Infectious Urethritis in Men and Women: Diagnosis and Treatment

Acute and recurrent infectious urethritis in men and women is commonly seen by physicians. Since specific therapy varies widely with the type of urethritis present, the proper diagnosis must be clearly established if curative drug therapy is to be selected. It is valuable, therefore, to review the diagnosis and therapy of the various forms of infectious urethritis that are recognized today in both men and women.     

Cefonicid as Therapy for Uncomplicated Gonococcal Urethritis Caused by Penicillinase-Producing Neisseria gonorrhoeae

Young men with uncomplicated gonococcal urethritis were treated with 1 gram of cefonicid given intramuscularly plus 1 gram of probenecid by mouth. Of 53 evaluable patients, 33 (62%) had penicillinase-producing Neisseria gonorrhoeae. All but one of these patients were cured. All men who had penicillin-sensitive infections were cured. Cefonicid was highly effective in the treatment of both penicillin-sensitive and penicillin-resistant N gonorrhoeae. Other than moderate pain at the site of injection, there were no adverse side effects. Cefonicid can be added to the group of newer cephalosporins that are effective in the treatment of gonococcal urethritis caused by either penicillin-sensitive or penicillin-resistant strains.     

Quantitative studies on the role of Ureaplasma urealyticum in non-gonococcal urethritis and chronic prostatitis

Quantitative determinations of U. urealyticum and M. hominis have been performed in 164 men with non-gonococcal urethritis (NGU) and 597 patients with chronic prostatitis. Evidence is provided that U. urealyticum plays an etiologic role in 29.3 percent of patients with non-gonococcal urethritis. Mixed infections of C. trachomatis and U. urealyticum, in high numbers, do occur in 11 percent of NGU cases. A constellation suggesting ureaplasma-associated disease could be observed in 13.7 to 15.2 percent of 597 patients with chronic prostatitis. M. hominis does not appear to be a causative agent of NGU or chronic prostatitis.     

Resistance to Gonorrhea Possibly Mediated by Bacterial Interference

Two men with no prior history of urethritis failed to develop gonorrhea after sexual exposures to women with genital gonococcal infection. Usual methods of prophylaxis, such as antibiotics or condoms, were not employed. The aerobic bacterial flora of these men's urethras consisted of several bacteria, some of which inhibited the in vitro growth of Neisseria gonorrhoeae. The hypothesis is suggested that bacterial interference may have played a role in protecting these men from gonorrhea.     

PCR for diagnosis of male Trichomonas vaginalis infection with chronic prostatitis and urethritis

The aim of this study was to assess the usefulness of PCR for diagnosis of Trichomonas vaginalis infection among male patients with chronic recurrent prostatitis and urethritis. Between June 2001 and December 2003, a total of 33 patients visited the Department of Urology, Hanyang University Guri Hospital and were examined for T. vaginalis infection by PCR and culture in TYM medium. For the PCR, we used primers based on a repetitive sequence cloned from T. vaginalis (TV-E650). Voided bladder urine (VB1 and VB3) was sampled from 33 men with symptoms of lower urinary tract infection (urethral charge, residual urine sensation, and frequency). Culture failed to detect any T. vaginalis infection whereas PCR identified 7 cases of trichomoniasis (21.2%). Five of the 7 cases had been diagnosed with prostatitis and 2 with urethritis. PCR for the 5 prostatitis cases yielded a positive 330 bp band from bothVB1 and VB3, whereas positive results were only obtained from VB1 for the 2 urethritis patients. We showed that the PCR method could detect T. vaginalis when there was only 1 T. vaginalis cell per PCR mixture. Our results strongly support the usefulness of PCR on urine samples for detecting T. vaginalis in chronic prostatitis and urethritis patients.     

The role of mycoplasmas in non-gonococcal urethritis: a review

The criteria that need to be fulfilled before regarding a mycoplasma as a cause of non-gonococcal urethritis (NGU) are outlined. Of the seven mycoplasmas that have been isolated from the human genitourinary tract, most cannot be considered as contenders for causing NGU. Although there is no evidence to support an etiological role for Mycoplasma hominis, it may be unwise to ignore this mycoplasma in view of its known pathogenicity in other situations. The cumulative weight of evidence indicates that strains of Ureaplasma urealyticum (ureaplasmas) cause NGU in some patients. The reason for their occurrence in the urethra of some men without disease needs to be established. Ureaplasmas do not seem to cause post-gonococcal urethritis. The role in NGU of M. genitalium, newly discovered in the male urethra, is unknown, but its biological features, morphological appearance, and ability to cause genital disease in marmosets suggest that it may be pathogenic for man.     

Role of Chlamydia trachomatis and HLA-B27 in sexually acquired reactive arthritis.

