Sexually Transmitted Diseases/Burning Urethra and Penis Tip

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QUESTION: Hi,

I'm 41, and live near New Haven, CT. My story is similar to some others I have seen posted on the web - but I have rarely seen any solutions or follow up to indicate any answer.  On Jan 18 - I did something very stupid: I went to a massage parlor, and after the massage, the masseuse began to perform oral sex. There was no vaginal sex.  Her mouth touched me for only a short time, and then I stopped her and left.  But, maybe it was too late? While the "official" testing results are all negative - there is certainly something going on, and I don't think that the urologist I've been seeing has too many more ideas left about what to do next.

Right after the event, I freaked, and went to urgent care and got tested and treated immediately (within 3 days) for gonorrhea and chlamydia. They gave me a shot (I don't know what), and I took Doxycycline 100mg 2X per day for 1 week.  The tests came back negative. Everything seemed OK.

About 4 weeks later, the burning starts. It's a sensitivity throughout the whole head, but especially painful right at the tip near the opening of the urethra.  I saw small changes in the skin around urethra - wouldn't necessarily call them "bumps" or "blisters", but just areas of swollen/inflamed, slightly redder/purple skin.  I was freaked out that it was Herpes or syphilis. I went to a Urologist, and he said I'm fine, and that what he saw was basically normal skin, and it was mostly in my head - i.e.: guilt syndrome. (If you keep looking for changes - you will see them, he said). I got tested for both HSV1 and 2 (kind of early at 4 1/2 weeks) and they both came back negative.  With a couple of days, I started to feel better.

Then, it came back. The pain and burning was increased, and seemed to travel down the urethra a bit (about half-way).  I went back to Urologist, and he gave me 1 week of Cipro and did a urine culture.  The culture turned out to be clear.

The intensity of the symptoms seem to come and go - sometimes on a daily -or, even hourly- basis (a 'good' day followed by a 'bad' day)

So, the next step (since the urine culture came back clear) was to treat me for a yeast/fungal infection with Clotrimazole - Betamethasone cream - which is both an anti-fungal and steroid, applied 2X per day. (That's been about 11 days now).  It's making me feel better - not 100% (maybe 50%-60% better),- certainly more livable than before I was applying the cream - but there is still clearly something wrong - there's still painful sensitivity at the tip of my penis, a moderate burning, and the feeling that I need to go to the bathroom even when I don't. It seems that sitting doesn't help matters any, and when I'm standing (or not thinking about it), it's a bit less intense.  Also, (likely with some of the burning reduced) when I first started applying the cream, I initially became more aware that my testicles ached, I felt like my groin area in general was tender, and it felt like I've pulled a muscle at the very top of my inner thigh/crotch area.  Some of that has subsided, but I do feel what seems to be a muscle pull in my thigh, and that things are just generally not "good".

Right now, my worry (which is admittedly not based on any fact or knowledge - just fear) is that the steroid is just making me feel better, but the anti-fungal is not fixing the root problem, and when I stop applying it, the intensity of burning is going to come back.  (because it may not be fungal??)  -  I guess I won't really know for sure until I get to the end of the 2 week treatment period and stop applying the cream. - But with the 2 weeks approaching, and continued symptoms, my concern is starting to grow.

I'm also not sleeping (or eating very much) and a nervous wreck at how I could be so stupid and disloyal to my wife. I've made an appointment with a psychiatrist to help deal with this.

In a very similar case that I saw on the web, the person got "scoped", and his Dr. apparently diagnosed prostatis, and put him on 30 days of CIPRO. (I didn't see any follow up, though, to determine whether that really worked).   

My Dr. said that with the negative urine culture and the 1 week of CIPRO, would rule out a prostate infection.  Is this the same as ruling out prostatis?  Is there something else that either he or I am missing?  Should I be requesting any other exams or tests for the prostate?

Last week (at 7.5 weeks out) I went for a full STD screen (HSV 1 & HSV 2, HIV, HEP B/C, Syphilis, Gonorrhea, & Chlamydia) - and everything came back as negative.  When I followed up with the Urologist, he said to stop applying the cream after two weeks, wait a month, and then give him a call - to let him know whether the relief was from steroids or anti-fungal.  The bumps or "inflamed" skin near the urethra on the tip seemed to be a bit bigger, but he again confirmed that the "inflamed" skin does not look like either herpes or genital warts, and said he would send me to a dermatologist to evaluate that once we knew more about the reaction after stopping the topical cream.

While I have faith in my Doctor, I'm hoping that maybe a specialist in STD treatment might be able to shed more light on what could be going on. What else can/should I do or ask?  Any advice/guidance would be most appreciated.

Any help, information, or advice would be most appreciated. If you can make any referrals to Doctors near New Haven, CT that might be best experienced to help me, that would also be greatly appreciated.

