Clinical and microbiological features of persistent or recurrent nongonococcal urethritis in men

Clinical significance of ureaplasmas in urogenital pathology

The clinical significance of Ureaplasmas in urogenital pathology is reviewed. Ureaplasmas belong to the class Mollicutes. Asymptomatic carriage of these bacteria is common, and most individuals do not develop disease. Ureaplasma urealyticum and Ureaplasma parvum are sexually transmitted bacteria among humans implicated in a variety of disease states including but not limited to: nongonococcal urethritis, adverse pregnancy outcomes, chorioamnionitis, and bronchopulmonary dysplasia in neonates. U. urealyticum has been associated with urethritis in men and is revealed in a high concentration that confirms its etiological role in the disease. Men with a high U. urealyticum load are considered for treatment, however, the data on the therapy efficiency have been insufficient so far. In symptomatic women, bacterial vaginosis should always be tested for, and the corresponding therapy should be prescribed in case of positive results.

Gram-Positive Uropathogens, Polymicrobial Urinary Tract Infection, and the Emerging Microbiota of the Urinary Tract

Gram-positive bacteria are a common cause of urinary-tract infection (UTI), particularly among individuals who are elderly, pregnant, or who have other risk factors for UTI. Here we review the epidemiology, virulence mechanisms, and host response to the most frequently isolated Gram-positive uropathogens: Staphylococcus saprophyticus, Enterococcus faecalis, and Streptococcus agalactiae. We also review several emerging, rare, misclassified, and otherwise underreported Gram-positive pathogens of the urinary tract including Aerococcus, Corynebacterium, Actinobaculum, and Gardnerella. The literature strongly suggests that urologic diseases involving Gram-positive bacteria may be easily overlooked due to limited culture-based assays typically utilized for urine in hospital microbiology laboratories. Some UTIs are polymicrobial in nature, often involving one or more Gram-positive bacteria. We herein review the risk factors and recent evidence for mechanisms of bacterial synergy in experimental models of polymicrobial UTI. Recent experimental data has demonstrated that, despite being cleared quickly from the bladder, some Gram-positive bacteria can impact pathogenic outcomes of co-infecting organisms. When taken together, the available evidence argues that Gram-positive bacteria are important uropathogens in their own right, but that some can be easily overlooked because they are missed by routine diagnostic methods. Finally, a growing body of evidence demonstrates that a surprising variety of fastidious Gram-positive bacteria may either reside in or be regularly exposed to the urinary tract and further suggests that their presence is widespread among women, as well as men. Experimental studies in this area are needed; however, there is a growing appreciation that the composition of bacteria found in the bladder could be a potentially important determinant in urologic disease, including susceptibility to UTI.

Costing of National STI Program Implementation for the Global STI Control Strategy for the Health Sector, 2016-2021

Introduction

In 2016 the World Health Assembly adopted the global strategy on Sexually Transmitted Infections (STI) 2016–2021 aiming to reduce curable STIs by 90% by 2030. We costed scaling-up priority interventions to coverage targets.

Methods

Strategy-targeted declines in Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum and Trichomonas vaginalis were applied to WHO-estimated regional burdens at 2012. Syndromic case management was costed for these curable STIs, symptomatic Herpes Simplex Virus 2 (HSV-2), and non-STI vaginal syndromes, with incrementally expanding etiologic diagnosis. Service unit costs were multiplied with clinic attendances and people targeted for screening or prevention, by income tier. Human papilloma virus (HPV) vaccination and screening were costed for coverage increasing to 60% of 10-year-old girls for vaccination, and 60% of women 30–49 years for twice-lifetime screening (including clinical follow-up for positive screens), by 2021.

Results

Strategy implementation will cost an estimated US$ 18.1 billion over 2016–2021 in 117 low- and middle-income countries. Cost drivers are HPV vaccination ($3.26 billion) and screening ($3.69 billion), adolescent chlamydia screening ($2.54 billion), and antenatal syphilis screening ($1.4 billion). Clinical management—of 18 million genital ulcers, 29–39 million urethral discharges and 42–53 million vaginal discharges annually—will cost $3.0 billion, including $818 million for service delivery and $1.4 billion for gonorrhea and chlamydia testing. Global costs increase from $2.6 billion to $ 4.0 billion over 2016–2021, driven by HPV services scale-up, despite vaccine price reduction. Sub-Saharan Africa, bearing 40% of curable STI burdens, covers 44% of global service needs and 30% of cost, the Western Pacific 15% of burden/need and 26% of cost, South-East Asia 20% of burden/need and 18% of cost.

