Ureaplasma urealyticum is associated with nongonococcal urethritis among men with fewer lifetime sexual partners: a case-control study

High burden of sexually transmitted infections among under-resourced populations in the Dominican Republic

Background

Sexually transmitted infections (STIs) are a major health issue, exacerbated by limited financial and infrastructural resources in developing countries.

Methods

Prevalence of STIs was assessed in two urban centers of the Dominican Republic (DR) among populations at high risk for STIs: pregnant youth, men who have sex with men (MSM), trans women (TG), batey residents, female sex workers, and people living with human immunodeficiency virus (HIV). We conducted a cross-sectional survey and biological specimen collection to screen for Chlamydia trachomatis, Neisseria gonorrhea, Mycoplasma genitalium, Trichomonas vaginalis (trichomoniasis), Treponema pallidum (syphilis), HIV, hepatitis B and C, and human papillomavirus (HPV) among at-risk populations between 2015 and 2018. Ureaplasma urealyticum testing was also conducted even though it is not considered a STI. A non-probability community sample was recruited. Descriptive statistics examined the prevalence of STIs by population.

Results

A total of 1991 subjects participated in the study. The median age was 26 years (range: 18-65). Most participants were female (65.3%), heterosexual (76.7%), and were not partnered (55.7%). Most of the participants reported unprotected vaginal sex in the last 6 months (54%); among MSM and TG almost half of the participants reported unprotected anal sex in the last 6 months and 17.6% reported drug use in the last 6 months. Almost half of the participants (49%) tested positive for one or more STIs. The most prevalent STI was Chlamydia trachomatis (12.8%), and human papillomavirus (11.9%). Among transgender women, 65.3% tested positive for an STI, 64.8% of female sex workers tested positive for an STI, and 53.8% of pregnant adolescents tested positive for an STI.

Conclusion

There is a high prevalence of STIs among key and under resourced populations in the DR. Our findings highlight the need to conduct further research to optimize prevention and care strategies for structurally vulnerable and under resourced populations in the DR.

Bacterial vaginosis-associated bacteria in cisgender men who have sex with women: prevalence, association with non-gonococcal urethritis and natural history

OBJECTIVES

Bacterial vaginosis-associated bacterium 2 (BVAB2), Mageeibacillus indolicus and Sneathia spp are highly predictive of bacterial vaginosis (BV) in cisgender women. They have been associated with non-gonococcal urethritis (NGU) in cisgender men in some but not all populations. We evaluated this association in a cross-sectional study of cisgender men who have sex with women only (MSW).

METHODS

MSW without gonorrhoea attending a sexual health clinic (SHC) from 2014 to 2018 completed a computer-assisted self-interview, clinical interview and examination. NGU was defined as ≥5 polymorphonuclear leucocytes/high-power field in urethral exudates plus either urethral symptoms or visible discharge. Urine was tested for Chlamydia trachomatis and Mycoplasma genitalium using Aptima (Hologic) and for BVAB2, M. indolicus, Sneathia spp, Trichomonas vaginalis, Ureaplasma urealyticum, Haemophilus influenzae, herpes simplex virus and adenovirus using quantitative PCR.

RESULTS

Of 317 MSW age 17-71, 67 (21.1%) had Sneathia spp, 36 (11.4%) had BVAB2, and 17 (5.4%) had M. indolicus at enrolment. Having ≥3 partners in the past 2 months was the only characteristic that was more common among MSW with than those without these bacteria (BVAB2: 47% vs 23%, M. indolicus: 53% vs 24%, Sneathia spp: 42% vs 22%; p≤0.03 for all). One-hundred seventeen men (37%) were diagnosed with NGU at enrolment. There was no significant association of BVAB2, M. indolicus or Sneathia spp with NGU (adjusted OR=0.59, 95% CI 0.14 to 2.43; aOR=3.40, 95% CI 0.68 to 17.06; aOR=0.46, 95% CI 0.16 to 1.27). Of 109 MSW with monthly samples, 34 (31.2%) had one of the bacteria at one or more follow-up visits, 22 of which were co-colonised with >1. Median persistence over 6 months did not differ significantly (BVAB2=30.5 days, IQR=28-87; M. indolicus=87 days, IQR=60-126; Sneathia spp=70 days, IQR=30-135; p≥0.20 for each comparison).

