Urethritis,std,mycoplasma or Chlamydia infection

Urethritis in Men
Post your experience 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:
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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
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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)

Irritation (from, for example, soap, spermicidal creams and deodorants) Urethral stricture Other inflammatory conditions (including lichen sclerosus et atrophicus, StevensJohnson syndrome, reactive arthritis, Reiter's syndrome) o Urinary calculi and foreign body No obvious cause 20-30%
o o o

Epidemiology

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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
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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
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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:

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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
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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
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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
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Full history including full sexual history. Examination: local looking for discharge, skin lesions and systemic examination.

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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 reexamine 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.
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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
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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
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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 tetracyclineresistant forms of U. urealyticum and an alternative may need to be tried, e.g. metronidazole or erythromycin.

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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
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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:
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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:
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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:
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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 βlactams 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:
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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]