Adenoviral non-gonococcal urethritis

Adenovirus-Associated Urethritis, a Not So Uncommon Entity. A Review of 91 Cases

BACKGROUND

Human adenovirus (HAdV) is likely an underdiagnosed cause of urethritis, although it was already associated with urethritis in descriptions published more than 40 years ago. Differential clinical features of this entity, such as meatitis, conjunctivitis, and a predominance of mononuclear white blood cells in first-void urine and/or urethral smear, can be useful to increase diagnostic suspicion.

METHODS

We retrospectively studied 91 episodes of HAdV-associated urethritis diagnosed for 9 years and 6 months after optimizing efforts to detect the pathogen mainly in patients with features suggestive of this condition.

RESULTS

Dysuria was the main symptom (84%), whereas meatitis was observed in 34% of cases. Furthermore, 40% of patients had conjunctivitis. Human adenovirus type D was the most prevalent HAdV (56%), although HAdV-C6, a type not previously associated with urethritis, was observed in 12 patients (13%).

CONCLUSIONS

Urethritis due to HAdV is not uncommon, and it is important to screen for it to avoid unnecessary treatments, contact tracing studies, and checkups. The use of multiplex polymerase chain reaction assays that include HAdV, for the diagnosis of urethritis, would raise awareness of its role in this entity.

Male non-gonococcal urethritis: From microbiological etiologies to demographic and clinical features

OBJECTIVES

To detect microorganisms responsible for male acute urethritis and to define the microbiology of non-gonococcal urethritis.

METHODS

The present study comprised 424 men with symptoms and signs compatible with acute urethritis. Their urethral swabs and first-voided urine underwent detection of the microorganisms. Demographic characteristics and clinical features of Mycoplasma genitalium-, Ureaplasma urealyticum-, Haemophilus influenza-, adenovirus- or Herpes simplex virus-positive monomicrobial non-gonococcal urethritis, or all-examined microorganism-negative urethritis in heterosexual men were compared with urethritis positive only for Chlamydia trachomatis.

RESULTS

Neisseria gonorrhoeae was detected in 127 men (30.0%). In 297 men with non-gonococcal urethritis, C. trachomatis was detected in 143 (48.1%). In 154 men with non-chlamydial non-gonococcal urethritis, M. genitalium (22.7%), M. hominis (5.8%), Ureaplasma parvum (9.1%), U. urealyticum (19.5%), H. influenzae (14.3%), Neisseria meningitidis (3.9%), Trichomonas vaginalis (1.3%), human adenovirus (16.2%), and Herpes simplex virus types 1 (7.1%) and 2 (2.6%) were detected. Although some features of monomicrobial non-chlamydial non-gonococcal urethritis or all-examined microorganism-negative urethritis were significantly different from those of monomicrobial chlamydial non-gonococcal urethritis, most features were superimposed.

CONCLUSIONS

Predicting causative microorganisms in men with non-gonococcal urethritis based on demographic and clinical features is difficult. However, the present study provides useful information to better understand the microbiological diversity in non-gonococcal urethritis, and to manage patients with non-gonococcal urethritis appropriately.

Adenovirus urethritis and concurrent conjunctivitis: a case series and review of the literature

We present eight cases and review the literature of concurrent urethritis and conjunctivitis where adenovirus was identified as the causative pathogen. The focus of this review concerns the identification of specific sexual practices, symptoms, signs and any serotypes that seem more commonly associated with such adenovirus infections. We discuss the seasonality of adenovirus infection and provide practical advice for clinicians to give to the patient.

Characteristics of acute nongonococcal urethritis in men differ by sexual preference

Nongonococcal urethritis (NGU) is a common clinical syndrome, but no etiological agent is identified in a significant proportion of cases. Whether the spectrum of pathogens differs between heterosexual men (MSW) and men who have sex with men (MSM) is largely unstudied but of considerable clinical relevance. A retrospective review was done using the electronic medical record database of Melbourne Sexual Health Centre, Australia. Cases were first presentations of symptomatic acute NGU with ≥ 5 polymorphonuclear leukocytes (PMNL)/high-powered field (HPF) on urethral Gram stain between January 2006 and December 2011. First-stream urine was tested for Chlamydia trachomatis and Mycoplasma genitalium by PCR. Demographic, laboratory, and behavioral characteristics of cases were examined by univariate and multivariable analyses. Of 1,295 first presentations of acute NGU, 401 (32%; 95% confidence interval [CI] of 29 to 34%) had C. trachomatis and 134 (11%; 95% CI of 9 to 13%) had M. genitalium detected. MSM with acute NGU were less likely to have C. trachomatis (adjusted odds ratio [AOR] = 0.4; 95% CI of 0.3 to 0.6) or M. genitalium (AOR = 0.5; 95% CI of 0.3 to 0.8) and more likely to have idiopathic NGU (AOR = 2.4; 95% CI of 1.8 to 3.3), to report 100% condom use for anal/vaginal sex (AOR = 3.6; 95% CI of 2.7 to 5.0), or to have engaged in sexual activities other than anal/vaginal sex (AOR = 8.0; 95% CI of 3.6 to 17.8). Even when C. trachomatis or M. genitalium was detected, MSM were more likely than MSW to report consistent condom use (OR = 4.7; 95% CI of 2.6 to 8.3). MSM with acute NGU are less likely to have the established bacterial sexually transmitted infections (STIs) and more likely to report protected anal sex or sexual activity other than anal sex prior to symptom onset than MSW. These data suggest that the etiologic spectrum of pathogens differs between MSM and MSW in acute NGU and that relatively low-risk practices are capable of inducing acute NGU.

The urethral smear as a tool in diagnosing adenovirus-induced urethritis

Adenovirus is a recognised cause of non-gonococcal urethritis, and is not uncommonly associated with extragenital signs and symptoms. This case report describes a patient with symptoms of conjunctivitis, meatitis and urethritis. The urethral smear revealed almost exclusively monocytes microscopically, raising the suspicion of a viral aetiology. Results confirmed the presence of adenovirus in both the eyes and urethra. Despite waning reliance on the urethral smear in sexual health clinics, it can still be an important diagnostic tool in assessing the aetiology of non-specific urethritis. Finding an obvious monocytic cell response in the urethral smear can indicate a viral cause and allow the clinician to optimise management, counsel appropriately, and potentially reduce unnecessary antibiotic use.

Nongonococcal urethritis: new views through the prism of modern molecular microbiology

The rapidly advancing technology of modern molecular microbiology has greatly improved our understanding of the epidemiology of sexually transmitted infections and the etiology and pathogenesis of the diseases they cause. It is now clear that Mycoplasma genitalium accounts for a significant proportion of nonchlamydial nongonococcal urethritis (NGU) cases. DNA sequencing of Ureaplasma spp has revealed a new species, Ureaplasma parvum. This organism may account for much of the colonization observed in asymptomatic men, which confounded many past studies of the role of Ureaplasma spp in NGU. At long last, we can say that Ureaplasma urealyticum is a true pathogen. The use of polymerase chain reaction technology has shown that Trichomonas vaginalis occurs more frequently in men with NGU than had been thought; however, such studies also have demonstrated that it is more prevalent in asymptomatic men. Finally, recent studies have shown that adenovirus should be added to the list of viral causes of NGU.