CONCLUSIONS

Neither BVAB2, M. indolicus nor Sneathia spp were associated with increased risk of prevalent NGU in MSW attending an SHC.

Corynebacterium glucuronolyticum in men with and without urethritis syndrome: An underrecognized pathogen or a bona fide commensal?

BACKGROUND

By analysing the largest collection of Corynebacterium glucuronolyticum (C. glucuronolyticum) isolates from a single centre thus far, we aimed to appraise a potential causal link between an infrequently isolated species and the urethritis syndrome in men.

METHODS

A total of 1055 Caucasian male individuals with or without urethritis syndrome were included in this single-centre case-control study. Group-wise comparisons were pursued by analysing sociodemographic, behavioural and microbiological specificities between the two groups. C. glucuronolyticum isolates from urethral specimens were identified using the analytical profile index biotyping system (API Coryne) and additionally confirmed by MALDI-TOF mass-spectrometry, with subsequent determination of their antimicrobial sensitivity profiles. Statistical significance was set at p < 0.05 (two-tailed).

RESULTS

C. glucuronolyticum was isolated in 5.08% of study participants with urethritis syndrome and 3.60% of those without it (p = 0.303). In the urethritis group, the species was more frequently found as a sole isolate (p = 0.041) and after prior infection with Chlamydia trachomatis (p = 0.025). The most frequent presentation of urethritis included a clear discharge in small or moderate amounts, without any pathognomonic findings. The resistance rates were 62.22% for clindamycin, 42.22% for tetracycline and 26.67% for ciprofloxacin.

CONCLUSIONS

Our study provides major insights on the relevance of urethral C. glucuronolyticum in non-gonococcal urethritis, with significant implications for further aetiological research and management approaches.

The Urethral Microbiota of Men with and without Idiopathic Urethritis

Nongonococcal urethritis (NGU) is a common genital tract syndrome in men, and up to 50% of cases are considered idiopathic, i.e., no etiological agent is identified. This poses challenges for clinicians in the diagnosis and treatment of NGU and often results in antibiotic misuse and overuse. Therefore, to identify potential infectious causes of urethritis and inform clinical management of urethritis cases, we characterized and compared the urethral microbiota of men with and without idiopathic urethritis. Participants were derived from a case-control study that examined viral and bacterial pathogens and sexual practices associated with NGU. Men with NGU who tested negative for established causes of NGU (Chlamydia trachomatis, Mycoplasma genitalium, Trichomonas vaginalis, adenoviruses, herpes simplex virus [HSV]-1, and/or HSV-2) were classified as idiopathic cases, and the controls were men reporting no current urethral symptoms. Men provided a urine sample that was used to characterize the urethral microbiota using 16S rRNA gene sequencing. Bacterial taxa associated with idiopathic urethritis were identified using analysis of compositions of microbiomes with bias correction. When stratified by sex of sexual partner, we found that the abundance of Haemophilus influenzae was significantly increased in men who have sex with men with idiopathic urethritis, and the abundance of Corynebacterium was significantly increased in men who have sex with women with idiopathic urethritis. Other taxa, including Ureaplasma, Staphylococcus haemolyticus, Streptococcus pyogenes, Escherichia, and Streptococcus pneumoniae/pseudopneumoniae, dominated the urethral microbiota of idiopathic urethritis cases but not controls, suggesting that these organisms may also contribute to urethritis. Importantly, the taxa we identified represent biologically plausible causes of urethritis and should be prioritized for future study.

Updates on Sexually Transmitted Urethro-cystitis

Purpose of Review

We performed recent literature review with the aim to address the updates in diagnosis and management of sexually transmitted urethro-cystitis.

Recent Findings

There are multiple, recently published studies that collectively lead to an organized stepwise plan for diagnosis and management of sexually transmitted urethro-cystitis.

Summary

Sexually transmitted urethro-cystitis is a common health condition that can be managed efficiently if the appropriate steps are taken in diagnosis and management.

