Urethritis: Rapid Evidence Review.

Urethritis refers to inflammation of the urethra and is classified as gonococcal (caused by Neisseria gonorrhoeae) or nongonococcal in origin (most commonly caused by Chlamydia trachomatis, Mycoplasma genitalium, or Trichomonas vaginalis). The most common signs and symptoms include dysuria, mucopurulent urethral discharge, urethral discomfort, and erythema. Diagnostic criteria include typical signs, symptoms, or history of exposure in addition to mucopurulent discharge, Gram stain of urethral secretions showing at least two white blood cells per oil immersion field, first-void urinalysis showing at least 10 white blood cells per high-power field, or a positive leukocyte esterase result with first-void urine. First-line empiric treatment consists of ceftriaxone and doxycycline; however, the antibiotic regimen may be targeted to the isolated organism. Repeat testing is not recommended less than three weeks after treatment because false-positive results are possible during this time. Patients treated for a sexually transmitted infection should have repeat screening in three months, with shared decision-making about future screening intervals. Patients treated for urethritis should abstain from sex for seven days after the start of treatment, until their partners have been adequately treated, and until their symptoms have fully resolved.

An overview of reactive arthritis.

Reactive arthritis, also known as Reiter syndrome, is a spondyloarthropathy that typically follows a urogenital or gastrointestinal infection, and is characterized by conjunctivitis, urethritis, and arthritis. The frequency of reactive arthritis in the United States is estimated at 3.5 to 5 patients per 100,000. Physician assistants (PAs) can manage the condition; therefore, they should be familiar with the disease's signs and symptoms, diagnostic criteria, and treatment regimens. Without proper management, reactive arthritis can progress to a chronic destructive arthritis. Prompt recognition of the condition is key to early intervention and a better patient outcome with fewer complications.

Relationships between diagnoses of sexually transmitted infections and urinary tract infections among male service members diagnosed with urethritis, active component, U.S. Armed Forces, 2000-2013.

A previous MSMR report found that 42.8% of all incident (first-time) urinary tract infections (UTIs) in males, but only 0.4% of such UTIs in females, were diagnosed as "urethritis, unspecified" (ICD-9: 597.80). This study explored the possibility that many of the diagnoses of urethritis in males represented sexually transmitted infections (STIs), even though ICD-9: 597.80 is explicitly reserved for cases of urethritis that are deemed to not be sexually transmitted. Examined were relationships between diagnoses of urethritis, diagnoses of STIs, and recurrent diagnoses of UTIs. Male service members who received a diagnosis of "urethritis, unspecified" (ICD-9: 597.80) had an increased risk of a subsequent UTI diagnosis, especially of "urethritis, unspecified," compared to all male service members. Most service members who were diagnosed with "urethritis, unspecified" had no documented diagnoses of an STI in their Military Health System health records; however, recurrent UTIs were more common among service members who did have documented STIs. The most commonly diagnosed STIs in this study were "other non-gonococcal urethritis" (which includes that caused by Chlamydia trachomatis) and gonorrhea.

The prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae infections among men with urethritis in Kuwait.

PURPOSE: Chlamydial non-gonococcal urethritis and gonorrhoea are the most common sexually transmitted bacterial infections worldwide. Data on these infections are scanty in the Islamic world, especially Kuwait. The objective of this study was to establish the prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae among men with symptomatic urethritis in Kuwait. METHODS: Men with urethral discharge seen and managed at eight governmental hospitals were recruited into the study. A pair of urethral swab and first-voided urine sample were taken from the patients and sent immediately to the laboratory where they were processed using strand displacement nucleic acid amplification kits (SDA; ProbeTec, Becton Dickinson); one pair per patient was studied. RESULTS: A total of 426 symptomatic men were studied, out of whom 155 (36.4%) were infected by either C. trachomatis or N. gonorrhoeae, or both. The overall prevalence rates of C. trachomatis and N. gonorrhoeae were 12.4% and 23.9%, respectively. There was no significant difference in chlamydial and gonococcal prevalence between Kuwaiti men and non-Kuwaitis (P>0.05). Infection rates were much lower in married men than unmarried men. Men in the age range of 21-35 years were more vulnerable to both infections. CONCLUSION: The findings show that N. gonorrhoeae and, to a lesser extent, C. trachomatis are common in men with urethritis in Kuwait. Appropriate preventive strategies that conform to Islamic rules and values should be of highest priority of the policymakers.

