Urethritis,std,mycoplasma or Chlamydia infection

Urethritis in Men
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Description

Urethritis describes urethral inflammation and can be the result of infectious or noninfectious
causes but is primarily a sexually acquired disease.

Urethritis can be diagnosed if any of the following are present:

• Mucopurulent or purulent discharge from urethral meatus.

• Gram stain of urethral smear showing >5 polymorphonuclear (PMN) cells per high
power field. This is the preferred test as it is rapid, highly sensitive and specific for both
nonspecific urethritis and gonorrhoea in asymptomatic men.1
• First pass urine (FPU) positive for >10 PMN per high power field. Some advocate the use
of positive leucocytes in FPU - but the sensitivity is low.

Classification of male urethritis2

1. Gonococcal urethritis - caused by Neisseria gonorrhoeae.3

2. Nongonococcal urethritis (NGU) - caused by a number of organisms other than N.
gonorrhoeae.
3. Persistent or recurrent urethritis - 20-60% cases treated for NGU.1 Probable multifactorial
causes but usually no identifiable cause. However, Mycoplasma genitalium (quite often
and up to 40% of cases), Ureaplasma urealyticum (tetracycline-resistant) , and
Trichomonas vaginalis have been implicated.2

Causes of nongonococcal urethritis1,2,4,5

• Chlamydia trachomatis (40%)6

• U. urealyticum (10-20%)
• M. genitalium (10-20%)
• T. vaginalis (1-17%)
• Rarer infective causes:
o Urinary tract infection (fewer than 6%)2
o Adenoviruses (2-4%)
o Herpes simplex viruses (2-3%)
o Occasionally, Candida spp., Haemophilus spp., Neisseria meningitidis, E.coli
infection, bacteroides infection
• Noninfective causes of NGU include:2
o Trauma (for example, catheterisation)
 o Irritation (from, for example, soap, spermicidal creams and deodorants)
o Urethral stricture
o Other inflammatory conditions (including lichen sclerosus et atrophicus, Stevens-
Johnson syndrome, reactive arthritis, Reiter's syndrome)
o Urinary calculi and foreign body
• No obvious cause 20-30%

Epidemiology

• Urethritis is the most common condition diagnosed and treated in men attending
genitourinary medicine (GUM) clinics in the UK. Over 80,000 cases are diagnosed every
year.
• Nongonococcal urethritis (NGU) is more common than gonococcal urethritis.
• Chlamydia has been estimated currently to infect 5-10% of sexually active women under
the age of 24 and men aged between 20-24.6 The diagnoses of chlamydial infections have
increased in both heterosexual and homosexual men.2
• Persistent or recurrent urethritis occurs in 10-20% of men treated for NGU.2
• Gonorrhoea is most common in men aged 20-24 years and rates of diagnosis in GUM
clinics increased between 1994-2002. However, recently the numbers have reduced.2

Presentation

• May be asymptomatic (10% of patients with gonorrhoea and 50% of patients with
chlamydial infections).2
• Urethral discharge - mucopurulent or purulent; with or without blood; more noticeable
after holding urine overnight and more common in gonococcal infection4. May have gone
unnoticed by the patient and be seen only on examination.2
• Urethral pruritus, dysuria or penile discomfort with a risk of sexually transmitted
infection (sexually active and has not used a condom or has recent new sexual partner).2
• Other symptoms associated with the cause, e.g. skin lesions in herpes simples virus.
• Systemic symptoms if involvement of other organs, e.g. conjunctivitis or arthritis

Examination may be normal or may reveal haematuria and/or lymphadenopathy.

There is currently a national screening programme for chlamydia.6

Identify high-risk patients2,7

• Sexually active
• Male
• Unprotected vaginal sex
• Homosexual or bisexual
• More common in cities
• Age <35-40 years
• Recent partner change
Investigations

Ideally this should be performed in a GUM clinic with available microscopy and medications -
for direct observation of treatment (DOT).2 In a GUM clinic the following will be done:

• Urethral smear - urethritis confirmed if on microscopy there are >5 polymorphonuclear

(PMN) lymphocytes per high power field. Microscopy will also reveal Gram-negative
intracellular diplococci (GNID) of gonorrhoea.
• FPU - best if patients hold urine for at least four hours prior to the test. Send for nucleic
acid amplification test (NAAT) to look for chlamydia and gonorrhoea.
• Pharyngeal and rectal swabs may also be needed.