Thank you very much,
Tim

ANSWER: Hello Tim,
I agree with your doctor, for the most part. However, you are in the age group with a higher incidence of benign and annoying prostate inflammation and possibly infection.  The biggest cause are germs in the bowel, which may or may not be well treated by ciprofloxacin or sulfamethaxazole (Bactrim), along with frequent ejaculation, to increase blood flow to the prostate (especially if you're taking an antibiotic!). Any type of irritation of the penis, urethra, testicles, anus, prostate may cause referred pain to any of those areas! So a prostate infection or irritation may cause the penile symptoms you are describing.

Worry and anxiety can make such symptoms worse. But as the tests have demonstrated, there is no evidence of STDs.

My advice to my own patients with your symptoms include: counseling for anxiety and guilt; relaxation with hot baths, relaxation exercises, yoga; frequent ejaculation  (with or without a regular partner), and sometimes an antibiotic (but your urine culture was negative).

Good luck!
--mark


---------- FOLLOW-UP ----------

QUESTION: Hi Mark,



Thank you so much for your advice.  I appreciate your guidance and help.  I do have a few remaining questions:



1) “other” STDs?  Are there any other STDs I should be concerned about?  While the standard test shows negative for 8 “standard” STDs, I’m 99.9% certain that the unprotected oral-genital contact is the cause for these symptoms (and that it’s not just a coincidence). Doesn’t that make it an “STD”?  Or, is there some other standard definition for STD?  If it was spread to me by such contact, is it also spreadable by me?  Is there some way to know for sure that I’m ‘clean’, or, at least, not contagious? (Even if we don't know for sure what is causing it?)


2) “Bumps”?  I know that the picture doesn’t show them very well, but there are small bumps on the tip at either side of the urethra opening.  I take it that you also agree with my Doctor that these don’t look like any of herpes, syphilis, or genital warts? While these are small, they are large enough (and located just right) that they interfere with the urine stream.  Any thoughts on what they might be?


3) Prostate testing: Does the negative urine culture rule out any prostate infection?  Or, should I be getting other tests to confirm that my prostate is OK?


4) Timing:  So, it sounds like at this point, your suggestion is that this is probably on a path to clear itself.  Any idea how long it should take?


I’m terrified that some relief has come with the steroids in the topical cream, and that when I stop applying it, it’s going to get worse.  I’ve seen a number of other posts on the internet with similar issues (burning problems after oral-genital contact, in which most tests come back negative, and there doesn’t appear to be any cure).  As I’ve said, the cream has been a help, but it does not seem to be “curing” the problem – just making it more livable.  I won’t really know until after Monday, when I stop applying the cream.



Again, thank you so much for your advice and help.

Tim

Answer
Hello Again, Tim,

1) “other” STDs?  Are there any other STDs I should be concerned about?  While the standard test shows negative for 8 “standard” STDs, I’m 99.9% certain that the unprotected oral-genital contact is the cause for these symptoms (and that it’s not just a coincidence). Doesn’t that make it an “STD”?  Or, is there some other standard definition for STD?  If it was spread to me by such contact, is it also spreadable by me?  Is there some way to know for sure that I’m ‘clean’, or, at least, not contagious? (Even if we don't know for sure what is causing it?)

Here's a partial list of STDs, some of which are common, many are absolutely not! In some of these cases, the causative agents may be communicable in sexual or non-sexual ways. In some cases the causative agents are listed, in some cases just the disease entity:
parasites: pubic lice, scabies
protozoa/amoeba/fungi: trichomonas, giardia lamblia, entamoeba histolytica, cyptosporidium, candida, cyrptosporidium
bacteria: gonorrhea, chlamydia, syphilis, hemophilus ducreyi/chancroid, lymphogranuloma venereum, granuloma inguinale, ureaplasma, mycoplasma, donovanoisis, campylobacter, shigella, salmonella
viruses: herpes 1&2, human papilloma virus (HPV)/warts, hepatitis B, HIV, molluscum contagiosum, cytomegalovirus, epstein barr virus

I've probably omitted a few! HOWEVER, this list is not given to freak  you out. Only to say that "STD tests" are pretty vague and more specific information is needed so you can be better informed.

2) “Bumps”?  I know that the picture doesn’t show them very well, but there are small bumps on the tip at either side of the urethra opening.  I take it that you also agree with my Doctor that these don’t look like any of herpes, syphilis, or genital warts? While these are small, they are large enough (and located just right) that they interfere with the urine stream.  Any thoughts on what they might be?

Normal variation in the skin. They come and go everywhere. That's what the skin does!

3) Prostate testing: Does the negative urine culture rule out any prostate infection?  Or, should I be getting other tests to confirm that my prostate is OK?