Conclusions

Costs of global STI control depend on price trends for HPV vaccines and chlamydia tests. Middle-income and especially low-income countries need increased investment, innovative financing, and synergizing with other health programs.

2016 European guideline on the management of non-gonococcal urethritis

We present the updated International Union against Sexually Transmitted Infections (IUSTI) guideline for the management of non-gonococcal urethritis in men. This guideline recommends confirmation of urethritis in symptomatic men before starting treatment. It does not recommend testing asymptomatic men for the presence of urethritis. All men with urethritis should be tested for Chlamydia trachomatis and Neisseria gonorrhoeae and ideally Mycoplasma genitalium using a nucleic acid amplification test (NAAT) as this is highly likely to improve clinical outcomes. If a NAAT is positive for gonorrhoea, a culture should be performed before treatment. In view of the increasing evidence that azithromycin 1 g may result in the development of antimicrobial resistance in M. genitalium, azithromycin 1 g is no longer recommended as first line therapy, which should be doxycycline 100 mg bd for seven days. If azithromycin is to be prescribed an extended course of 500 mg stat, then 250 mg daily for four days is to be preferred over 1 g stat. In men with persistent NGU, M. genitalium NAAT testing is recommended if not previously undertaken, as is Trichomonas vaginalis NAAT testing in populations where T. vaginalis is detectable in >2% of symptomatic women.

Management of non-gonococcal urethritis

Non-gonococcal urethritis (NGU), or inflammation of the urethra, is the most common treatable sexually transmitted syndrome in men, with approximately 20-50 % of cases being due to infection with Chlamydia trachomatis and 10-30 % Mycoplasma genitalium. Other causes are Ureaplasma urealyticum, Trichomonas vaginalis, anaerobes, Herpes simplex virus (HSV) and adenovirus. Up to half of the cases are non-specific. Urethritis is characterized by discharge, dysuria and/or urethral discomfort but may be asymptomatic. The diagnosis of urethritis is confirmed by demonstrating an excess of polymorpho-nuclear leucocytes (PMNLs) in a stained smear. An excess of mononuclear leucocytes in the smear indicates a viral etiology. In patients presenting with symptoms of urethritis, the diagnosis should be confirmed by microscopy of a stained smear, ruling out gonorrhea. Nucleid acid amplifications tests (NAAT) for Neisseria gonorrhoeae, C. trachomatis and for M. genitalium. If viral or protozoan aetiology is suspected, NAAT for HSV, adenovirus and T. vaginalis, if available. If marked symptoms and urethritis is confirmed, syndromic treatment should be given at the first appointment without waiting for the laboratory results. Treatment options are doxycycline 100 mg x 2 for one week or azithromycin 1 gram single dose or 1,5 gram distributed in five days. However, azithromycin as first line treatment without test of cure for M. genitalium and subsequent Moxifloxacin treatment of macrolide resistant strains will select and increase the macrolide resistant strains in the population. If positive for M. genitalium, test of cure samples should be collected no earlier than three weeks after start of treatment. If positive in test of cure, moxifloxacin 400 mg 7-14 days is indicated. Current partner(s) should be tested and treated with the same regimen. They should abstain from intercourse until both have completed treatment. Persistent or recurrent NGU must be confirmed with microscopy. Reinfection and compliance must be considered. Evidence for the following recommendations is limited, and is based on clinical experience and guidelines. If doxycycline was given as first therapy, azithromycin five days plus metronidazole 4-500 mg twice daily for 5-7 days should be given. If azithromycin was prescribed as first therapy, doxycycline 100 mg x 2 for one week plus metronidazole, or moxifloxacin 400 mg orally once daily for 7-14 days should be given.

2015 UK National Guideline on the management of non-gonococcal urethritis

We present the updated British Association for Sexual Health and HIV guideline for the management of non-gonococcal urethritis in men. This document includes a review of the current literature on its aetiology, diagnosis and management. In particular it highlights the emerging evidence that azithromycin 1 g may result in the development of antimicrobial resistance in Mycoplasma genitalium and that neither azithromycin 1 g nor doxycycline 100 mg twice daily for seven days achieves a cure rate of >90% for this micro-organism. Evidence-based diagnostic and management strategies for men presenting with symptoms suggestive of urethritis, those confirmed to have non-gonococcal urethritis and those with persistent symptoms following first-line treatment are detailed.