Inflammatory arthritis, tendinitis, and fasciitis after non-specific urethritis ("sexually acquired reactive arthritis" (SARA)) was studied prospectively in 531 men with non-specific urethritis, with particular reference to the frequency of isolation of Chlamydia trachomatis and the presence of HLA-B27. Satisfactory cultures were obtained from the urethral swabs from 384 patients; and HLA typing was performed on 482, of whom 30 (6%) were HLA-B27-positive. Arthritis developed in 16 patients, and five of the 14 (36%) with satisfactory cultures were positive for C trachomatis; 135 of the patients without arthritis were also positive for C trachomatis, an identical proportion. Seven of the 15 patients (40%) with arthritis who were HLA-typed were HLA-B27-positive. Six of the 30 patients with HLA-B27 developed peripheral arthritis in contrast to only nine of the 452 patients lacking the antigen, suggesting a tenfold increase susceptibility. C trachomatis, however, was no more prevalent in cultures from HLA-B27-positive men than from the others. Thus carriage of C trachomatis is unlikely to be influenced by HLA-B27. C trachomatis may be an important pathogen in some cases of SARA but does not appear to be an exclusive trigger factor for this condition.     

Characteristics of associated microflora of ejaculate from males with gonococcal infections

Species composition and biological properties of aerobic and anaerobic microflora from an ejaculate from males with acute and chronic gonococcal infection and from healthy men were studied. Patients with gonococcal infection were shown to present quantitative and qualitative changes in microbiocenosis of the reproductive tract. Patients with acute gonorrhea displayed decreased species diversity in contrast to healthy persons, while different species of associated with gonococci microbes with high persistent potential, were cultured in patients suffering from a chronic form of infection. The role of revealed pathological biocenosis patterns in developing chronic infection as well as postgonorrheal gonococci-free urethritis is discussed.     

The first case of lymphogranuloma venereum in a woman in East-Central Europe and its multiple co-infections

We are reporting the first case of lymphogranuloma venereum in women in East-Central Europe. A 22-year-old heterosexual woman attended our department of venereology. She complained about a burning sensation in the urethra and vaginal discharge. Many tests were performed, and lymphogranuloma venereum, syphilis, gonorrhea, chlamydial urethritis and cervicitis, genital herpes, genital warts, and hepatitis C were diagnosed. Lymphogranuloma venereum was originally endemic in tropical and subtropical areas, but since 2003, outbreaks of this infection have been reported in North America, Europe, and Australia in men who have sex with men (MSM) community. To date, all cases of lymphogranuloma venereum in the Czech Republic appeared in men, predominantly in HIV-positive MSM. There are not many evidences about lymphogranuloma venereum (LGV) in women in developed countries. This report underlines the need for awareness of lymphogranuloma venereum in women among gynecologists, venereologists, and other physicians not only in Western Europe, but across all European countries.     

How often is genital yeast infection sexually transmitted?

We analysed data from a computer-based bank of clinical records of patients seen in a clinic for sexually transmitted diseases over a three-year period to investigate the association between genital yeast infections and sexually transmitted diseases (STDs). We classified STDs as primary and secondary syphilis; gonorrhoea; lymphogranuloma venereum; trichomoniasis; scabies; pediculosis; genital herpes; warts; and molluscum contagiosum. Of a total of 2984 disease episodes among women, 1054 (35-3%) included yeast infections, whereas only 382 (6-9%) of 5501 episodes in heterosexual men were associated with yeast infections, We found a significant association between yeast infection and STD and non-specific genital infection (non-specific urethritis (NSU) and procitis in men, and female contacts of men with NSU), which suggested that yeast infection was sexually acquired in 414 out of 1054 disease episodes in women (39%) and 110 out of 382 episodes in heterosexual men (29%). We conclude that sexually active patients with genital yeast infections should be screened for other STDs particularly non-specific genital infection.     

Mycoplasma genitalium: an emerging cause of sexually transmitted disease in women

Mycoplasma genitalium is an emerging sexually transmitted pathogen implicated in urethritis in men and several inflammatory reproductive tract syndromes in women including cervicitis, pelvic inflammatory disease (PID), and infertility. This comprehensive review critically examines epidemiologic studies of M. genitalium infections in women with the goal of assessing the associations with reproductive tract disease and enhancing awareness of this emerging pathogen. Over 27,000 women from 48 published reports have been screened for M. genitalium urogenital infection in high- or low-risk populations worldwide with an overall prevalence of 7.3% and 2.0%, respectively. M. genitalium was present in the general population at rates between those of Chlamydia trachomatis and Neisseria gonorrhoeae. Considering more than 20 studies of lower tract inflammation, M. genitalium has been positively associated with urethritis, vaginal discharge, and microscopic signs of cervicitis and/or mucopurulent cervical discharge in seven of 14 studies. A consistent case definition of cervicitis is lacking and will be required for comprehensive understanding of these associations. Importantly, evidence for M. genitalium PID and infertility are quite convincing and indicate that a significant proportion of upper tract inflammation may be attributed to this elusive pathogen. Collectively, M. genitalium is highly prevalent in high- and low-risk populations, and should be considered an etiologic agent of select reproductive tract disease syndromes in women.     

