Problems with non-gonococcal urethritis

Updates on Sexually Transmitted Urethro-cystitis

Purpose of Review

We performed recent literature review with the aim to address the updates in diagnosis and management of sexually transmitted urethro-cystitis.

Recent Findings

There are multiple, recently published studies that collectively lead to an organized stepwise plan for diagnosis and management of sexually transmitted urethro-cystitis.

Summary

Sexually transmitted urethro-cystitis is a common health condition that can be managed efficiently if the appropriate steps are taken in diagnosis and management.

Clinical profile and co-infections of urethritis in males

BACKGROUND

Infectious urethritis are classified in N. gonorrhoeae (NG) urethritis and non-gonococcal urethritis, caused commonly by C. trachomatis (CT) or M. genitalium (MG) in Western Europe. The primary objective of the study is to evaluate the association between the clinical profile and the pathogens. Secondly, to assess the prevalence of co-infections.

METHODS

The clinical profile of urethritis in men caused by NG, CT and MG confirmed by nucleic acid amplification test (NAAT) on first void urine has been retrospectively collected. The clinical profiles comprised the assessment of dysuria and/or discharge and the clinical-dermoscopic examination of the genitalia. Serological tests for syphilis and HIV were also performed.

RESULTS

A total of 101 episodes of NAAT confirmed NG, CT or MG urethritis were identified. The prevalence for each pathogen was 50.60%, 33.73% and 15.66%, respectively. Co-infections were observed in few cases (four MG+CT, one NG+CT, one NG+MG), with M. hominis, U. urealitycum and U. parvum positivity found concomitantly in 7-8% cases. The median age of patients was 33 years. Dysuria was reported in 88% cases (95% NG, 79% CT, 78% MG urethritis). Urethral discharge was found in 86% of cases, including purulent discharge in 61% (98% NG, 70% MG) and transparent in 25% (64% CT). Dysuria and purulent discharge were observed in 95% NG, 54% MG and 29% CT cases, whereas dysuria and transparent discharge were observed in 50% CT, 23% MG and in none of NG cases (P<0.01). Balanitis/meatitis was observed in 24% of cases, genital warts in 12% and proctalgia in 4%.

CONCLUSIONS

NAAT is crucial for defining urethritis etiology. Dysuria is the most common symptom. Gonococcal urethritis present with purulent discharge, whereas transparent discharge is associated with non-gonococcal pathogens. Co-infections are rare. Clinical exam may detect other infectious diseases, in particular genital warts.

2016 European guideline on the management of non-gonococcal urethritis

We present the updated International Union against Sexually Transmitted Infections (IUSTI) guideline for the management of non-gonococcal urethritis in men. This guideline recommends confirmation of urethritis in symptomatic men before starting treatment. It does not recommend testing asymptomatic men for the presence of urethritis. All men with urethritis should be tested for Chlamydia trachomatis and Neisseria gonorrhoeae and ideally Mycoplasma genitalium using a nucleic acid amplification test (NAAT) as this is highly likely to improve clinical outcomes. If a NAAT is positive for gonorrhoea, a culture should be performed before treatment. In view of the increasing evidence that azithromycin 1 g may result in the development of antimicrobial resistance in M. genitalium, azithromycin 1 g is no longer recommended as first line therapy, which should be doxycycline 100 mg bd for seven days. If azithromycin is to be prescribed an extended course of 500 mg stat, then 250 mg daily for four days is to be preferred over 1 g stat. In men with persistent NGU, M. genitalium NAAT testing is recommended if not previously undertaken, as is Trichomonas vaginalis NAAT testing in populations where T. vaginalis is detectable in >2% of symptomatic women.

Management of non-gonococcal urethritis

Non-gonococcal urethritis (NGU), or inflammation of the urethra, is the most common treatable sexually transmitted syndrome in men, with approximately 20-50 % of cases being due to infection with Chlamydia trachomatis and 10-30 % Mycoplasma genitalium. Other causes are Ureaplasma urealyticum, Trichomonas vaginalis, anaerobes, Herpes simplex virus (HSV) and adenovirus. Up to half of the cases are non-specific. Urethritis is characterized by discharge, dysuria and/or urethral discomfort but may be asymptomatic. The diagnosis of urethritis is confirmed by demonstrating an excess of polymorpho-nuclear leucocytes (PMNLs) in a stained smear. An excess of mononuclear leucocytes in the smear indicates a viral etiology. In patients presenting with symptoms of urethritis, the diagnosis should be confirmed by microscopy of a stained smear, ruling out gonorrhea. Nucleid acid amplifications tests (NAAT) for Neisseria gonorrhoeae, C. trachomatis and for M. genitalium. If viral or protozoan aetiology is suspected, NAAT for HSV, adenovirus and T. vaginalis, if available. If marked symptoms and urethritis is confirmed, syndromic treatment should be given at the first appointment without waiting for the laboratory results. Treatment options are doxycycline 100 mg x 2 for one week or azithromycin 1 gram single dose or 1,5 gram distributed in five days. However, azithromycin as first line treatment without test of cure for M. genitalium and subsequent Moxifloxacin treatment of macrolide resistant strains will select and increase the macrolide resistant strains in the population. If positive for M. genitalium, test of cure samples should be collected no earlier than three weeks after start of treatment. If positive in test of cure, moxifloxacin 400 mg 7-14 days is indicated. Current partner(s) should be tested and treated with the same regimen. They should abstain from intercourse until both have completed treatment. Persistent or recurrent NGU must be confirmed with microscopy. Reinfection and compliance must be considered. Evidence for the following recommendations is limited, and is based on clinical experience and guidelines. If doxycycline was given as first therapy, azithromycin five days plus metronidazole 4-500 mg twice daily for 5-7 days should be given. If azithromycin was prescribed as first therapy, doxycycline 100 mg x 2 for one week plus metronidazole, or moxifloxacin 400 mg orally once daily for 7-14 days should be given.