An increasing number of sexually transmitted diseases are treated in primary care. However, in a
primary care setting microscopy may not be available and the following approach can be taken:2,8

• Diagnose urethritis if urethral discharge present or if symptoms are in a high-risk patient.

• Give appropriate general advice for a patient with urethritis2. For example:
o Encourage the patient to attend a GUM clinic with reasons.
o Explain likely causes.
o Stress importance of partner notification.
o Explain complications of inadequate treatment.
o Emphasis importance of abstaining from sex (including oral sex) for seven days
after treatment (if azithromycin is used) or on completion (if doxycycline used)
and until symptoms have resolved and partners have also completed treatment.
• Urine dipstick positive for leucocytes supports the diagnosis of urethritis and if normal
can also help exclude urinary tract infection.
• Threads in urine passed after holding for at least four hours supports diagnosis.
• FPU - send for NAAT to look for chlamydia and gonorrhoea.6

• Need to check with local laboratory as to which test they perform - some may require
urethral swabs to be sent.
Differential diagnosis2

• Physiological discharge
• Candidiasis
• Cystitis
• Urethral malignancy

Associated diseases

Patients with urethritis should be counselled and offered testing for HIV, hepatitis and syphilis.9

Approach to a patient with symptoms suggestive of urethritis

• Full history including full sexual history.

• Examination: local looking for discharge, skin lesions and systemic examination.
 • Refer to GUM clinic if possible.
• Urethral smear for microscopy and/or FPU (both ideally performed if urine held for at
least four hours).
• If smear positive - manage as below.
• If smear negative and no definitive evidence of urethritis then defer treatment and re-
examine one week later. Also, check mid-stream urine sample for urinary tract infection.
• Screen for other sexually transmitted infections.
• There is some debate as to whether there should be blind treatment of those with
symptoms and at high risk of infection or those unlikely to return for follow-up.

Management2,10

Treatment is the same in HIV-negative and HIV-positive patients. Always use local guidelines
where possible.

• Nongonococcal urethritis (NGU) - azithromycin 1 gm as single oral dose is first line or

doxycycline 100 mg bd for seven days.1
• Gonococcal urethritis3 - cefixime 400 mg single oral dose or ceftriaxone 250 mg as single
IM dose. Quinolones are an alternative provided no resistance.
• Empirical treatment - cover C. trachomatis, e.g. doxycycline 100 mg bd for 7 days or
azithromycin 1 gm as single oral dose.

Patient education2

• Need to explain the diagnosis, treatment, adverse effects and importance of completing
the course of antibiotics.
• Discuss methods of prevention including advice on safe sex, e.g. condom use.
• Must avoid sexual intercourse until infection cleared up and partner checked out.
• Contact tracing - important to maintain patient confidentiality. Need to trace sexual
contacts in the last four weeks and up to six months if asymptomatic (for NGU).

Further management2

• Patients should be followed up for review at approximately two weeks.

• Take this opportunity to reinforce health education.
• Assess compliance and efficacy.
• Test of cure can also be performed for gonorrhoea, e.g. nucleic acid amplification test
(NAAT) or repeat culture 72 hours after treatment has finished. It is not routine for
chlamydia unless the patient is pregnant, noncompliance is suspected or re-exposure may
have occurred.6
• If there are persistent symptoms or persistent urethritis despite being asymptomatic,
consider treatment failure, reinfection or infection with an uncommon pathogen, e.g. T.
vaginalis. Treat with the original course of antibiotics if the course was not completed.
• If doxycycline was used initially there is a need to be aware that there are tetracycline-
resistant forms of U. urealyticum and an alternative may need to be tried, e.g.
metronidazole or erythromycin.
 • If there is no laboratory evidence of infection then advise no sexual intercourse for seven
days and until the partner completes treatment.
• If symptoms continue for >3 months consider the possibility of complications, e.g.
prostatitis, epididymitis.
• If there is persistent or recurrent nongonococcal urethritis (NGU) treat with erythromycin
or metronidazole.

Complications2

• Epididymitis and/or orchitis

• Prostatitis
• Systemic dissemination of gonorrhoea, e.g. conjunctivitis, skin lesions
• Reactive arthritis
• Pelvic inflammatory disease (PID) - infection of female partners with the organisms that
cause urethritis can cause PID and subsequent complications
• Reiter's syndrome
• HIV transmission increased

Causes

The disease is classified as either gonococcocal urethritis or non-gonococcal urethritis (NGU),

based on its causation. NGU, sometimes called non-specific urethritis (NSU), has both infectious
and non-infectious causes.