Urine tests look for common BACTERIAL pathogens that cause kidney or bladder infections. But not necessarily prostate infections. Diagnosing prostate conditions is frequently a diagnosis of exclusion. This means, testing negatively for common things with trials of therapy relieving symptoms cinches a diagnosis. There are no good imaging tests (like x-ray, ultrasound), and prostate biopsy is too invasive a test with risks outweigh the benefits.

4) Timing:  So, it sounds like at this point, your suggestion is that this is probably on a path to clear itself.  Any idea how long it should take?

From several weeks to several months. The palliative treatments-- preventing constipation, hot sitz baths, avoidance of certain common medications such as antihistamines and decongestants, frequent ejaculation to increase blood supply, etc.


I’m terrified that some relief has come with the steroids in the topical cream, and that when I stop applying it, it’s going to get worse.  I’ve seen a number of other posts on the internet with similar issues (burning problems after oral-genital contact, in which most tests come back negative, and there doesn’t appear to be any cure).  As I’ve said, the cream has been a help, but it does not seem to be “curing” the problem – just making it more livable.  I won’t really know until after Monday, when I stop applying the cream.

Steroid creams are designed to reduce the inflammation; going off the medication "cold turkey" may result in a TEMPORARY rebound in the inflammatory symptoms you may have. Weaning you off the cream may be helpful. The primary problem is your "terror" which is a rather exaggerated response. You may need counseling or therapy to address this unusually strong emotional reaction! Talk with your doctor(s)!!

Good luck!
--mark  

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Mark P. Behar

Expertise

Almost any question or concern about gay men's health issues, sexually transmitted infections, abnormal Pap smears, anal cytology (anal "Pap smears"), etc. There is no such thing as “d/d free” or “clean” (free of infection), so why do so many of us deceive ourselves into thinking that some people are indeed totally free from a potentially infectious disease, like HIV, herpes, hepatitis, syphilis, chlamydia, warts, gonorrhea, etc., just because they say so? Clinical laboratory tests are not perfect, and having a “negative” or “nonreactive” test does not mean that a person is free from infection. Perhaps at the moment the test was taken, the person was uninfected; or, perhaps, the test wasn’t sensitive enough to detect presence of the infection. There is really no way that anyone can determine that they are truly “disease free,” and there are over a hundred of infectious conditions that can be spread without your knowing anything. Rather than trying to “pre-screen” or “serosort” a potential sex-mate with deceptive questions that are impossible to know by today’s technologies, a wiser option may be to consider everyone infected with something, and either use appropriate protective measures (“safer sex”), or accept the responsibility and consequences of possibly “catching” something from someone who’s hotter than expected (pun intended!). There is much research that supports the contention that an HIV positive person reliably taking HIV medications, and having an undetectable viral load, presents a lower risk for transmission of HIV than people who may think or say they are HIV negative, but are not. Food for thought!

Experience

Family Practice PA since 1981; Volunteer Clinician for Brady East STD (BESTD) Clinic, Milwaukee, since 1977; answered STD questions submitted to their web site. Professionally lectured at national and regional Physician Assistant and Nurse Practitioner conferences, and at national gay & lesbian health conferences on topics including HIV/AIDS, herpes, hepatitis, STDs, human papilloma virus (the cause of venereal warts), abnormal Pap smears, gay and lesbian health issues, among others.

Organizations
Co-Founder, Lesbian, Bisexual, & Gay Physician Assistant Caucus of the American Academy of Physician Assistants, Inc.; American Academy of Physician Assistants; Wisconsin Academy of Physician Assistants; National Co-Chair (2012-16), National Association of Black and White Men Together: A Gay, Multiracial Organization for All People (NABWMT)

Publications
Journal of the American Academy of Physician Assistants (JAPA) Q Visions, Quarterly Newsletter of the NABWMT

Education/Credentials
Bachelor's of Arts, 1972 (University of Wisconsin, Milwaukee, WI) Graduate Credits Experimental Psychology, 1972-75 (Tulane University, New Orleans, LA) Physician Assistant, Bachelor's of Science, 1981 (George Washington University, Washington, DC); Masters in Physician Assistant Studies, 2000 (University of Nebraska Medical Center, Omaha, NE)

Awards and Honors
Colposcopy Recognition Award (CRA), the American Association of Colposcopy and Cervical Pathology; Distinguished Fellow, Clinical Preceptor, American Academy of Physician Assistants; Fellow, Wisconsin Academy of Physician Assistants

Past/Present Clients
Brady East STD Clinic, Milwaukee, WI Milwaukee Health Services, Inc. (Martin Luther King Heritage Health Center), Dept. of Family Medicine and Early Intervention Program for HIV Infected Persons

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