Herpetic Urethritis, NGU or Something Else?

[migelos]

I am 57 year old male with longtime HSV-1 infection. Had multi encounters with HSV-2 infected woman. All intercourse used condoms, gving/receiving oral NO condoms. My symptoms are now 6 weeks old. Slight-moderate burning at penis tip during urination. Then afterwards, an inflammatory pain comes inside my urethra around the penis head and lasts from several minutes to 2 hours. On a pain scale from 0-10, it usually fluctuates between 1 and 3, and at times gets to 5. I have not had any discharge or blood in urine. No fevers, chills or lesions. There seems to be no obstruction with urine flow. Upon the positive HSV-2 igM result began a five-day 4x200 mg treatment of acyclovir, which did not help. I then took the urine tests and swabs and all was negative, no blood, no evidence of chlamydia, gonorrea, no discharge. Then two rounds of multi ABs, no help. Now 6 weeks into this, I  do not know if this is HSV-2 related, still no lesions. Besides my general concern about what to do, I have these specific questions. 1) If my urethra was always covered during intercourse and assuming that HSV-2 infection from her mouth to my genitals is unlikely, would it be possible that the virus entered through an unprotected part of my penis or genitals and somehow got into my urethra and infected my urethra alone? Am I correct about the low probability of HSV-2 infection from receiving unprotected oral?
2) Do you think this is HSV-2 or merely NGU that won't go away, or something else?
3) When I do retest, is any HSV-2 not based on glycoprotein G accurate?
4) As I am in Bolivia, is there a way to take my blood here and send it to your lab for testing, or should I just do an Elisa here? I have been told that since I am already HSV-1-infected, any non-glycoprotein G-based HSV-2 IgG test would probably show up positive.  

[Terri Warren, RN, Adult Nurse Practitioner]

You're welcome.

Terri

[migelos]

thank you very much, Terri, that does it!

[Terri Warren, RN, Adult Nurse Practitioner]

Sorry.  I will try to elaborate for you.  If you used a condom for all intercourse related activities, your urethra itself was not exposed to HSV 2 infection.  The reason I answered your question with information about HSV 1 is because the only HSV your urethra would be exposed to, specifically, is HSV 1 from oral sex.  To be clear, I think HSV 2 infection in the urethra alone in this situation is extremely unlikely.  While it is possible that you could have contracted HSV 2 genitally, I think having urethral symptoms with no skin presentations is extremely unlikely.  If you had acquired HSV 2 genitally, I would expect some genital lesions as well as urethral symptoms, especially since you did use a condom.

We don't really have worries about HSV penetrating a condom, particularly latex condoms as they provide good protection.  However, since condoms reduce the risk of acquiring herpes overall by about 30-50%, you could still have acquired herpes.  but you have no skin lesions per your post, so I think it is very unlikely that you would get herpes and have only urethral symptoms.

Urethritis with no skin lesions with HSV 2 infection is, in my experience, with a first infection, would be very unusual.  I have not seen this particular presentation ever in 32 years of practice.

In terms of my answer to your question about when to test, I would again say that if you continue to have sex with this person, the testing date is a moving target.  If you don't have sex with this person any more, then I would recommend that you allow 4 months from the encounter before you test for greatest accuracy.  Statistics suggest that 50% of people who acquire HSV 2 will be positive after 3 weeks, 70% after 6 weeks, and most everyone else by 4 months from the encounter.  the test that you should use should be one based on glycoprotein G or the western blot.  These tests include herpeselect or the type specific test by Captia that LabCorp uses.  You may also use the Biokit, an in office test.

I hope this response more fully meets your needs.

Terri

[migelos]

i am unhappy with Terri Warren's very limited response to my paid query. She did not address my specific questions!

[migelos]

Terri, if you would take a look at my identical post in the community forum it gives more details and maybe it would help you shed more light on my case. thanks.

[migelos]

Terri, I am asking you about hsv-2 infection to my urethra, not hsv-1...I would like to know if hsv-2 entering uncovered penis skin could penetrate and somehow get into my urethra without creating lesions on my penis. Also, how uncommon is urethritis without lesions as the only symptom of first outbreak.

[Terri Warren, RN, Adult Nurse Practitioner]

I think NGU due to the traditional organisms is unlikely given your constant condom use is unlikely.  And since you already have HSV 1, new infection at the urethra is very unlikely.  

The IgM test is not useful.  And I would stop taking antiviral therapy if you want to continue to test as it may throw off the results.  

And ELISA would be fine as a place to start.  And yes, it needs to be type specific for certain!  But if you are having regular sex with this person, the test is always going to be a moving target (not that you shouldn't have sex with this person).  

Terri