Recent insights suggest the need for the STI field to embrace a more eco-social conceptual framework: A viewpoint

A large number of countries are being confronted with twin epidemics of increasing STI incidence and antimicrobial resistance (AMR). This has led to calls to intensify STI screening of high STI prevalence populations. The available evidence suggests that this will have little impact on STI prevalence but a significant deleterious effect on AMR. We suggest that this call to intensify STI screening is one of the several errors that stem from the way that the STI-field has been dominated by a biomedical individualistic conceptual framework. This framework views STIs as obligate pathogens that can and should be eradicated by intensive seek-and-destroy activities. We evaluate five types of evidence that suggest that a multi-level, socio-ecological framework would provide a more accurate portrayal of the important determinants of STI prevalence and AMR spread. By incorporating concepts such as limiting STI screening to scenarios with clear evidence of net-benefit and considering 'antimicrobial footprint' thresholds, this framework would be more likely to result in a better balance between targeting STI prevalence whilst minimizing the risk of AMR emerging.

UAA-AAUS guideline for M. genitalium and non-chlamydial non-gonococcal urethritis

Non-chlamydial non-gonococcal urethritis (NCNGU) is defined as urethritis with neither Neisseria gonorrhoeae nor Chlamydia trachomatis. Possible causative agents of NCNGU include Mycoplasma genitalium, Ureaplasma urealyticum, Ureaplasma parvum, Mycoplasma hominis, Trichomonas vaginalis, and so on. Among these microorganisms, the pathogenicity of M. genitalium and T. vaginalis to the male urethra has been confirmed so far. The Asian Association of Urinary Tract Infection and Sexually Transmitted Infection (AAUS) belonging to the Urological Association of Asia (UAA) had developed the guidelines regarding NCNGU and the present guidelines were updated from previous edition. Relevant references were meticulously reviewed again and latest studies were collected. In addition to the levels of evidence, the recommendation grades were defined using the modified GRADE methodology. Herein, we present the new edition of the UAA-AAUS guidelines for M. genitalium and non-chlamydial non-gonococcal urethritis.

Clinical profile and co-infections of urethritis in males

BACKGROUND

Infectious urethritis are classified in N. gonorrhoeae (NG) urethritis and non-gonococcal urethritis, caused commonly by C. trachomatis (CT) or M. genitalium (MG) in Western Europe. The primary objective of the study is to evaluate the association between the clinical profile and the pathogens. Secondly, to assess the prevalence of co-infections.

METHODS

The clinical profile of urethritis in men caused by NG, CT and MG confirmed by nucleic acid amplification test (NAAT) on first void urine has been retrospectively collected. The clinical profiles comprised the assessment of dysuria and/or discharge and the clinical-dermoscopic examination of the genitalia. Serological tests for syphilis and HIV were also performed.

RESULTS

A total of 101 episodes of NAAT confirmed NG, CT or MG urethritis were identified. The prevalence for each pathogen was 50.60%, 33.73% and 15.66%, respectively. Co-infections were observed in few cases (four MG+CT, one NG+CT, one NG+MG), with M. hominis, U. urealitycum and U. parvum positivity found concomitantly in 7-8% cases. The median age of patients was 33 years. Dysuria was reported in 88% cases (95% NG, 79% CT, 78% MG urethritis). Urethral discharge was found in 86% of cases, including purulent discharge in 61% (98% NG, 70% MG) and transparent in 25% (64% CT). Dysuria and purulent discharge were observed in 95% NG, 54% MG and 29% CT cases, whereas dysuria and transparent discharge were observed in 50% CT, 23% MG and in none of NG cases (P<0.01). Balanitis/meatitis was observed in 24% of cases, genital warts in 12% and proctalgia in 4%.

CONCLUSIONS

NAAT is crucial for defining urethritis etiology. Dysuria is the most common symptom. Gonococcal urethritis present with purulent discharge, whereas transparent discharge is associated with non-gonococcal pathogens. Co-infections are rare. Clinical exam may detect other infectious diseases, in particular genital warts.

Urethral Microbiota in Men: Association of Haemophilus influenzae and Mycoplasma penetrans With Nongonococcal Urethritis

BACKGROUND

Nongonococcal urethritis (NGU) is a common syndrome with no known etiology in ≤50% of cases. We estimated associations between urethral bacteria and NGU in men who have sex with men (MSM) and men who have sex with women (MSW).

METHODS

Urine was collected from NGU cases (129 MSM, 121 MSW) and controls (70 MSM, 114 MSW) attending a Seattle STD clinic. Cases had ≥5 polymorphonuclear leukocytes on Gram stain plus symptoms or discharge; controls had <5 PMNs, no symptoms, no discharge. NGU was considered idiopathic when Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, Trichomonas vaginalis, adenovirus, and herpes simplex virus were absent. The urethral microbiota was characterized using 16S rRNA gene sequencing. Compositional lasso analysis was conducted to identify associations between bacterial taxa and NGU and to select bacteria for targeted qPCR.