Microbial causative agents of male urethritis.

The incidence of Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma hominis, Neisseria gonorrhoeae and Trichomonas vaginalis was studied in men with urethritis. Out of 150 examined men 48.7% had the positive isolation of U. urealyticum, 26.0% C. trachomatis, 22.7% N. gonorrhoeae, 18.7% M. hominis and in one (0.7%) patient T. vaginalis was found. None of the above mentioned microorganisms was detected in 24.7% of examined men. In 43.3% cases only one agent was isolated. In 23.3% of the men the combination of two agents, in 8.0% the combination of three and in 0.7% even the combination of four studied microorganisms was observed. C. trachomatis was most frequently observed in combination with N. gonorrhoeae (15 cases) and U. urealyticum (14 cases). M. hominis and U. urealyticum occurred simultaneously in 22 examined men.N.gonorrhoeae was most frequently found together with U. urealyticum (16 cases). Concerning the occurrence of other bacteria and yeasts, no significant difference was found between the groups positive and negative for the above mentioned microorganisms.     

Arterial Hypertension and Ischemic Heart Disease: Comparison in Epidemiological Studies

Forty cases of gonococcal urethritis were treated with oxytetracycline using various dosage schedules; there were 37 cures and three failures. The most convenient and most effective dosage was found to be 250 mg. oxytetracycline, given as a single intramuscular injection of 5 c.c.A series of 40 patients with non-gono-coccal urethritis was also collected. Two cases of urethritis due to Trichomonas vaginalis and two due to Candida albicans were removed from the series. Of the 36 cases which remained, cure was obtained with the use of oxytetracycline in different dosages in 30 cases; six cases were failures. The dosage which gave the best result in the therapy of non-gonococcal urethritis was 250 mg. oxytetracycline (5 c.c.), given as a single intramuscular injection, plus 250 mg. orally, four times a day for four days.The effectiveness of oxytetracycline in the treatment of urethritis has not decreased.     

Enzyme immunoassay in the diagnosis of Chlamydia trachomatis infections in diverse patient groups

An enzyme immunoassay (EIA) in parallel with cell culture was used to investigate the extent of infections due to Chlamydia trachomatis. EIA reactive confirmed in cell culture was taken as positive. C. trachomatis was found in 6 (26.0%) of 23 men with symptomatic non-gonococcal urethritis (NGU), ten (17.2%) of 58 symptom-free males and in three of 4 with postgonococcal urethritis. Among 106 asymptomatic pregnant women studied the incidence of C. trachomatis was 8.5% while a higher incidence (16.7%) was found in those with symptoms. C. trachomatis positivity in asymptomatic and symptomatic post-natal screening were 11.4% and 7.7%. Of 43 symptomatic non-pregnant females investigated, 7 (16.3%) were found to be positive for C. trachomatis. Of 3 women with PID, 2 (66.7%) harboured C. trachomatis in their cervix while in another 29 infertile women, C. trachomatis was positive in 3 (8.1%). Contraceptives appeared to have an effect on the chlamydial positivity. Comparative testing of EIA with the standard cell culture method in this study indicate EIA as a suitable alternative for the definitive diagnosis of chlamydial infection in high prevalence settings and with caution in low prevalence settings.     

Patients' compliance with follow-up after treatment of gonococcal urethritis.

By means of telephone tracing 96% follow-up was achieved in men treated for gonococcal urethritis. A large proportion (34.8%) of patients required one or more calls before follow-up could be obtained. Frequency of sexual re-exposure, proportion with persistent gonorrhea or reinfection, and interval between initial therapy and follow-up were greater in those who required telephone contact for follow-up than in the group who returned for follow-up. Failure to reappear for follow-up does not imply either bacteriologic cure or disappearance of symptoms. Control of gonococcal infection still depends largely upon aggressive methods of case finding, appropriate therapy and careful follow-up.     

TRICHOMONAS URETHRITIS IN MALES

Trichomonas urethritis in the male should be suspected in all chronic cases of urethritis. The diagnosis is easily established by the hanging-drop method of examining the urethral discharge, or the first-glass urine specimen. Curative treatment is readily accomplished by the use of urethral instillations of Carbarsone suspension using 1 capsule of Carbarsone per ounce of distilled water.     

