[Management of sexually transmissible diseases in an urban environment in Cameroon in 1992]

During the progress, in 1989, of a programme of social marketing of condoms in Cameroon, it was obvious that this approach should be supplemented by a similar programme for the management of STD's. Nine surveys were carried out in 1992 in Yaounde and Douala in the sexually most active male population (in the general community, at the workplace and in the leisure environment) in order to collect the basic data necessary for its implementation. Treatment essentially consists of mono-chemotherapy with drugs which are generally inefficient against the two principal etiologies of urethritis: Neisseria gonorrhoeae and Chlamydia trachomatis. The cost of treatment is considered excessive and leads to poor follow-up of the complete prescription. Simultaneous treatment of partners should be developed. All these data have been taken into account for the elaboration of a pilot programme which should be implemented in 1993.

[Control of retrograde urethrocystitis by converted Y-type urethral catheter]

A converted Y-type urethral catheter was used to curb retrograde urethrocystitis due to indwelling urethral catheter. Satisfactory results were obtained in 30 cases. Injection of 0.5% bromo-geramine (10 ml) into the bladder through the bypass tube killed effectively the bacteria in the indwelling catheter. The device had the functions of urine deposit, urine conduction, bladder and urethral washing as well as urine sample collection. The connection between indwelling urethral catheter and the conducting tube was not dismantled during the procedure. So it reduced the chance of extraneous contamination.

Screening for urethral infection in adolescent and young adult males

We evaluated the urinary leukocyte esterase (LE) dipstick as a predictor of a positive urethral culture for Neisseria gonorrhoeae and/or Chlamydia trachomatis in adolescent and young adult males. Sexual and sexually transmitted disease (STD) histories were also analyzed to determine predictors of infection. Subjects were recruited from sexually active males attending an adolescent medicine clinic. Patients were interviewed regarding presence of symptoms of urethritis and a variety of clinical variables. First-voided urine for LE dipstick and urethral swabs for gonorrhea and C. trachomatis cultures were obtained. One hundred patients (mean age, 19.2 years) were asymptomatic; 50 patients (mean age, 19.0 years) had symptoms of urethritis. In asymptomatic patients, the sensitivity, specificity, predictive value positive (PVP), and predictive value negative (PVN) of the LE dipstick were 0.31, 0.92, 0.57, and 0.90, respectively. These values were 0.66, 0.71, 0.76, and 0.60, respectively, in symptomatic patients. In each patient group the dipstick was more sensitive in detecting, and a better predictor of, a positive culture for gonorrhea than Chlamydia. LE dipstick results and clinical variables were evaluated as correlates of infection using stepwise logistic regression. A positive LE dipstick and four additional variables increased the probability of obtaining a positive culture for one or both organisms from symptomatic patients. These variables were the following: sexual contact in the previous month with a partner diagnosed as having a sexually transmitted disease, having ever used a condom, five or more lifetime sexual partners, and more than one sexual partner in the past month. Only a positive LE dipstick entered the model as a predictor of infection in asymptomatic patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Family practice management in urethritis. II. Comparison of clinical management to the protocol]

OBJECTIVE

To describe general practitioners' approach to and management of urethritis in men, and to compare this with a general practice protocol for urethritis.

DESIGN

Descriptive.

SETTING

General practices in Amsterdam.

PATIENTS AND METHODS

In 13 general practices in Amsterdam (23,510 patients, of whom 11,627 men) all episodes of urethritis in men (n = 55) were recorded during one year (complaints, medical management, diagnosis, medication, follow-up).

OUTCOME MEASURES

Description of the diagnostic and therapeutic approach and the course of episodes; rough comparison with the urethritis protocol.

RESULTS

In 25% the urine sediment was examined; other office tests were rarely performed. In 30 to 40% out of office microbiological tests were performed. In 50% of new diagnoses medication was underdosed, in some cases medication was wrong or not broad enough. In 25% explicit education was offered. In 22% new medication was given in the follow-up encounter.