Idiopathic urethritis in young men in the United States: prevalence and comparison to infections with known sexually transmitted pathogens.

PURPOSE: Urethritis is the most common male reproductive tract disease syndrome; yet 20-50% of diagnosed cases have no defined etiology, and few population-level data exist on the prevalence or etiology of the syndrome. We estimated the prevalence of urethritis among young men in the United States and compared correlates of idiopathic cases to correlates of detected infections with sexually transmitted pathogens. METHODS: Questionnaire data and urine specimens from 5,447 men aged 18-27 years participating in Wave III of the National Longitudinal Study of Adolescent Health were analyzed. Symptomatic urethritis was defined as self-reported dysuria or urethral discharge in the past 24hours. Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, and Mycoplasma genitalium were identified using nucleic acid amplification tests. Idiopathic urethritis (IU) was defined as urethral symptoms in the absence of these four pathogens. Stratified weighted analyses generated population-based estimates. RESULTS: Urethritis was reported by 1.2% (95% CI=.8-1.6%) of men, of whom 82.4% (61.1-93.3%) had IU. Men with previous STD diagnoses (aOR=9.3 [95% CI=3.0-28.7]), or fewer (1-4) or no lifetime vaginal sex partners (aOR=7.5 [2.9-19.3] and aOR=7.2 [1.9-27.4]), were more likely to have IU compared with men without urethral symptoms or identified pathogens, whereas men of Native American or Asian/Pacific Islander descent (aOR=.04 [.01-.2]) and heavy drinkers (aOR=.08 [.03-.2]) were less likely to have IU. Unlike infection with known pathogens, IU was not associated with black race, Hispanic ethnicity, or age at sexual debut. CONCLUSIONS: Urethral symptoms were rarely associated with known pathogens. IU and known pathogens were associated with distinct characteristics.

[Non-chlamydial non-gonococcal urethritis].

Besides Chlamydia trachomatis, various microorganisms could cause non-gonococcal urethritis (NGU). Recently, Mycoplasma genitalium and Ureaplasma urealyticum (biovar 2) have been suggested to be other pathogens of NGU independent of C. trachomatis. Clinical findings of non-chlamydial NGU, including M. genitalium--or U. urealyticum-postive NGU, are not different from those of chlamydial NGU. M. genitalium and U. urealyticum (biovar 2) are susceptible to tetracyclines, macrolides, and fluoroquinolones. However, the post-treatment presence of M. genitalium in the urethra is significantly associated with persistent or recurrent urethritis. Eradication of this mycoplasma from the urethra is essential for managing M. genitalium-positive NGU. In treatment of non-chlamydial NGU, therefore, the antimicrobial agents that are active against M. genitalium should be chosen.

Asymptomatic urethral infection in male sexually transmitted disease clinic attendees.

The purpose of this study is to determine the prevalence of asymptomatic male patients with urethral infections attending a government sexually transmitted infection clinic in Hong Kong and their microbiological profile. A total of 274 consecutive male patients without any symptoms for urethral infections were recruited. A questionnaire was used to record the symptoms, sexual history and demographics. Further assessment, including urethral smear for Gram stain, gonococcal culture and polymerase chain reaction (PCR) for Chlamydia trachomatis (CT), Mycoplasma genitalium (MG) and Ureaplasma urealyticum (UU) were performed. In 274 asymptomatic patients, 36 patients had non-gonococcal urethritis (NGU) and two patients had positive gonococcal culture. Among the asymptomatic patients with NGU, there were 6 (16.6%), 10 (22.8%) and five (13.9%) patients with positive PCR for CT, UU and MG, respectively. In addition, there were 14 asymptomatic patients with positive PCR for CT but without evidence of NGU. In conclusion, urethral infections were identified in a significant number of asymptomatic male patients and therefore, routine screening for this group is warranted.

Is there a role for leucocyte esterase testing in non-invasive screening using nucleic acid amplification tests of asymptomatic men?

With the increasing pressure to achieve the government's 48 hour access target for departments of genitourinary (GU) medicine better utilization of resources must be part of the solution. The leucocyte esterase (LE) test has been shown to perform as well as a urethral smear in asymptomatic men in identifying chlamydia-positive individuals and is likely to perform better in detecting genitalium-positive individuals than chlamydia-positive men. The LE test, which is both inexpensive and non-invasive, offers an interim, evidence-based, solution to the issue of whether asymptomatic men attending departments of GU medicine should be screened for the presence of urethral inflammation.