Predicting the effectiveness of antibiotic therapy in the treatment of gonorrhea

A complex method is suggested to prognosticate the efficiency of treating gonorrheal urethritis in men with allowance for a preliminary determination of the cell respiration activity in agents. In the case of low indices of these processes, it is possible to stimulate aerobic processes in gonococci if applying for 4 days before the specific treatment daily subcutaneous injections of plasmol (a biostimulator) by the ascending scheme and local irrigation of the urethra by oxygen cocktails through irrigators of special design. The developed method has the author certificate (A. c. 1107867 USSR). Application of the method shortens significantly the terms of treatment, the number of the infection recurrences being considerably decreased. To accelerate the determination of the sensitivity to antibiotics the procedure of genococcus microcultivation in special chambers is applied which permits observing the growth and reproduction of microorganisms in the phase-contrast microscope.     

Infection uro-génitale masculine àChlamydia trachomatis: Vers une meilleure approche diagnostique

Chlamydia trachomatis is the most frequently sexually transmitted pathogen in humans, with an estimated 92 million new cases occurring worldwide each year, However, this number is probably underestimated, particularly for men who are less likely to be screened than women. C. trachomatis serovar D-K causes a variety of clinical syndromes in men and women. C. trachomatis may cause urethritis, epididymitis and prostatitis in young sexually active men, less than 35 years of age. 50% of infected men remain asymptomatic. Sexually active males with asymptomatic urethritis constitute a significant reservoir of potential infection for women, in whom the consequences of lower genital tract infection are likely to be more severe. Chlamydial infections have never been easy to diagnose. Because Chlamydiae are obligate intracellular pathogens, the objective of specimen collection should usually be to include the host cells that harbour the organisms. The sensitivity and specificity of diagnostic tests forC. trachomatis have been shown to be directly related to the adequacy of the specimen. Infection may be symptomatic or asymptomatic with a small number of elementary bodies present at the site of infection. The conventional approach to laboratory diagnostic testing forC. trachomatis infections consisted of cell culture of inocula prepared from urogenital specimens. Cell culture requires appropriate collection of cell scrapings from the urethra, and optimal transport and storage conditions of specimens to preserve viable organisms. Antigen and nucleic acid detection technologies were developed during the 1980s and have been extensively applied to diagnosis due to their lower cost, a lower level of expertise, preservation of infectivity during transport, and a shorter time to obtain the results. Unfortunately, most of these tests are less sensitive thanin vitro cell culture, and may miss a large number ofChlamydia infected individuals. Nucleic acid amplification technologies have therefore been developed, and application of these tests has shown that culture is not as sensitive as previously believed and that the prevalence ofC. trachomatis infection is higher in most populations. These assays can use non-invasive specimens such as first void urine and semen, and do not require special storage conditions. Advantages of nucleic acid amplification tests are their ability to detect even a small amount of organisms. This enables a high detection rate forC. trachomatis in symptomatic persons, diagnosis of chlamydial infections in asymptomatic individuals with a small number of elementary bodies, and diagnosis of persistent infections.     

Epidemiology of sexually transmitted Chlamydia trachomatis infections in male patients

868 male urethritis patients were studied for the presence of chlamydiae in the 1981-1986 period. 36% of NGU, 31.3% of gonococcal urethritis and 58.8% of PGU urethritis patients presented C. trachomatis infections as detected by cell culture inoculation. Chlamydial infection was recorded more often in the 21-30 years age group (30.8%), in unmarried patients (70.6%), as well as in people with low educational degree (46.6% of cases), 42.3% of the C. trachomatis cases were already confronted with one or more urethritis episodes. 24.7% of patients have been subjected to a previous antichlamydial treatment.     

The transferrin receptor expressed by gonococcal strain FA1090 is required for the experimental infection of human male volunteers

Iron, an essential nutrient for most microorganisms, is sequestered by the host to decrease the concentration of iron available to bacterial pathogens. Neisseria gonorrhoeae , the causative agent of gonorrhoea, can acquire iron by direct interaction with human iron-binding proteins, including the serum glycoprotein, transferrin. Iron internalization from host transferrin requires the expression of a bacterial receptor, which specifically recognizes the human form of transferrin. Two gonococcal transferrin-binding proteins have been implicated in transferrin receptor function, TbpA and TbpB. We constructed a gonococcal transferrin receptor mutant without the introduction of additional antibiotic resistance markers and tested its ability to cause experimental urethritis in human male volunteers. The transferrin receptor mutant was incapable of initiating urethritis, although the same inoculum size of the wild-type parent strain, FA1090, causes urethritis in >90% of inoculated volunteers. To our knowledge, this is the first experimental demonstration that a bacterial iron acquisition system is an essential virulence factor for human infection.