Persistent urethritis and prostatitis due to Trichomonas vaginalis: A case report

The present report describes a case of persistent urethritis accompanied by prostatitis due to Trichomonas vaginalis in a young male patient. The importance of the laboratory diagnosis of trichomoniasis in persistent or recurrent urethritis (ie, testing samples from multiple sites) is highlighted, with the aim of improving the clinical recognition of this pathogen.

Mycoplasma genitalium urethritis in men

Mycoplasma genitalium was first isolated from two men with non-gonococcal urethritis (NGU) and thereafter shown to produce urethritis in subhuman primates, inoculated intraurethrally. This mycoplasma has been detected significantly more often in patients with acute NGU, particularly in patients with non-chlamydial NGU, than in subjects without urethritis. The prevalence of M. genitalium-positive non-chlamydial NGU ranges from 18 to 46% of all non-chlamydial NGU cases. In addition, the persistence of M. genitalium in the urethra after antimicrobial chemotherapy is associated with persistence or recurrence of NGU. The various results reported to date tend to support the proposition that M. genitalium is a pathogen of NGU. M. genitalium is highly susceptible to tetracyclines, macrolides, and some new fluoroquinolones, but the clinical data on the chemotherapy in M. genitalium-positive NGU is extremely limited. Because of the possible association between the post-treatment presence of M. genitalium in the urethra and persistent or recurrent NGU, the eradication of this mycoplasma from the urethra is essential in the management of patients with M. genitalium-positive NGU. Further studies are required to establish the optimal chemotherapy for M. genitalium-positive NGU.

Antibodies to Chlamydia trachomatis heat-shock protein 60 kDa and detection of Mycoplasma genitalium and ureaplasma urealyticum are associated independently with chronic nongonococcal urethritis

BACKGROUND

Chronic nongonococcal urethritis (NGU) is a well-recognized clinical problem in genitourinary medicine clinics, but its etiology and optimal management are poorly understood.

GOAL

The authors showed previously that antibody to chlamydial hsp60 is associated with urethritis 30 to 92 days after treatment of acute NGU (chronic NGU) and that the detection of ureaplasmas or is associated with chronic NGU in which symptoms or signs are present. The aim was to determine whether these associations are independent of each other.

STUDY DESIGN

This was a longitudinal prospective follow-up study over a 3-month period of 86 men with acute NGU. Men were tested for, ureaplasmas, and antibody to chlamydia hsp60 at presentation and during follow-up.

RESULTS

The detection of either ureaplasmas or (OR, 29.45; 95% CI, 1.78-487) and the occurrence of hsp60 antibody at 30 to 92 days' follow-up (OR, 26.45; 95% CI, 1.34-523) were associated independently with the development of chronic NGU 30 to 92 days after treatment of acute NGU. The presence of chlamydial hsp60 antibody at 30 to 92 days was not associated with the development of chronic NGU in which symptoms or signs were present (P= 0.363). Chlamydial hsp60 antibody associated, however, with chronic NGU in which there were no symptoms or signs (P = 0.01).

CONCLUSION

The results suggest that the immune response to chlamydial hsp60 may have a role in the etiology of chronic NGU in asymptomatic men who have no discharge on examination. The clinical relevance of this is unknown.

Mycoplasma genitalium: another important pathogen of nongonococcal urethritis

PURPOSE

We reviewed findings on the pathogenic role of Mycoplasma genitalium in nongonococcal urethritis and the treatment of men with M. genitalium positive nongonococcal urethritis.

MATERIALS AND METHODS

We reviewed literature selected from peer reviewed journals listed in MEDLINE and from resources cited in those articles from 1967 to January 2001.

RESULTS

M. genitalium was first isolated from 2 men with nongonococcal urethritis and thereafter it was shown to cause urethritis in subhuman primates inoculated intraurethrally. This mycoplasma has been detected significantly more often in patients with acute nongonococcal urethritis, particularly in those with nonchlamydial nongonococcal urethritis, than in those without urethritis. The prevalence of M. genitalium positive nonchlamydial nongonococcal urethritis is 18.4% to 45.5% of all nonchlamydial nongonococcal urethritis cases. In addition, the persistence of M. genitalium in the urethra after antimicrobial chemotherapy is associated with persistent or recurrent nongonococcal urethritis. M. genitalium is highly susceptible to tetracycline, macrolide and some new fluoroquinolones. The regimen of 100 mg. doxycycline orally twice daily for 7 days, which is recommended for chlamydial nongonococcal urethritis, seems to be effective for M. genitalium positive nongonococcal urethritis, although clinical data to substantiate this regimen are limited.