Causes include:

• Adenovirus
• Uropathogenic Escherichia coli (UPEC)
• Herpes simplex
• Mycoplasma genitalium
• Reiter's syndrome
• Trichomonas spp.
• Isotretinoin therapy

Doses of isotretinoin greater than 60 milligrams/square meter induced URETHRITIS. [1]

Urethritis was reported in 2 male patients who were being treated with isotretinoin for acne
vulgaris. After discontinuation and treatment with antibiotics, urethritis resolved. [2]

[edit] Symptoms

In men, purulent discharge usually indicates a urethritis of gonococcal nature, while clear
discharge indicates urethritis of non-gonococcal nature. Urethritis is difficult to diagnose in
women because discharge may not be present, however, the symptoms of dysuria and frequency
may be present.
[edit] Diagnosis

Usually, the patient undresses and puts on a gown. With male patients, the physician examines
the penis and testicles for soreness or any swelling. The urethra is visually examined by
spreading the urinary meatus apart with two gloved fingers, and examining the opening for
redness, discharge and other abnormalities. Next, a cotton swab is inserted 1–4 cm into the
urethra and rotated once. To prevent contamination, no lubricant is applied to the swab, which
can result in pain or discomfort. The swab is then smeared onto a glass slide and examined under
a microscope. A commonly used cut-off for the diagnosis of urethritis is 5 or more
polymorphonuclear leukocytes per HPF, but this definition has recently been called into doubt.[3]

The physician sometimes performs a digital rectal exam to inspect the prostate gland for swelling
or infection.

[edit] Treatment

A variety of drugs may be prescribed based on the cause of the patient's urethritis. Some
examples of medications based on causes include:

• Clotrimazole (Mycelex) - Trichomonial

• Fluconazole (Diflucan) - Monilial
• Metronidazole (Flagyl) - Trichomonial
• Nitrofurantoin - Bacterial
• Nystatin (Mycostatin) - Monilial
• Co-trimoxazole, which is a combination of Sulfamethoxazole and
Trimethoprim in a ratio of 5 to 1 (Septrin, Bactrim) - Bacterial

Proper perineal hygiene should be stressed. This includes avoiding use of vaginal deodorant
sprays and proper wiping after urination and bowel movements. Intercourse should be avoided
until symptoms subside.

[edit] Prevention

Risk of some causes of urethritis can be lessened by avoiding:

• unprotected sex (or any sex)

• chemicals that could irritate the urethra; this could include detergents or
lotions as well as spermicides or contraceptives.
• irritation caused by manual manipulation of the urethra
 chlamtdia

Chlamydia infection (from the Greek, χλαμύδα meaning "cloak") is a common sexually
transmitted infection (STI) in humans caused by the bacterium Chlamydia trachomatis. The term
Chlamydia infection can also refer to infection caused by any species belonging to the bacterial
family Chlamydiaceae. C. trachomatis is found only in humans.[1] Chlamydia is a major
infectious cause of human genital and eye disease. Chlamydia infection is one of the most
common sexually transmitted infections worldwide; it is estimated that about 1 million
individuals in the United States are infected with chlamydia.[2]

C. trachomatis is naturally found living only inside human cells. Chlamydia can be transmitted
during vaginal, anal, or oral sex, and can be passed from an infected mother to her baby during
vaginal childbirth. Between half and three-quarters of all women who have a chlamydia infection
of the neck of the womb (cervicitis) have no symptoms and do not know that they are infected.
In men, infection of the urethra (urethritis) is usually symptomatic, causing a white discharge
from the penis with or without pain on urinating (dysuria). Occasionally, the conditions spreads
to the upper genital tract in women (causing pelvic inflammatory disease) or to the epididymis in
men (causing epididymitis). If untreated, chlamydial infections can cause serious reproductive
and other health problems with both short-term and long-term consequences.
Chlamydia conjunctivitis or trachoma is a common cause of blindness worldwide. The World
Health Organization estimates that it accounted for 15% of blindness cases in 1995, but only
3.6% in 2002.[3][4]

Genital disease

Chlamydial cervicitis in a female patient characterized by mucopurulent cervical discharge,

erythema, and inflammation.

Male patients may develop a white, cloudy or watery discharge (shown) from the tip of the penis.

