Dr. Roach Column: Searching for a cause of mystery discharge

Dr. Keith Roach M.D.

DEAR DR. ROACH: Back in late 2014, I noticed a dampness in my underwear -- no coloration, only dampness. I consulted a gastroenterologist about a possible anal discharge. After obtaining a history, we took some conservative approaches to deal with this, including probiotics and exercises for the anal muscles. After there was no change, we did a colonoscopy and the report said it my colon was normal, with no fistulas or fissures.

I was then referred to a rectal surgeon, who did a sonogram with a new tool, and found no abnormalities. He then dealt with many of my hemorrhoids, again with no change.

It has been over five years since this began, and while it has not improved, it has not worsened either. There is no fecal or urinary incontinence, the discharge is clear and has a very faint smell. I have dealt with it by using padding in my underwear to catch it. The discharge seems to be more present in the front of the pad. What could this be? And what can I do about it? -- B.R.

ANSWER: While leakage from the urethra or rectum is not uncommon, confusion about the cause after such a prolonged course is not the norm. It seems to me that you have had a thorough evaluation of the rectal area, so it should be worthwhile to evaluate the urinary side. The fact that the discharge is nearly odorless makes rectal leakage less likely.

A British physician once wrote, "Once you eliminate the impossible, whatever remains, no matter how improbable, must be the truth" (he put it in the words of his detective character, Sherlock Holmes). One consideration would be a urethral diverticulum. This is a blind pouch coming off of the urethra, the tube that drains the bladder. A small amount of urine can enter the diverticulum and you would not be able to control it, nor possibly even notice it, when it comes out.

Another possibility is ejaculatory fluid. Most of the fluid in semen is made by the seminal vesicles and the prostate gland, with a small amount produced by the bulbourethral glands. Fluid from the seminal vesicles and prostate is thick and milky, with the bulbourethral glands making a clear fluid. Fluid can discharge from these glands, especially after a bowel movement.

I recommend an evaluation by a urologist.

DR. ROACH WRITES: A recent column on vulvodynia inspired many letters from readers. Several readers noted that they were ultimately diagnosed with interstitial cystitis, and that treatment for this condition relieved their vulvovaginal pain. Several women noted that changing the type of underwear and even toilet tissue was effective at relieving pain, concerning for the diagnosis of contact dermatitis.

Some readers wrote in that a low oxalate diet improved their symptoms. Well-done studies have shown no consistent benefit from a low oxalate diet, and I do not recommend it. A major change in diet is not easy, and is likely to cause a placebo effect. This could explain why some women get relief from their symptoms.

Estrogen cream can be effective for some women, especially post-menopausal women with changes in the vulva and vagina from loss of estrogen.

Finally, one woman reminded me that there are medical treatments, such as tricyclic antidepressants, which affect how pain is processed in the brain. These can give significant, if not complete, relief.