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URETHRITIS
DEFINITION
Urethral inflammation most often manifested by urethral discharge, dysuria, or meatal pruritis confirmed by the laboratory finding of increased number of polymorphonuclear leukocytes (PMNs) on Gram-stained urethral smear or in the sediment of a first voided urine.
I. Etiology
Nongonococcal urethritis:
|
Chlamydia trachomatis |
30-50% |
|
Ureaplasma urealyticum |
15-25% |
|
Trichomonas vaginalis |
<5% |
|
Herpes Simplex Virus |
<5% |
|
Candida albicans |
<1% |
|
Miscellaneous bacteria |
<1% |
|
Mycoplasma genitalium |
? |
|
Bacteroides urealyticum |
? |
|
Other (E. Coli, Haemophilus species) |
? |
|
Unknown |
20-30% |
II. Epidemiology
NGU is more common than GU in the U.S. and in much of the developed world; GU may account for up to 80% of the cases of acute urethritis in some undeveloped areas.
The ratio of NGU to GU is greater among groups of higher socioeconomic status in the U.S. For example, comparisons of men with NGU versus GU show that those with NGU more often are white, with higher education, higher socioeconomic status, and fewer number of sexual partners.
On college campuses, more than 85% of urethritis is nongonococcal.
The peak age is similar for both NGU and GU: 20-24.
NGU and GU have an increased incidence during the summer months.
Compared with GU, NGU is relatively less prevalent among homosexual than among heterosexual men with urethritis.
E. Coli::
May be associated with cystitis.
Rx: Doxycycline vs. TMP/SMX.
HSV:
Urethritis occurs in 15-30% of men with primary HSV infection and in much fewer with recurrent HSV. Most of these patients have penile lesions but some do not.
Trichomonas vaginalis:
Recent data suggest that trichomonas is an increasing cause of NGU.
Yeasts:
Yeasts are not a frequent cause of NGU. Yeasts are rarely detected in urethritis studies but some men with balanitis have sx. of urethritis.
CMV:
Role in causing urethritis is unclear, but probably is not important.
III. Clinical Manifestations
|
Clinical Features |
NGU |
GU |
|
Incubation period |
7-14 days |
2-8 days |
|
Onset |
Gradual |
Abrupt |
|
Dysuria |
Mild |
Severe |
|
Asymptomatic |
>10% |
1-3% |
|
Discharge |
|
|
|
Quality |
Mucoid |
Purulent |
|
Quantity |
Less |
More |
IV. Diagnosis
Second option - 3 or more hours since last void.
Examine urethra for discharge - Stripping of the penis may increase the yield.
Swab specimen/urethral Gram stain:
Look for presence of Gram-negative intracellular diplococci (GNID).
5 or more WBC/oil-immersion field = urethritis.
First void urine (FVU):
15-20 WBC/400x = urethritis.
Test for GC and Chlamydia (CT) with culture or nonculture method.
CT - insert swab > 2cm for optimal results.
GC - ok to culture urethral exudate.
Do not culture for Ureaplasma.
If dx equivocal, treat vs. reevaluate.
Asymptomatic urethritis:
~ 1/3 of men in an STD clinic with NGU may be without signs or symptoms.
FVU may be more sensitive than urethral Gram stain for detecting urethral leukocytosis.
Leukocyte esterase test (LET) is less sensitive than FVU but, easier to perform.
Diagnosis of Gonorrhea:
|
Site |
Gram Stain Sensitivity (%) |
Gram Stain Specificity (%) |
Culture Sensitivity (%) |
|
Urethra of symptomatic males |
95 |
95 |
96-100 |
|
Urethra of asymptomatic males |
60 |
95 |
96-100 |
|
Cervix of symptomatic females |
40-70 |
95 |
96-100 |
|
Rectum of symptomatic males |
30-65 |
95 |
90-98 |
|
Pharynx |
Unknown - Not recommended |
Unknown - Not recommended |
Unknown - Not recommended |
V. Treatment (Refer to current CDC Treatment Guidelines)
Gonococcal Urethritis (Treat for co-existent chlamydial infection):
Ciprofloxacin: 500 mg PO x1
Ofloxacin: 400 mg PO x1
Chlamydial and NGU:
Erythromycin: 500 mg QID x7 days (base)
[or ethylsuccinate 800 mg QID x7 days]
Azithromycin: 1 gm orally x1
Ofloxacin*: 300 mg BID x7 days
* Note that ofloxacin is recommended by the CDC for treatment of chlamydial infection, but have not yet been fully evaluated in the treatment of NGU.