Chlamydial infection of the neck of the womb (cervicitis) is a sexually transmitted infection
which is asymptomatic for about 50-70% of women infected with the disease. The infection can
be passed through vaginal, anal, or oral sex. Of those who have an asymptomatic infection that is
not detected by their doctor, approximately half will develop pelvic inflammatory disease (PID),
a generic term for infection of the uterus, fallopian tubes, and/or ovaries. PID can cause scarring
inside the reproductive organs, which can later cause serious complications, including chronic
pelvic pain, difficulty becoming pregnant, ectopic (tubal) pregnancy, and other dangerous
complications of pregnancy.

Chlamydia is known as the "Silent Epidemic" because in women, it may not cause any
symptoms in 75% of cases[6], and can linger for months or years before being discovered.
Symptoms that may occur include: unusual vaginal bleeding or discharge, pain in the abdomen,
painful sexual intercourse (dyspareunia), fever, painful urination or the urge to urinate more
frequently than usual (urinary urgency).

In men, Chlamydia shows symptoms of infectious urethritis (inflammation of the urethra) in

about 50% of cases[6]. Symptoms that may occur include: a painful or burning sensation when
urinating, an unusual discharge from the penis, swollen or tender testicles, or fever. Discharge, or
the purulent exudate, is generally less viscous and lighter in color than for gonorrhea. If left
untreated, it is possible for Chlamydia in men to spread to the testicles causing epididymitis,
which in rare cases can cause sterility if not treated within 6 to 8 weeks. Chlamydia is also a
potential cause of prostatitis in men, although the exact relevance in prostatitis is difficult to
ascertain due to possible contamination from urethritis.[7]

Pathophysiology

Chlamydiae have the ability to establish long-term associations with host cells. When an infected
host cell is starved for various nutrients such as amino acids (e.g. tryptophan),[12] iron, or
vitamins, this has a negative consequence for Chlamydiae since the organism is dependent on the
host cell for these nutrients. Long-term cohort studies indicate that approximately 50% of those
infected clear within a year, 80% within two years, and 90% within three years.[13]

The starved chlamydiae enter a persistent growth state wherein they stop cell division and
become morphologically aberrant by increasing in size.[14] Persistent organisms remain viable as
they are capable of returning to a normal growth state once conditions in the host cell improve.

There is much debate as to whether persistence has in vivo relevance. Many believe that
persistent chlamydiae are the cause of chronic chlamydial diseases. Some antibiotics such as β-
lactams can also induce a persistent-like growth state, which can contribute to the chronicity of
chlamydial diseases.

Diagnosis

The diagnosis of genital chlamydial infections evolved rapidly from the 1990s through 2006.
Nucleic acid amplification tests (NAAT), such as polymerase chain reaction (PCR), transcription
mediated amplification (TMA), and the DNA strand displacement amplification (SDA) now are
the mainstays. NAAT for chlamydia may be performed on swab specimens collected from the
cervix (women) or urethra (men), on self-collected vaginal swabs, or on voided urine. Urine and
self-collected swab testing facilitates the performance of screening tests in settings where genital
examination is impractical. At present, the NAATs have regulatory approval only for testing
urogenital specimens, although rapidly evolving research indicates that they may give reliable
results on rectal specimens.

Because of improved test accuracy, ease of specimen management, convenience in specimen

management, and ease of screening sexually active men and women, the NAATs have largely
replaced culture, the historic gold standard for chlamydia diagnosis, and the non-amplified probe
tests. The latter test is relatively insensitive, successfully detecting only 60-80% of infections in
asymptomatic women, and often giving falsely positive results. Culture remains useful in
selected circumstances and is currently the only assay approved for testing non-genital
specimens.
Treatment

Chlamydia trachomatis inclusion bodies (brown) in a McCoy cell culture.

C. trachomatis infection can be effectively cured with antibiotics once it is detected. Current
Centers for Disease Control guidelines provide for the following treatments:

• Azithromycin 1 gram oral as a single dose, or

• Doxycycline 100 milligrams twice daily for seven to fourteen days.
• Tetracycline
• Erythromycin

Untested Treatments

• Ciprofloxacin 500 milligrams twice daily for 3 days. (Although this is not an
approved method of treatment.)

β-lactams are not suitable drugs for the treatment of chlamydia. While they have the ability to
halt growth of the organism (i.e. are microbistatic), these antibiotics do not eliminate the
bacteria. Once treatment is stopped, the bacteria will begin to grow once more. (See below for
Persistence.)

An option for treating partners of patients (index cases) diagnosed with chlamydia or gonorrhea
is patient-delivered partner therapy (PDT or PDPT), which is the clinical practice of treating the
sex partners of index cases by providing prescriptions or medications to the patient to take to
his/her partner without the health care provider first examining the partner.[18]