Diagnostic utility of urethral smears in predicting urethral chlamydia in HIV-infected men

We collected data from 218 HIV-infected men to assess the usefulness of the urethral smear and symptoms in predicting Chlamydia trachomatis infection. Prevalence of urethral chlamydia was 9%. A polymorphonuclear leucocyte (PMNL) count ≥5 was 73% sensitive and 71% specific for C. trachomatis infection. Adjusted odds ratio for risk of chlamydial infection was significant for urethral irritation (7.48; 1.54–36.4), a PMNL count of 20 or more (9.83; 2.52–8.4) and a PMNL count of 5–19 (4.10; 1.34–12.5). We had to perform 50 urethral smears in HIV-positive men without symptoms to treat one case of C. trachomatis at the time of visit. Findings suggest that the presence of symptoms, in particular urethral irritation may be associated with chlamydial urethritis and that the higher the urethral PMNL count, the more likely it is for C. trachomatis to be detected. The findings in this study also lend further support to recent guidelines that urethral microscopy is not useful in asymptomatic men and hence should be abandoned.

Is the urethral smear necessary in asymptomatic men attending a genitourinary medicine clinic?

Available evidence does not support the performance of urethral smears in asymptomatic men

A comparison of clinical features between chlamydial and non-chlamydial urethritis in men negative for gonococcal infection who attended a urological outpatient clinic in Japan

OBJECTIVES

The objective of this study was to investigate the clinical features of non-gonococcal urethritis in men who attended a urological outpatient clinic in Japan.

MATERIALS AND METHODS

This study included a total of 194 patients diagnosed as having non-gonococcal urethritis and subsequently judged as cured following antibiotic therapy between January 2001 and June 2005. Clinical data were analyzed after dividing these patients into two groups as follows: 96 patients with chlamydial urethritis (CU) and 98 with non-chlamydial urethritis (NCU).

RESULTS

The incubation period in the CU group was significantly longer than that in the NCU group (P = 0.0020). The incidence of severity of symptoms in the NCU group was significantly greater than that in the CU group (P = 0.022), and the interval between the appearance of the initial symptom and consulting the clinic was significantly shorter in the NCU group than in the CU group (P = 0.0015). The proportion of commercial sex workers (CSWs) as the causative partner in the NCU group was significantly greater that in the CU group (P < 0.001), and the incidence of oral sex as the causative mode of sexual interaction was significantly more frequent in the NCU group than that in the CU group (P = 0.021). The duration of antibiotic therapy until cured was significantly longer in the CU group than in the NCU group (P = 0.0051). Furthermore, multivariate analysis showed that whether the infection involved CU or NCU was independently associated with the treatment interval irrespective of other factors examined (P = 0.041).

CONCLUSIONS

These findings suggest that the clinical characteristics of CU and NCU clearly differ and that CU tends to require a longer time to cure than NCU; therefore, among patients with non-gonococcal urethritis, it would be particularly important to effectively control the spread of CU.

Ectopic Pregnancies and Reproductive Capacity After Chlamydia trachomatis Positive and Negative Test Results: A Historical Follow-Up Study

BACKGROUND

Recent studies have shown that women with Chlamydia trachomatis-positive test results worry about their future fertility.

GOAL

The goal of this study was to give women infected with C. trachomatis a fertility prognosis by analyzing ectopic pregnancies and birth rates

STUDY DESIGN

An historical follow-up study in a cohort of 22,264 women tested for the infection was conducted.

RESULTS

Cox regression analysis with time-dependent covariates showed that women with at least 1 C. trachomatis-positive test result had a lower incidence rate of ectopic pregnancy than women with negative test results only (adjusted hazard ratio, 0.55; 95% confidence interval [CI], 0.31-0.96). We found comparable birth rates in the 2 groups (adjusted hazard ratio, 0.92; 95% CI, 0.84-1.00).

CONCLUSIONS

Counseling of women with a C. trachomatis-positive test result should emphasize the benefit of detection and treatment of the infection in terms of future morbidity.