|
Doxycycline vs. Erythromycin vs. Azithromycin for Chlamydia infection | |||
|
|
Doxycycline |
Erythromycin |
Azithromycin |
|
Regimen |
100 mg BID x 7 d |
2 g/d x7 d |
1 g single dose |
|
Efficacy for CT |
95-100% |
85-95% |
95-100% |
|
Efficacy for non-CT |
60-80% |
60-80% |
60-80% |
|
NGU/MPC |
|
|
|
|
GC coverage |
85-90% |
70-80% |
85-90% |
|
Use in pregnancy |
No |
Yes |
Unknown (category B) |
|
Cost |
Low |
Low |
High |
|
Tolerance |
Good |
Fair |
Excellent |
Other management considerations:
Follow-up:
Patients should be instructed to return for evaluation if symptoms persist or recur after completion of therapy. Symptoms alone, with documentation of signs or laboraory evidence of urethral inflammation, are not a sufficient basis for re-treatment. Patients should be instructed to abstain from sexual intercourse until therapy is completed.
Partner Referral:
Patients should refer all sexual partners for the past 60 days for evaluation and treatment. A specific diagnosis may facilitate partner referral. Therefore, testing for gonorrhea and chlamydia is encouraged.
Recurrent or persistent urethritis:
There should be document objective signs of urethritis before initiating antimicrobial therapy. Effective regimens have not been identified for treating patients who experience persistent symptoms or frequent recurrences following treatment. Patients with persistent or recurrent urethritis should be re-treated with the initial regimen if they failed to comply with the treatment regimen or if they were re-exposed to an untreated sex partner. Otherwise, a wet mount examination and culture of an intraurethral swab specimen for T. Vaginalis should be performed. Urologic examinations do not usually reveal a specific etiology. If the patient was compliant with the initial regimen and re-exposure can be excluded, the following regimen is recommended:
Treatment for recurrent/persistent urethritis:
and
Erythromycin base 500 mg orally 4 times a day for 7 days,
or
Erythromycin ethylsuccinate 800 mg orally 4 times a day for 7 days.
Etiologic hypotheses:
Persistent infection:
Resistent pathogen.
Chronic "non-bacterial" prostatitis:
Reiter's variant:
Autoimmune process.
Guidelines for management of recurrent or persistent urethritis:
Re-examine and establish objective evidence of urethritis by urethral smear and culture for GC and CT. Question closely regarding re-exposure during or after treatment, compliance with oral regimen and concurrent treatment of partner.
If suspect reinfection -->consider retreatment with doxycycline and retreatment of partner.
If NGU persists:
Examine for trichomonas with NS wet mount (culture if wet mount negative). KOH for yeast.
Note any penile lesions suggesting HSV.
Ask about chemical irritants.
Treat with alternate regimen if a - e negative (e.g., consider erythromycin to retreat chlamydia and to cover ureaplasma urealyticum.
Stress abstinence or condom use while trying to establish whether problem is possible reinfection or true persistence.
Complications:
Both local and systematic complications of urethritis in men are now unusual in developed countries. The symptoms of urethritis will in most cases resolve even if the patient remains untreated.
95% of untreated patients with acute GU will be free of symptoms 6 months after onset.
Symptoms of NGU subside gradually over 1-3 months in most patients.
In 20-30% of men with NGU prostatic involvement is documented but this is usually asymptomatic and responds to standard treatment.
Both chlamydia and gonorrhea can infect the conjunctiva.
Reiters syndrome complicates 1-2% of NGU.
Disseminated gonococcal infection occurs infrequently.
Sponsored by a grant from the Centers for Disease Control and Prevention