Abnormal Penile Discharge In Men

Abnormal penile discharge is any substance that comes out of the penis that’s neither urine or semen.

This discharge usually comes out of the urethra, which runs through the penis and exits at the head. The penile discharge may be watery (clear) or cloudy (containing pus) and/or bloody.

Discharge from the penis is commonly the sign of a sexually transmitted infection (STI) although not all. That is why it requires prompt and accurate diagnosis and treatment by a medical practitioner. Penile discharges that are pre-ejaculate and ejaculate due to sexual arousal are considered normal.

Penile discharge and it’s associated symptoms

Penile discharge can vary in colour from clear to yellow or green and in amount from scanty to profuse. The timing also varies from loss in the morning only to throughout the day.

Penile discharge often accompanied by other symptoms, and not necessarily all including the following:

• Painful / burning urination (Dysuria)
• Urethral itchiness 
• Blood in urine (Hematuria) or blood in semen (hemospermia)
• Painful intercourse or ejaculation

Causes of penile discharge

Penile discharge can be caused by STD or non-STD related infection. Penile discharge due to sexually transmitted infection are subdivided into either gonococcal urethritis and non gonococcal urethritis (non specific urethritis). The non STD causes are due to either urinary tract infection, balanitis, smegma, and prostatitis. In this article, I would focus more about the STD related infection.

• Gonococcal urethritis (gonorrhoea)

Gonorrhoea is a sexually transmitted disease (STD) caused by infection with the Neisseria gonorrhoeae bacterium. In the US, 583,405 cases of gonorrhoea were reported to CDC in 2018 alone.

1. Gonorrhoea incubation period: it will usually take up to 2-5 days from exposure to symptoms. Without treatment, the symptoms of urethritis (inflammation of the urethra) and purulent (pus-containing) discharge will peak within two weeks.

2. What does the Gonorrhoea discharge look like?

Discharge occurs in 95 % of men and is white or cloudy in 10 % of them. When the infection begins to resolve, the discharge may change from purulent to mucoid (mucus-like). Recent urination can make the discharge appear less purulent. 

3. How does gonorrhoea transmit?

Gonorrhoea often transmit through sexual intercourse, including oral sex. Without treatment, the infection can continue for many months and cause complications.

• Non-gonococcal or non-specific urethritis (NSU)

The term non-gonococcal urethritis (NGU) is used when the condition is not caused by the gonorrhoea. NGU is sometimes referred to as non-specific urethritis (NSU) when no cause can be found. 

1. NGU can have a number of possible causes, including:

• irritation or damage to the urethra due to detergent or soap
• sexually transmitted infections (STIs) : Chlamydia , Trichomonas
• other infections : such as a urinary tract infection (UTI)

2. Several different organisms (bugs) can cause the syndrome:

• Chlamydia trachomatis : 25 – 60 % %
• Mycoplasma genitalium : up to 25 %
• Ureaplasma urealyticum : 15 – 25 %
• Trichomonas vaginalis : 17 %
• Herpes simplex / Yeast : rare

3. How does NSU transmit?

NGU are usually spread through sex or contact with infected genital fluids (semen or vaginal fluid). You can get chlamydia and other NSU through:

• unprotected vaginal, anal or oral sex
• sharing sex toys that are not washed or covered with a new condom each time they’re used
• your genitals coming into contact with your partner’s genitals – this means you can get chlamydia from someone even if there’s no penetration, orgasm or ejaculation

Thus, practising safer sex is the best way to reduce the chances of it. Safer sex involves using barrier contraception, such as condoms, and having regular checks at sexual health clinics.

Also read: Penis & Foreskin Infections

How to diagnose the organism that causes Penile discharge?

The colour and consistency of the discharge only does not help to distinguish NSU from gonococcal urethritis. There are few tests that can be done to diagnose the causes of penile discharge, and all may be carried out to make sure the diagnosis is correct. The infecting organism might be identified from these samples.

The tests are:

• Urethral swab test : a sample of fluid is taken from your urethra using a swab, which is like a small cotton bud. The swab may have a small plastic loop or cotton tip at the end; it’s not painful, but can feel a little uncomfortable for a few seconds
• Urine test : To make the test more accurate, you’ll be asked not to pee for at least 2 hours before providing a urine sample or ‘first catch’ urine sample (urine taken from when you first begin to pass urine).
• Microscopic examination of the discharge obtained from a urethral swab can be done to diagnosed gonococcal urethritis.

Asymptomatic urethritis is also common at around 16% of cases  and typically non-gonococcal in etiology. Patients may be detected with partner screening for STIs or with physical examination revealing unrecognized urethral discharge. The development of more sensitive tests, such as polymerase chain reaction, allow for more precise diagnosis, particularly in patients with no symptoms and especially if they are sexual contacts of proven infected women. 

STD Screening In Malaysia

Treatment options for penile discharge

Depending on the cause, a course of antibiotics is usually the first point of defence for penile discharge:

• Gonorrhoea

Gonorrhoea can be cured with the right treatment. CDC recommends a single dose of 250mg of intramuscular ceftriaxone plus 1g of oral azithromycin. 

• Non Specific Urethritis 

Depends on the causative organism 

1. Chlamydia trachomatis / Ureaplasma / Mycoplasma : 

Doxycycline 100mg twice daily for seven days or a single dose of azithromycin 1g as a single dose.

2. Trichomonas: 

Metronidazole two times a day for seven days.

3. Herpes Simplex Virus:

valacyclovir: 1000 mg orally twice daily for 7 days

Sexual partners

If you have penile discharge, you will be asked who you had sex with in the past 2 months. Anyone you have had sex with in the past two months will need to be tested and treated. Partners are almost always treated whether they have symptoms or not. If you have not had sex in the past two months, your last partner should be tested. Sexual partners should be given similar treatment.

There are a few ways you can tell partners about STI testing. Some people want to tell partners in person, others want to tell partners anonymously. You can talk to your health care provider about what ways might work best for you.

After treatment

You and your partner should wait at least 2 weeks after you both finish treatment to resume sexual activity. Y

our doctor may advise you to follow up for testing after 1month with a repeat urine or swab test (known as a ‘test of cure’) to make sure the infection is completely gone. Men who receive a diagnosis of Gonorrhoea or NGU should be tested for other STD such as HIV and syphilis.

What if symptoms persist?

Unfortunately, some types NSU don’t respond to the usual antibiotic treatment and we call this “antibiotic resistance.” They’ve been seeing a rise in these stronger bacteria for several years. However, most suspected treatment failures are likely to be re-infections rather than actual treatment failures.

If you continue to have symptoms a few days after treatment, see your doctor again. They may do further tests or prescribe a longer course of different antibiotics. 

What are the complications of untreated penile discharge?

1. If left untreated, gonorrhoea can also spread to the blood and cause disseminated gonococcal infection (DGI). DGI is usually characterized by arthritis, tenosynovitis, and/or dermatitis. This condition can be life threatening.
2. Reactive arthritis  – when the immune system starts attacking healthy tissue, which can lead to joint pain and conjunctivitis
3. Epididymo-orchitis – inflammation inside the epididymis and testis.
4. Infection of the prostate (prostatitis)
5. Increased risk of contracting other STIs and HIV
6. Anal infection is common especially, but not only, when the infection is transmitted by anal intercourse. 
7. Infection can went into the joint, brain and heart causing condition called Septic arthritis, meningitis and endocarditis
8. Infertility can also occur in late complications.