Genitourinary chlamydial infection: a reappraisal and hypothesis

Our understanding of genitourinary chlamydial infection and disease remains limited. That natural defences and/or apparently adequate treatments leave some patients with latent disease is suspected. There is, however, no consensus as to its nature. Furthermore, many patients, most obviously males, presenting with similar or identical symptoms and signs remain unexplained in microbiological terms; this in spite of many years of dedicated research endeavour. The recent trend towards an impasse has coincided with a growing acquaintance with the immunobiology and immunopathology of chlamydial infections. The time would seem to have arrived for a reappraisal of available clinical and laboratory observations. A hypothesis with research suggestions is presented for discussion.

Peripheral blood T cell proliferative response to chlamydial organisms in gonococcal and non-gonococcal urethritis and presumed pelvic inflammatory disease

OBJECTIVE

To study peripheral blood mononuclear cell (PBMC) proliferative response to Chlamydia trachomatis elementary bodies in (a) controls, (b) various stages of gonococcal (c) and non-gonococcal urethritis, and (d) women with a clinical diagnosis of pelvic inflammatory disease (PID).

METHODS

We categorised 102 men presenting to a GUM clinic with urethritis by organisms (C trachomatis (CT) or Neisseria gonorrhoeae (NG) (both by culture), and whether it was their first (urethritis naive) or subsequent (urethritis experienced) attack. 23 women presenting to the clinic with a clinical diagnosis of PID were also investigated. We measured PBMC proliferative responses to C trachomatis (DK20--an oculogenital strain, serovar E), lysate of McCoy cells (used to propagate chlamydiae), and the recall antigen PPD. Controls were 37 men and women without present or past history of urethritis or chlamydial infection. Results were expressed as the ratio of the stimulation index (SI) obtained with DK20 compared with McCoy cells (DK index), and the ratio of the SI obtained with DK20 compared with PPD (PPD index).

RESULTS

The median SI to DK20 in the urethritis was 12.7 which was significantly higher than the controls (7.6, p < 0.003). The median SI to the recall antigen PPD was similar in the urethritis patients (17.4) and the controls (22.4). All urethritis patient subgroups had a significantly higher DK index and PPD index than the controls. There was no difference in the PPD and DK index between urethritis naive and urethritis experienced patients and between the culture positive and culture negative urethritis subgroups. In PID patients only the PPD index was significantly higher than the controls.

CONCLUSION

Men presenting with urethritis and women presenting with PID both have significantly greater peripheral blood mononuclear cell proliferative responses to the DK20 strain of C trachomatis than controls. A similar T cell proliferative response pattern in urethritis naive patients with either gonococcal or non-gonococcal urethritis could be because low sensitivity of CT culture failed to diagnose some cases of C trachomatis. However, it may also signify earlier exposure of the patients to chlamydial antigens (for example, C pneumoniae), cross reacting antigens such as heat shock proteins from other microbial species, or a "bystander" activation of chlamydia specific memory T cells trafficking through mucosal lymphoid tissue during urethritis. These results suggest evidence of T cell mediated response to C trachomatis cannot be used as a diagnostic tool.

Urethral lymphocyte isolation in non-gonococcal urethritis

AIMS

A pilot feasibility study to investigate the local immune response in patients with non-gonococcal urethritis (NGU).

METHODS

Urethral lymphocytes were extracted from first void urine (FVU) of patients with non-gonococcal urethritis and gonorrhoea using magnetic beads coated with antibody against either the pan-T cell marker CD2 or to CD4. The CD2+ and CD4+ lymphocyte content of FVU were compared between chlamydia-positive and chlamydia-negative and between first and subsequent attacks of NGU.

RESULTS

Median CD2+ lymphocyte content of FVU was significantly higher in cases of gonorrhoea and chlamydia-positive urethritis than in chlamydia-negative NGU. Median CD2+ lymphocyte content of FVU in chlamydia-negative NGU was 15.6 x 10(4), (n = 14 range 3.2-111) which was significantly lower than in chlamydia positive NGU (35.2 x 10(4), n = 18, range 7.4-390 p = 0.037) and gonorrhoea (67.7 x 10(4), n = 8 range 13-501, p = 0.019). Comparing the first with subsequent attacks of NGU, CD2+ cell numbers were greater in those presenting with their first episode of chlamydia-negative NGU (21.8 x 10(4), range 5.6-111) compared with those who had experienced NGU before (12.3 x 10(4), range 3.2-20.4, p = 0.033), but not in those presenting with chlamydia-positive NGU. There was no difference in CD4+ cells between any of the groups.

CONCLUSION

The lower total lymphocyte content of subsequent attacks of chlamydia-negative NGU compared with the first attack chlamydia-positive and negative NGU suggests that a different aetiology may be operating in some of these patients. Sufficient lymphocytes can be isolated from the urethra in patients with NGU for studies of lymphocyte subsets to be carried out.