RESULTS

Among NGU cases, 45.2% were idiopathic. Based on compositional lasso analysis, we selected Haemophilus influenzae (HI) and Mycoplasma penetrans (MP) for targeted qPCR. Compared with 182 men without NGU, the 249 men with NGU were more likely to have HI (14% vs 2%) and MP (21% vs 1%) (both P ≤ .001). In stratified analyses, detection of HI was associated with NGU among MSM (12% vs 3%, P = .036) and MSW (17% vs 1%, P < .001), but MP was associated with NGU only among MSM (13% vs 1%, P = .004). Associations were stronger in men with idiopathic NGU.

CONCLUSIONS

HI and MP are potential causes of male urethritis. MP was more often detected among MSM than MSW with urethritis.

Diagnosis of some genital-tract infections: part 2. Molecular tests and the new challenges

Promptly and accurately diagnosing genital-tract infections is key to instituting appropriate treatment and control of sexually transmitted infections (STIs). Ano-genital tract testing for STIs in the last two decades has not entirely moved away from insensitive methods but it is now at least dominated by highly sensitive molecular methods. These tests can be ordered through the internet for use at home, with self-taken specimens then returned, usually by post, to a clinic or laboratory for testing. The increasing ease of access of the public to this situation, together with increasing on-line health-seeking behaviour, has resulted in a gap between commercial and NHS management pathways for STIs. Crucially, patients who order multiplex test kits on-line for use at home, and other non-specialists, may not realize that it is worthwhile testing only for Neisseria gonorrhoeae, Chlamydia trachomatis, and possibly Trichomonas vaginalis, and Mycoplasma genitalium if the person is symptomatic or their current partner is infected. The detection and recommended treatment of micro-organisms which to some extent are part of the genital-tract microbiome, such as Mycoplasma hominis, Ureaplasma spp. or Gardnerella vaginalis, which do not cause symptoms in the majority of those infected, cannot be recommended. We argue that a shift from specialist-led to patient- and non-specialist-led STI management, in the presence of a clinical leadership vacuum, has increased the risk of inappropriate and unnecessary treatment which will drive macrolide, tetracycline and metronidazole antimicrobial resistance. However, in the past 5–6 years several groups have been able to show the value of on-line testing as a consequence of targeting the most important micro-organisms and using molecular tests to allow rapid and appropriately informed treatment. This should herald a brighter future, although there is still a need for leadership to expertly guide commercial and NHS sectors alike. In turn, this requires dedicated genito-urinary medicine commissioning to be maintained at a time when it appears to be most under threat.

Management of sexually transmissible infections in the era of multiplexed molecular diagnostics: a primary care survey

Background Data regarding sexually transmissible infections (STI) often originate from STI clinics, screening programs or laboratory-based studies, thus are biased for specific risk groups or lack clinical details. This real-life observational study presents sample data of most young adult Israeli population by exploiting the centralised diagnostic and documentation platforms resulting from a mandatory military service at the age of 18 years for both genders.

METHODS

All STI diagnoses of Israeli Defence Forces soldiers during a 6-month period were reviewed. Patients with Chlamydia trachomatis (CT), Mycoplasma genitalium (MG), Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV) (major-STI) and Ureaplasma urealyticum (UU), Ureaplasma parvum (UP) and Mycoplasma hominis (MH) (equivocal STI) were compared with STI-negative controls.

RESULTS

Sexually transmissible infection positivity rates (n=2816) were as follows: CT 6.6%; MG 1.9%; NG 0.7%; TV 0.5%; UU 15.7%; UP 28.2%; and MH 6.2%. The CT+MG coinfection rate was 4.1%, yet CT+NG coinfections were rare (≈0.5%). More than half of the patients with ureaplasmas and/or MH were treated; 40% of them were recommended partner treatment. Most antibiotics were prescribed to patients with equivocal infections. Classic STI symptoms in males were linked to major-STI and UU, while females were asymptomatic or presented non-specific symptoms.

CONCLUSIONS

The judicious use of antibiotics in the era of antimicrobial resistance necessitates re-evaluating the significance of equivocal pathogen detection and reporting (MH, UU, UP). Likewise, universal empiric treatment for NG should be reconsidered in light of its low rates in non-high-risk groups. Conversely, a high MG rate, a pathogen with potential resistance to common STI protocols, requires evaluation of guidelines adequacy.

