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Question:
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| I am very active sexually. Now, I have a green discharge coming out of my penis upon urination. I have tested negative for syphilis, gonorrhea, chlamydia etc. What could it be?
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Answer:
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| Thank you for your inquiry. If the "Etc." includes testing negative for other sources of bacterial infection then this is surprising and I would strongly recommend re-testing. I would expect that initial tests should have included direct swab and culture of the discharge and treatment based o the results... but even if no positive results, still providing treatment albeit necessarily selected empirically. As the discharge is continuing best to get re-tested ASAP. If you'll sit through a short primer on STDs, this is a very common question that comes in by direct e-mail (commonly early in the working week) so it may be worth going into more detail. URETHRAL DISCHARGE is the commonest presentation of STD in men. The cause is almost always either gonococcal (due to gonorrhea) or non-gonococcal infection. The commonest cause of non-gonococcal infections is chlamydia (but other sexually-acquired bacteria may be responsible). In about a quarter of all cases no bacteria can be identified and the diagnosis is then truly non-specific urethritis (inflammation of the urethra). It's important that the treating doctor has both an accurate picture of the patient's sexual contact history, as well as the ability to perform a thorough physical and genital examination and access to the required laboratory tests. Making the diagnosis can be difficult, time-consuming and frustrating for both patient and doctor otherwise. Don't think that anything you've done is best left unsaid because if the history is inaccurate, the diagnosis will be as well, and the doctor is bound to keep your information confidential. On physical examination the doctor will look especially at the skin, not just of the genitals, may also look at soles of the feet, mouth, eyes, and joints as well. A sample of the discharge should always be sought and if this is not present at the time of examination then at the least a urethral swab should be taken. The sample should always been examined both under the microscope as well as cultured - the most common reason for failure to diagnose and treat adequately is both parties' (doctor and patient) unwillingness to wait for the culture results and modify the initial treatment if then indicated. The second most common reason for diagnostic and treatment failure is not looking for chlamydia (present in 30-50% of men with a non-gonococcal infection). The third most common reason for treatment failure is not treating both sexual partners, who themselves don't abstain from sex long enough for the treatment to take effect - instead the infection swaps between partners, dodging effective treatment. In a number of cases penicillin is still the drug of choice but penicillin-resistant strains are becoming more common and this should be remembered if treatment fails. (The culture if done will identify resistant strains and define the appropriate antibiotic). Again, the commonest reasons for failure of treatment which is appropriate for the infection, are 1) failure to stop having sex, and concurrent or later re-infection; and 2) failure to complete the full course of treatment. After a course of treatment, the same microbiological tests should be carried out to ensure the patient has been cured. The female partner of a man with chlamydia-negative non-gonococcal urethritis should be treated despite the absence of an organism. PROSTATITIS is usually caused by non-gonococcal infections and can be especially difficult to cure. Pain is the most troublesome symptom; it may be located in bladder area, at the tip of the penis (common), in the scrotum, the creases of the groin, between the legs or even at the thighs. There may also be pain on urination, blood in the sperm, and the chronicity of the symptoms may cause loss of libido and depression. The prostate is usually not especially tender on examination, nor is it enlarged. To make a diagnosis, one must obtain a specimen of prostatic secretion for microscopy and culture and the prostate must be massaged to get this. As you can imagine this procedure is not comfortable and should be carried out only by the skilled; it can precipitate an epididymitis of the scrotum if carried out in the presence of a posterior urethritis or bladder infection and therefore these should be excluded or treated first. TREATMENT for prostatitis is a course of a broad spectrum antibiotic which will penetrate the prostatic fluid. REITER'S DISEASE is a rare (1%) complication of non-gonococcal urethritis, and is the name when there is associated joint involvement (and sometimes, eye involvement) with NGU. The leg joints, especially knees, ankles, and feet, are particularly affected. The diagnosis and treatment should be undertaken by a specialist physician. VAGINAL DISCHARGE. Not all vaginal discharges are pathological (i.e. caused by disease) and as opposed to males the commonest cause of an infective discharge is (non-sexually transmitted) fungal infection. Other, STD, causes are again gonococcal, chlamydial, and non-STD causes are Trichomonas and Gardnerella plus assorted other less common bacteria. As with urethral discharge, regardless of the possible cause, a careful history and examination plus the appropriate