CONCLUSIONS

(Comparison with protocol.) Urine sediment examination as an effective test is performed insufficiently often. Other office tests are rarely performed, in accordance with the protocol. Out of office microbiological tests are performed too often, judged by the few changes of diagnosis and the character of new medication in the follow-up. First treatment is often underdosed and sometimes wrong. First treatment should preferably be broad, adequately dosed and independent of out of office microbiology. Too little education is given concerning the risks of ascending infections in female partners and of HIV infection. The referral rate is very low. It is important to pay attention to the outcome of this study in (postgraduate) education for general practitioners, as they treat the vast majority of urethritis patients.

Comparison of urethral reaction to full silicone, hydrogen-coated and siliconised latex catheters

Indwelling urinary catheter may induce an inflammatory reaction or even stricture of the urethra. Catheter encrustation and urinary infection are other disadvantages associated with long-term catheterisation. In the present study, 77 male patients were catheterised randomly as part of their normal treatment with 1 of 3 different types of catheter: 22 siliconised latex, 28 hydrogel-coated latex and 27 full silicone catheters. The mean duration of catheterisation was 2.2 days. The urethral inflammatory reaction was assessed from cytological urethral swab specimens. Catheter encrustation was studied using scanning electron microscopic (SEM) analysis. The full silicone catheters induced the mildest degree of inflammation in the urethra, the percentage mean of inflammatory cells in smears being 20%. In both latex catheter groups the value was 36%. Neither the age of the patients nor the duration of catheterisation had any effect on the inflammatory reaction, which was more marked in patients with haemodynamic abnormalities. The hydrogel coating effectively prevented encrustation, while siliconised latex catheters were the least resistant to encrustation. The inflammatory reaction was variable in all patients. The use of urethral catheters should be restricted and suprapubic tubes should be used instead, particularly in patients with shock-like circulatory changes. By developing the biocompatibility and physical properties of urinary catheters, more compatible devices may be manufactured.

An analysis of and intervention in the sexual transmission of disease

Sexually transmitted diseases are a serious threat to the public health. Indeed, when an individual seeks medical treatment for a sexually transmitted disease, health authorities frequently attempt to identify, procure, and treat that individual's sexual contact(s). We conducted a comparative analysis of three alternative approaches to tracing the sexual partners of individuals diagnosed as having a sexually transmitted disease. The first approach involved counseling individuals (n = 27) infected with either gonorrhea or nongonococcal urethritis and exhorting them to procure their sexual partners for treatment. In addition to counseling, the second and third approaches involved distributing "occasion cards" for patients to use when informing sexual contacts of the need for treatment. Moreover, in the second approach, the counselor (a nurse or physician) informed infected patients (n = 19) that they and their partners could waive the $3 clinic fee contingent upon the partners seeking treatment within 1 week. In the third approach, the counselor asked infected persons (n = 19) to accept a follow-up telephone contact if their sexual partners failed to seek treatment within 1 week. The third approach was most effective. Ninety percent of the partners identified through this approach sought treatment, versus only about 60% of the partners in the other two conditions. The third approach was also the least expensive, costing about $2.95 to procure each partner for treatment.

Nongonococcal urethritis incidence has fallen at one university health service: are "safer sex" messages being heard?

The authors determined the incidence of nongonococcal urethritis (NGU) longitudinally in patients attending a university health service between August 1986, and May 1988. During this period, the authors observed a statistically significant fall in NGU incidence. This fall coincided with awareness of AIDS risks due to national and local media encouragement of condom use and avoidance of anonymous or promiscuous contacts. Although the authors have no evidence that these educational efforts resulted in the observed fall in NGU incidence, other examined, potentially intervening variables can not completely explain the observed changes. A fall in NGU incidence may be a marker for a more generally decreased risk of sexually transmitted diseases (STDs) in at least some men.

