconazole). However, I have seen no objective evidence in support. As you know, yeasts are sufficiently ubiquitious that isolation from the genital tract says little or nothing about pathogenesis.
Perhaps most important for your friend, there is no evidence that any harm every comes; for example, no known association with later urethral stricture, impaired fertility, or any other serious outcome. And no known health implications for sex partners.
At this point, my advice is that all antibiotics be stopped for at least several weeks. Then if symptoms continue, seeing a urologist makes sense. Not that they are any better at this than other physicians -- but that's the way to sort out for sure whether there is an element of prostatitis, either infectious or noninfectious. Being off antibiotics for a while is important in proper evaluation of that possibility.
Bottom line: You can safely assure your friend that this is an inconvenience more than a serious health threat; that he should stop antibiotics; and get a urology consultation in a few weeks.
I hope this helps. Best wishes-- HHH, MD
It sounds pretty certain that your friend's problem started out as garden-variety nongonococcal urethritis (NGU), either chlamydial or nonchlamydial. Probably nonchlamydial, since chlamydial NGU has a much lower relapse/persistence frequency than those not associated with C. trachomatis.
Even with ideal management, the relapse rate is quite high for nonchlamydial NGU, and patients like your friends are very common in STD clinics -- and we are no better at managing them than you have been. When cases continue to recur despite the recommended regimens, all of which he has had, the most likely scenario is that no infection is responsible. Whether there is a component of prostate gland involvement remains a conundrum. There is lots of speculation about it, largely because the symptoms of prostatitis and persistent urethritis are essentially identical. However, the few studies on this topic were unable to establish a link between NGU and prostatitis. That said, post-coital exacerbation of symptom in your friend certainly is consistent with a prostate problem. And the association with non-genital sex suggests an endogenous origin, not repeated new infections.
There is at least one circumstance in which urethritis appears to have a non-infectious, presumably immunologic etiology. Men with nonsexually acquired reactive arthritis (formerly called Reiter's syndrome), e.g. triggered by campylobacter, shigella, or other inflamatory colitis often have NGU which presumably is immunologic in origin. It is logical to suppose there are other circumstances, and I can imagine such a problem being triggered by an initial infectious urethritis.
There has also been speculation that some such cases are due to Candida or other yeasts. This belief is more common in Europe than N. America, and STD clinics in the UK often try courses of antifungal therapy (e.g., oral fluconazole). However, I have seen no objective evidence in support. As you know, yeasts are sufficiently ubiquitious that isolation from the genital tract says little or nothing about pathogenesis.
Perhaps most important for your friend, there is no evidence that any harm every comes; for example, no known association with later urethral stricture, impaired fertility, or any other serious outcome. And no known health implications for sex partners.
At this point, my advice is that all antibiotics be stopped for at least several weeks. Then if symptoms continue, seeing a urologist makes sense. Not that they are any better at this than other physicians -- but that's the way to sort out for sure whether there is an element of prostatitis, either infectious or noninfectious. Being off antibiotics for a while is important in proper evaluation of that possibility.
Bottom line: You can safely assure your friend that this is an inconvenience more than a serious health threat; that he should stop antibiotics; and get a urology consultation in a few weeks.
I hope this helps. Best wishes-- HHH, MD
Many thanks for your thoughts. I, too, have been wishing that someone would check for PMNs, which no-one apparently has. And I'm glad you advise stopping the antibiotics. I concur.
When "Sam" read your response, his first comment was, "Is he saying it's all in my head?" The discussion continues...
Again, I greatly appreciate your accessibility as well as your expertise. I've read many of your articles. As the Rastas say, Massive Respect.
When "Sam" read your response, his first comment was, "Is he saying it's all in my head?" The discussion continues...
Again, I greatly appreciate your accessibility as well as your expertise. I've read many of your articles. As the Rastas say, Massive Respect.
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