CONCLUSIONS

The various results reported to date tend to support the proposition that M. genitalium is a pathogen of nongonococcal urethritis. However, currently diagnostic methods for this important mycoplasma are not available in clinical practice. Because of the possible association of the posttreatment presence of M. genitalium in the urethra with persistent or recurrent nongonococcal urethritis, eradication of this mycoplasma from the urethra is essential for managing M. genitalium positive disease. However, clinical data on treating M. genitalium positive nongonococcal urethritis are extremely limited. Thus, further studies are required to develop new diagnostic methods that would be available in clinical settings and establish a new treatment algorithm for nongonococcal urethritis, including M. genitalium positive disease.

Association of Mycoplasma genitalium persistence in the urethra with recurrence of nongonococcal urethritis

BACKGROUND

Most patients with recurrent symptomatic nongonococcal urethritis receive negative test results for Chlamydia trachomatis and Ureaplasma urealyticum, and the cause of such recurrence usually is unknown.

GOAL

To assess the association of Mycoplasma genitalium with recurrent nongonococcal urethritis.

STUDY DESIGN

In this study, 72 men with nongonococcal urethritis were treated with levofloxacin. Before and after treatment, symptoms and signs were assessed and first-pass urine was examined for C trachomatis, M genitalium, U urealyticum, and Mycoplasma hominis by polymerase chain reaction-based assays.

RESULTS

In 6 of 45 men who had no symptoms and no evidence of inflammation after treatment, nongonococcal urethritis recurred. Of these 6 men, 5 had positive test results for M genitalium before levofloxacin treatment, which remained positive afterward. After the second treatment for recurrent nongonococcal urethritis, one man was still had a positive test result for the mycoplasma and experienced a subsequent recurrence.

CONCLUSIONS

This study suggests that the persistence of M genitalium in the urethra may be associated with recurrence of nongonococcal urethritis.

Etiology of nongonococcal nonchlamydial urethritis

The majority of cases of acute nongonococcal urethritis (NGU) are due to causes other than infection with Chlamydia trachomatis. Pathogens implicated as causes of nonchlamydial nongonococcal urethritis (NCNGU) include Mycoplasma genitalium, Ureaplasma urealyticum, Trichomonas vaginalis, and primary infection with herpes simplex virus. In a majority of cases of acute NCNGU, no pathogen can be isolated. The etiology of chronic NCNGU is unknown.

Risk factors for urethritis in heterosexual men. The role of fellatio and other sexual practices

BACKGROUND

Nonchlamydial nongonococcal urethritis (NGU) is a common sexually transmitted disease (STD) in heterosexual men. Prior studies have suggested that NGU may be acquired by insertive oral sex.

GOAL

To assess the association of oral sex and other sexual practices with nonchlamydial NGU in heterosexual men in order to better understand this syndrome and to guide its prevention and treatment. Risk factors for urethral gonorrhea and chlamydial infection were explored to contrast with NGU.

STUDY DESIGN

A retrospective case-control study was conducted among heterosexual men attending as STD clinic during 1993 and 1994. The study included 4,848 men who were sexually active within the prior 2 months and had urethral specimens obtained for Gram's stain, culture for Neisseria gonorrhoeae, and culture for Chlamydia trachomatis.

RESULTS

Insertive oral sex was not shown to be an independent risk factor for NGU. Independent predictors of nonchlamydial NGU by multivariate analysis included African-American race (odds ratio [OR] 3.71, 95% confidence interval [95% CI] 3.06 to 4.50) and having > or = two sex partners in the prior 2 months (OR 1.45, 95% CI 1.20 to 1.75). History of using condoms "always" was negatively associated with NGU (OR 0.59, 95% CI 0.43 to 0.79), gonorrhea (OR 0.31, 95% CI 0.17 to 0.56), and chlamydial infection (OR 0.67, 95% CI 0.44 to 1.03).

CONCLUSIONS

This study supports the sexually transmitted nature of nonchlamydial NGU but did not confirm an association with oral sex. However, the analysis was compromised by the rarity of insertive oral sex as patients' only sexual exposure. Consistent condom use protects against all causes of sexually acquired urethritis.