Epidemiological treatment of sexual contacts prevents recurrence of non-gonococcal urethritis

Of 98 male patients with non-gonococcal urethritis (NGU) who had regular female consorts who received concurrent epidemiological treatment, NGU recurred in four (16%) men whose treated partners were initially chlamydia positive and 20 (27%) men whose treated partners were initially chlamydia negative. Of 32 men whose regular female sexual partners refused to attend, 26 (77%) men suffered a recurrence of NGU. All study patients were selected because they were in monogamous relationships and returned to the clinic either because of a recurrence of NGU or for unrelated reasons at least 12 months after treatment. We recommend the routine epidemiological treatment of all sexual contacts of men with NGU.

Nonspecific urethritis in men

The epidemiology, diagnostic criteria, and etiology of nonspecific urethritis in men are discussed. Microbiological examinations have indicated that in the vast majority of these patients Chlamydia trachomatis and Ureaplasma urealyticum are the main causes for the disease. Treatment of the disorder has centered on the use of tetracyclinelike drugs, and with proper treatment cure can be obtained in the majority of patients.

Effect of epidemiological treatment of contacts in preventing recurrences of non-gonococcal urethritis

Clinical investigations of the usefulness of routine epidemiological treatment of sexual contacts of men with non-gonococcal urethritis (NGU) have produced conflicting results that could have been due to the selection of patients. In this study, which was undertaken in a provincial city, 100 men with untreated sexual partners and 100 demographically similar men with treated sexual partners were reviewed for recurrences of NGU over 12 months. Prolonged courses of tetracyclines were found to be beneficial particularly when the sexual partner gave positive results to tests for chlamydiae. There was, however, no clinical evidence that the men benefited from routine epidemiological treatment of their sexual partners.

Advantages of adding a course of tetracycline to single dose ampicillin and probenecid in the treatment of gonorrhoea

Chlamydia trachomatis was reisolated from 11 of 12 men with gonorrhoea who had initially yielded chlamydiae and who had been treated with ampicillin and probenecid (AMP) only, but from none of five such men treated with ampicillin and probenecid followed by tetracycline (AMPT). These results correlated with the absence of postgonococcal urethritis (PGU) in the group treated with AMPT. C trachomatis was isolated or reisolated from 20 of 25 women after treatment with AMP, compared with none of 14 women treated with AMPT. We recommend the addition of a course of tetracycline to the routine single dose treatment for gonorrhoea in men and women.

The effect of chemical intravaginal contraceptives and Betadine on

The purpose of this study was to find a barrier contraceptive agent capable of controlling infections and sexual transmission of Ureaplasma urealyticum from the female genital tract, especially to help reduce nongonococcal urethritis in males caused by this organism. Therefore, the in vitro antimicrobial activity of six intravaginal contraceptives and BetadineR against the eight serotypes of the organism was investigated. The results indicate that some of these contraceptives produce partial inhibition of the Ureaplasma at low dilutions, while BetadineR produces a ureaplasmacidal effect up to dilutions of 1:64. These effects appear not to be due primarily to the pH of these agents. Thus, some of these agents may have a potential role in controlling transmission of Ureaplasma urealyticum.

Treatment of uncomplicated gonorrhea with rosoxacin

In a randomized, double-blind, dose-ranging study, single oral doses of rosoxacin were used to treat 126 patients with uncomplicated genital or anorectal gonorrhea. Neisseria gonorrhoeae was eradicated from 5 (28%) of 18 men treated with 100 mg, compared with 101 (94%) of 108 men and women treated with 200 mg, 300 mg, or 400 mg (P less than 0.001). Susceptibility to rosoxacin was determined for 6 pretreatment gonococcal isolates from these patients and for 194 stored clinical isolates; 296 (98.7%) of these 300 isolates, including 10 strains of penicillinase-producing N. gonorrhaeae, required a minimal inhibitory concentration of less than or equal to 0.062 microgram/ml. Urethral or cervical infection with Chlamydia trachomatis coexisted with gonococcal infection in 14 (22%) of 63 patients and persisted in 7 of 10 patients treated with rosoxacin. Postgonococcal urethritis developed in 11 (34%) of 32 men who were monitored for 12 to 30 days. Sixty-four subjects (51%) developed transient dizziness, drowsiness, altered visual perceptions, or other symptoms suggestive of central nervous system dysfunction after treatment with rosoxacin, but these symptoms were not clearly dose related. Rosoxacin in doses of greater than or equal to 200 mg appears to be effective for single-dose treatment of uncomplicated gonorrhea, but further studies of its possible central nervous system toxicity are indicated.