Aetiology and prevalence of mixed-infections and mono-infections in non-gonococcal urethritis in men: a case-control study

OBJECTIVES

Chlamydia trachomatis (CT) and Mycoplasma genitalium (MG) cause the majority of non-gonococcal urethritis (NGU). The role of Ureaplasma urealyticum (UU) in NGU is unclear. Prior case-control studies that examined the association of UU and NGU may have been confounded by mixed infections and less stringent criteria for controls. The objective of this case-control study was to determine the prevalence and aetiology of mixed infections in men and assess if UU monoinfection is associated with NGU.

METHODS

We identified 155 men with NGU and 103 controls. Behavioural and clinical information was obtained and men were tested for Neisseria gonorrhoeae and CT, MG, UU and Trichomonas vaginalis (TV). Men who were five-pathogen negative were classified as idiopathic urethritis (IU).

RESULTS

Twelve per cent of NGU cases in which a pathogen was identified had mixed infections, mostly UU coinfections with MG or CT; 27% had IU. In monoinfected NGU cases, 34% had CT, 17% had MG, 11% had UU and 2% had TV. In controls, pathogens were rarely identified, except for UU, which was present in 20%. Comparing cases and controls, NGU was associated with CT and MG monoinfections and mixed infections. UU monoinfection was not associated with NGU and was almost twice as prevalent in controls. Men in both the case and control groups who were younger and who reported no prior NGU diagnosis were more likely to have UU (OR 0.97 per year of age, 95% CI 0.94 to 0.998 and OR 6.3, 95% CI 1.4 to 28.5, respectively).

CONCLUSIONS

Mixed infections are common in men with NGU and most of these are UU coinfections with other pathogens that are well-established causes of NGU. UU monoinfections are not associated with NGU and are common in younger men and men who have never previously had NGU. Almost half of NGU cases are idiopathic.

[Current diagnosis and treatment of sexually transmitted infections]

BACKGROUND

In recent years, there has been an increasing incidence of sexually transmitted infections (STI), which in turn play a major role in urological clinical routine.

OBJECTIVES

Which STIs are relevant in urological clinical routine? What kind of recommendations for diagnosis and treatment exist?

MATERIALS AND METHODS

Review of evidence-based recommendations from the literature, current guidelines of the European Association of Urology and the Robert-Koch-Institute.

RESULTS

STIs can be differentiated into those that cause genital, anal, perianal or oral ulcers from STIs that cause urethritis, cervicitis, or urethral or vaginal discharge. Asymptomatic courses are frequently observed. For diagnosis predominantly amplification methods are recommended. The local resistance situation should be considered. Special attention is paid to the worldwide increasing resistance of gonococci. The sexual partner should also be treated. In addition, diagnosis and therapy of other STIs should be made due to the high rate of co-infection.

CONCLUSIONS

Due to the increasing incidence of STIs, the recognition and evidence-based treatment of these infections is essential to avoid ascending infections, long-term consequences, and further transmissions. It is important to assure the infectious material before initiating therapy to be able to switch from the initially initiated calculated therapy (also considering the local resistance situation) to a test-appropriate therapy.

The Role of Ureaplasma spp. in the Development of Nongonococcal Urethritis and Infertility among Men

Ureaplasma spp. are a genus of bacteria for which two human-associated species exist: Ureaplasma urealyticum and Ureaplasma parvum Their definition as a pathogen in the context of nongonococcal urethritis (NGU) and infertility among males remains highly controversial, largely due to historically high rates of isolation of these bacteria from the urethra of seemingly healthy men. This review summarizes the emerging evidence suggesting a true pathogenic role of these bacteria under specific conditions, which we term risk factors. We examine the historical, clinical, and experimental studies which support a causal role for Ureaplasma spp. in the development of NGU as well as some of the proposed mechanisms behind the association of Ureaplasma spp. and the development of infertility. Finally, we discuss the potential for developing a case-by-case risk-based approach toward the management of men who present with seemingly idiopathic NGU but who are positive for Ureaplasma spp.