Ureaplasma urealyticum in the urogenital tract of patients with chronic prostatitis or related symptomatology

To elucidate the role of Ureaplasma urealyticum as a causative organism in chronic prostatitis we investigated its incidence in the urogenital tract in 131 chronic prostatitis patients and 120 prostatodynia patients; the presence of common bacteria or Chlamydia trachomatis was also recorded. According to the 4-glass localisation test, U. urealyticum (> or = 10(3) ccu/ml) was isolated from the prostates of 16 prostatitis patients and 2 prostatodynia patients; 5 of these prostatitis patients (but neither of the prostatodynia patients) had other bacteria in specimens after prostatic massage. Thus U. urealyticum was the sole organism isolated from the prostates of 11 prostatitis and 2 prostatodynia patients, which suggests that it is an aetiological agent in some cases of chronic non-bacterial prostatitis.

Genital infections in men associated with Chlamydia trachomatis

The advent of new diagnostic procedures has made it possible for urologists to detect chlamydial presence in genital infections. Many studies have shown chlamydial association with urethritis. However, its presence in prostatitis and epididymitis has not been clearly defined yet. In this study we investigated the presence of Chlamydia trachomatis using enzyme linked immuno assay (ELISA) antigen and antibody detection method in sexually active men with different genital infections. We have found that in 32.1% of patients with non-gonococcal urethritis chlamydial antigen is detectable. We also have been able to detect chlamydial antigen in two patients with chronic non-bacterial prostatitis, but in no patients with epididymitis. We conclude that besides its presence in urethritis, there is an association between chlamydia and chronic prostatitis. Yet, further studies are needed to delineate this association more clearly.

Recurrent arthritis in Reiter's syndrome: a function of inapparent chlamydial infection of the synovium?

Present or prior infection with any of several common bacterial pathogens has been strongly implicated in the development of Reiter's syndrome (RS). However, because Chlamydia trachomatis is the most common sexually transmitted bacterial pathogen in the western hemisphere, this organism has emerged as a major causative agent of the disease. An important but as yet poorly understood aspect of chlamydia-related RS is the recurrence of active arthritis in the absence of any overt infection or reinfection with the organism. In this article, a large body of published clinical and experimental observations strongly suggesting that some chlamydial infections in humans can be inapparent--not detectable by standard culture or antibody-based laboratory screening methods--is reviewed. The authors' own initial molecular genetic studies, which support that contention, are summarized. Based on these data, the argument is developed that not only does inapparent chlamydial infection occur in humans, but such infections may have significant consequences in terms of the pathogenesis of RS, including the possible causation of recurrent episodes of disease in the absence of active infection. The therapeutic implications of potential inapparent chlamydial infections as they relate to RS are discussed.

Approach to men with urethritis and urologic complications of sexually transmitted diseases

The most important causes of urethritis, and epididymitis in younger men, are C. trachomatis and N. gonorrhoeae. Management of these syndromes requires a thorough sexual history, genital examination, evaluation for objective and laboratory evidence of infection, antimicrobial therapy directed toward the major etiologies, and evaluation and treatment of sexual partners. Treatment of N. gonorrhoeae requires use of a single-dose regimen active against this organism, plus a 7- to 10-day tetracycline regime active against C. trachomatis and nongonococcal urethritis. With recommended regimens, microbiologic failure is infrequent in compliant patients. Recurrent urethritis is frequent, however. The management of patients with persistent or recurrent symptoms requires careful reevaluation of the patient, documentation of urethritis, and re-treatment with antimicrobials if urethritis is documented by positive cultures or increased numbers of polymorphonuclear leukocytes in urethral secretions. Additional treatment beyond this point usually is not indicated, even though a proportion of men will remain symptomatic and some of these will have increased numbers of polymorphonuclear leukocytes in urethral secretions. The most important causes of prostatitis, and epididymitis in older men or men with urethral structural abnormalities, are classical urinary tract pathogens rather than sexually transmitted pathogens. Management of these infections includes documentation of the infection and treatment directed toward the specific pathogen. Men with symptoms of "prostatitis" must be evaluated using both urine and prostatic secretions to document infection and inflammation. The majority of men with such symptoms do not have an infection that can be documented. These men respond poorly to medications. Men with documented chronic bacterial prostatitis require long courses of antimicrobials to effect cure. In some cases, however, the disease is intractable, and chronic suppression with antimicrobials may be necessary.