A trial of minocycline given after exposure to prevent gonorrhea

In a prospective evaluation of antibiotic prophylaxis against gonorrhea, 1080 men were given 200 mg of oral minocycline or placebo after sexual intercourse with prostitutes in a Far Eastern port. Later, at sea, gonococcal infection was detected in 57 of 565 men given placebo and 24 of 515 men given minocycline (P less than 0.001). Minocycline prophylaxis completely prevented infection by gonococci susceptible to 0.75 microgram or less of tetracycline per milliliter, reduced the risk of infection or prolonged the incubation period in men exposed to gonococci susceptible to 1.0 to 2.0 micrograms per milliliter, but did not prevent infection or prolong incubation in men exposed to gonococci resistant to 2.0 micrograms. Minocycline did not increase the proportion of asymptomatic infections. Minocycline prophylaxis would probably have limited effectiveness as a public-health measure because of the tendency to select resistant gonococci.

A simple operation for postcoital urethrotrigonitis in women

Definitive treatment of postcoital urethrotrigonitis, or "honeymoon cystitis", as it is commonly called, has only been paid serious attention since 1967. It has been suggested (O'Donnell, 1959) that the introduction of bacteria into the urethra is more likely when the urethra assumes a relatively hypospadiac position during coitus. This is commonly associated with incomplete rupture of the hymen. Division of the anterior bridge of the hymen on either side of the external urethral meatus appears to be as effective as more complicated procedures in preventing ascending infection associated with coitus.

The condom and gonorrhoea

The use of the condom by male patients attending a clinic specialising in sexually transmitted diseases has been assessed over a period of six months. Condom users were divided into those who used them properly and invariably, and those who did not. In the group studied, correct use of the condom was associated with a significantly lower probability of acquiring gonorrhoea (P less than 0-001) and a significantly higher chance of there being no sexually transmitted disease diagnosed (P less than 0-0005). The diagnosis-rate of non-specific urethritis, however, did not differ among the groups.

Estrogen treatment of postmenopausal women. Benefits and risks

Estrogen treatment of postmenopausal women is effective in relieving the symptoms of vasomotor instability and urogenital atrophy; estrogen treatment is effective in preventing accelerated bone loss and osteoporosis in young women following castration, but in postmenopausal women aging is a more important determinant of accelerated bone loss than is decreased estrogen secretion. Low-dose estrogen treatment of postmenopausal women neither prevents nor increases the risk of arteriosclerotic cardiovascular disease or cerebral vascular disease. It cannot be definitively established that estrogen treatment of postmenopausal women causes an increased incidence of breast tumors, but it is clear that such treatment does not prevent these tumors. It is established that estrogen treatment of postmenopausal women increases the risk ratio of endometrial carcinoma.

Spectinomycin versus tetracycline for the treatment of gonorrhea

Spectinomycin and tetracycline are alternative drugs to penicillin in the treatment of gonorrhea. To compare the efficacy of these agents and their propensity to select resistant gonococci, we treated 4043 patients randomly with either 2 or 4 g of spectinomycin once or 9 g of oral tetracycline for four days. Minimum cure rate for anogenital gonorrhea was 94 per cent with either drug. Oropharyngeal infection responded poorly to spectinomycin in men, with failure of therapy in six of 11. Postgonococcal urethritis in men was less common after tetracycline than after spectinomycin (P less than 0.005). Spectinomycin failure was not related to drug resistance. Tetracycline failure correlated with resistance (P less than 0.0002); one fifth of the isolates resistant to 1.0 mug per milliter of tetracycline were not eradicated. For several reasons, including the appearance of beta-lactamase-producing gonococci, it is no longer clear that penicillin G is the "drug of choice" for gonorrhea. Spectinomycin and tetracycline are equally acceptable alternatives, each with distinct advantages and disadvantages.