Uroflow in murine urethritis.

OBJECTIVES: To develop a noninvasive method to measure urinary flow rate in the mouse. This could be useful for the study of bladder outlet obstruction, as well as processes affecting detrusor function in the awake animal. Genetically engineered mice can improve our understanding of a variety of human bladder diseases. METHODS: A metabolic cage without a fecal separation screen was placed above a precision balance that reported the mass of the excreta pan every 100 ms. A computational algorithm identified voids suitable for assessment of uroflow from other excretory events. These algorithms were verified by comparison with a series of images obtained automatically before and during the excretory events. Intraurethral acetic acid was used to induce urethritis and to verify the sensitivity of the measurement technique. RESULTS: Automatic categorization and characterization of uroflow was successful. Brief exposures of the urethra of the female C57BL6/J mouse to 2% acetic acid decreased uroflow and increased the void duration without a change in the voided volume. CONCLUSIONS: This method will enable studies of urologic function in mice of differing age, sex, strain, and genetic constitution. Murine urethritis can be differentiated from cystitis, known to be associated with a decrease in voided volume. The observed changes were consistent with urethral obstruction induced by local swelling and inflammation.

Antibodies to Chlamydia trachomatis heat-shock protein 60 kDa and detection of Mycoplasma genitalium and ureaplasma urealyticum are associated independently with chronic nongonococcal urethritis.

BACKGROUND: Chronic nongonococcal urethritis (NGU) is a well-recognized clinical problem in genitourinary medicine clinics, but its etiology and optimal management are poorly understood. GOAL: The authors showed previously that antibody to chlamydial hsp60 is associated with urethritis 30 to 92 days after treatment of acute NGU (chronic NGU) and that the detection of ureaplasmas or is associated with chronic NGU in which symptoms or signs are present. The aim was to determine whether these associations are independent of each other. STUDY DESIGN: This was a longitudinal prospective follow-up study over a 3-month period of 86 men with acute NGU. Men were tested for, ureaplasmas, and antibody to chlamydia hsp60 at presentation and during follow-up. RESULTS: The detection of either ureaplasmas or (OR, 29.45; 95% CI, 1.78-487) and the occurrence of hsp60 antibody at 30 to 92 days' follow-up (OR, 26.45; 95% CI, 1.34-523) were associated independently with the development of chronic NGU 30 to 92 days after treatment of acute NGU. The presence of chlamydial hsp60 antibody at 30 to 92 days was not associated with the development of chronic NGU in which symptoms or signs were present (P= 0.363). Chlamydial hsp60 antibody associated, however, with chronic NGU in which there were no symptoms or signs (P = 0.01). CONCLUSION: The results suggest that the immune response to chlamydial hsp60 may have a role in the etiology of chronic NGU in asymptomatic men who have no discharge on examination. The clinical relevance of this is unknown.

High incidence of treatment failure of Neisseria gonorrhoeae isolates to ciprofloxacin in male gonococcal urethritis in Delhi.

Several treatment failures and widespread antimicrobial resistance to ciprofloxacin have been documented, subsequent to its initial recommendation in 1989 as a single dose alternative therapy for gonorrhoea. Still, it continues to be part of various treatment schedules in National STD control guidelines including India. This prompted us to study the current status of this drug in the treatment of gonorrhoea. Thirty-five male patients with gonococcal urethritis were included in the study. The susceptibility to penicillin, tetracycline, ciprofloxacin and ceftriaxone was determined by Kirby-Bauer disc diffusion method and minimum inhibitory concentration (MIC) of ciprofloxacin by agar plate dilution method. The clinical and bacteriological response was assessed on day 5 after treatment with single dose ciprofloxacin, 500 mg. The sensitivity pattern of Neisseria gonorrhoeae was observed to be: ceftriaxone 100%, azithromycin 100%, tetracycline 65.7%, penicillin 40% and ciprofloxacin 5.7% by disc diffusion method. The MIC for ciprofloxacin was below 0.06 microg/mL (sensitive) in one (2.5%) isolate only. On the fifth day a large number of treatment failures (88.5%) were seen with ciprofloxacin while none was noted one week after re-treatment with ceftriaxone. The location of endemic quinolone-resistant N. gonorrhoeae (QRNG) in New Delhi has increased alarmingly, resulting in an extremely high proportion of therapeutic failures, and thus requiring appropriate alterations in the presently recommended treatment regimens.