laboratory tests will be required. Even more so than in men, the symptoms, while helpful, are a poor guide to the diagnosis. The examination should again be both external / visual and internal / visual and with swabs for accurate diagnosis, however in the case of females examination with a speculum is required for all but the simplest and most obvious external infections. All specimens should be tested for all the common fungal and bacterial causes of non-normal discharge. Microscopy alone (without culture) will miss 50% of gonococcal and chlamydial cases. Of course, cervical cytology ("Pap smear") should be checked also if it hasn't already been done in the last year. TREATMENT of the problem should of course be directed at the cause as identified above. Note that fungal infections are not often sexually transmitted but the male partner should be seen if, firstly, they have symptoms, and secondly, if the woman has frequent occurrences. PELVIC INFLAMMATORY DISEASE is the most important complication associated with chlamydia positive, chlamydia negative and gonococcal infections - about 10% of women will develop this after one of these three infections. Long term problems after recovery from an acute episode of PID are considerable; chronic abdominal pain, menstrual disturbances, pain with intercourse, tubal pregnancy, and most disastrously, sterility. The proportion of patient with tubal infections who develop tubal blockages rises from 10% in a first infection to 75% with three or more attacks. It is absolutely essential if this diagnosis is made for an episode of pelvic pain and / or vaginal discharge associated with pelvic symptoms, that it is investigated carefully and treated properly and a cure obtained and proven to be obtained. The diagnosis and treatment should be undertaken by a specialist physician (gynaecologist). GENITAL HERPES Infection of the genitals with herpes simplex is common and very difficult to treat. The first attack is usually recognized by the patient, as multiple painful genital ulcers appear after an incubation period of about 1 week. The lesions start with redness, then blister, ulcerate, and finally crust. The lesions persist for about 2 weeks, then heal over the course of the third week. About one-third of patients have vague constitutional symptoms with the first attack, such as fever and overall unwellness. Rarely, patients have more severe symptoms of generalized viral infection. Treatment of the acute attack remains generally unsatisfactory. Pain may be relieved by bathing the lesions in warm salt water (1/2 tsp to 1/2 litre); icepacks; and simple analgesics. Recurrent infections give rise to much anxiety and seem to occur at intervals of about 120 days. The rate of recurrence seems to depend on the type of virus, and therefore it is worth testing for the cause of lesions if possible; patients with HSV Type 2 tend to suffer earlier and more frequent recurrences. It is also unfair to the patient and partner to make the diagnosis only on clinical grounds; whenever possible, microscopy and culture should be used to confirm the diagnosis. Usually there are warning symptoms of a recurrence, and the symptoms and signs of the attack are milder than the initial attack. TREATMENT Only a very few (specifically antiviral) agents are of benefit in acute or recurrent herpes, to reduce viral shedding, healing time, and duration of symptoms. Since lesions are widespread, especially in women, condoms do not provide protection and sex should be avoided while lesions are present. Even between acute attacks, the virus can be shed and condoms may be useful then. AIDS / HIV INFECTION AIDS is defined as an illness characterized by one or more indicator diseases. At present, even if the test is negative or equivocal, the diagnosis may be made on the presence of such disease(s). The HIV (Human Immunodeficiency Virus) which causes AIDS (the Acquired ImmunoDeficiency Syndrome) is transmitted sexually, in blood products, and during birth. Acute infection may be accompanied by a transient non-specific illness similar to glandular fever, or may be entirely symptomless and go unrecognised. After an indeterminate time (months - years depending on a large number of health, nutritional and environmental factors) then patient may develop the clinical disease indicators arising as a result of the damage the virus inflicts on the body's immune system. No cure or vaccine is currently available; therefore prevention is the only useful approach. It cannot be over-emphasized that sex with one partner, safe sex or no sex at all are the only effective strategies both in preventing individual infections and slowing down a global epidemic which is already of alarming proportions. No-one likes to hear this as it constrains behaviour seriously, but then, no-one likes to die before their time either... It is strongly recommended that when in an environment where casual sex is a possibility, condoms are bought and carried by both sexes; this does not constitute an index of promiscuity or infidelity but is a sensible adjustment to one of life's more difficult realities. If one suspects one may have contracted the infection, a test is vital to both make an early diagnosis and thereby have access to life- and quality of life-prolonging treatments, as well as to protect one's partner. Tests can be arranged rapidly and with confidentiality (please contact SOS or your medical advisors as soon as possible if you suspect the need for such a test). TREATMENT There is neither cure nor vaccine yet.
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