Detection of ureaplasmas and bacterial vaginosis associated bacteria and their association with non-gonococcal urethritis in men

No aetiology is found in up to 40% of men with symptomatic urethritis. Male partners of women with bacterial vaginosis (BV) may be at higher risk of non-gonococcal urethritis (NGU). The aim of this study was to examine the role of BV associated bacteria in first-void urine (FVU) in 97 asymptomatic men without urethritis (controls) and 44 men (cases) with NGU including 20 men with idiopathic urethritis (IU) attending a Swedish STD-clinic between January and October 2010. BV-associated bacteria and ureaplasmas were detected by quantitative PCR assays. All BV associated bacteria, except Megasphaera-like type 1, were strongly positively correlated with U. urealyticum p<0.005 and even stronger with the combined U. urealyticum and U. parvum load (p<0.0005) suggesting that ureaplasma induced elevated pH may stimulate the growth of BV associated bacteria. No statistically significant differences were found between IU cases and controls in the prevalence or load of BV associated bacteria or ureaplasmas. In multiple logistic regression, Megasphaera-like type 1 was associated with IU (p = 0.03), but most positive FVU samples contained very few bacteria and the finding may not be clinically relevant.

Should we be testing for urogenital Mycoplasma hominis, Ureaplasma parvum and Ureaplasma urealyticum in men and women? - a position statement from the European STI Guidelines Editorial Board

At present, we have no evidence that we are doing more good than harm detecting and subsequently treating Mycoplasma hominis, Ureaplasma parvum and Ureaplasma urealyticum colonizations/infections. Consequently, routine testing and treatment of asymptomatic or symptomatic men and women for M. hominis, U. urealyticum and U. parvum are not recommended. Asymptomatic carriage of these bacteria is common, and the majority of individuals do not develop any disease. Although U. urealyticum has been associated with urethritis in men, it is probably not causal unless a high load is present (likely carriage in 40-80% of detected cases). The extensive testing, detection and subsequent antimicrobial treatment of these bacteria performed in some settings may result in the selection of antimicrobial resistance, in these bacteria, 'true' STI agents, as well as in the general microbiota, and substantial economic cost for society and individuals, particularly women. The commercialization of many particularly multiplex PCR assays detecting traditional non-viral STIs together with M. hominis, U. parvum and/or U. urealyticum has worsened this situation. Thus, routine screening of asymptomatic men and women or routine testing of symptomatic individuals for M. hominis, U. urealyticum and U. parvum is not recommended. If testing of men with symptomatic urethritis is undertaken, traditional STI urethritis agents such as Neisseria gonorrhoeae, Chlamydia trachomatis, M. genitalium and, in settings where relevant, Trichomonas vaginalis should be excluded prior to U. urealyticum testing and quantitative species-specific molecular diagnostic tests should be used. Only men with high U. urealyticum load should be considered for treatment; however, appropriate evidence for effective treatment regimens is lacking. In symptomatic women, bacterial vaginosis (BV) should always be tested for and treated if detected.

Ureaplasma urealyticum: the Role as a Pathogen in Women's Health, a Systematic Review

PURPOSE OF REVIEW

To evaluate the role of Ureaplasma urealyticum as a genital pathogen in women's health. Three aspects were analyzed: (1) preterm delivery (PTD); (2) female infertility; and (3) lower genital tract pathology including pelvic inflammatory disease (PID), cervicitis, and genital discomfort (discharge, burning).

RECENT FINDINGS

A systematic review was performed. Searching PUBMED and EMBASE for published articles from January 2003 to September 2017 using the key word "Ureaplasma urealyticum" yielded 1835 manuscripts. These were further screened using defined inclusion criteria: (1) original peer-reviewed observational studies; (2) English language; (3) U. urealyticum was specifically isolated; (4) present "cases"/"exposed" and "controls"/"unexposed" to enable calculating an association between U. urealyticum and the outcome studied. Altogether, 32 studies were included that underwent quality scoring based on methodology, sample size, study population, and method of identification of U. urealyticum. The association of U. urealyticum and PTD was inconsistent between the studies. Eight of the ten prospective studies failed to show an association between U. urealyticum and PTD, yet four of the six case control studies found a positive association. Regarding female infertility and genital discomfort, five of the six studies for each of these topics failed to find an association. Only two studies met the inclusion criteria for cervicitis with conflicting conclusions. Unfortunately, none of the studies met the inclusion criteria for PID. It seems that U. urealyticum has a limited role as a pathogen in female infertility, cervicitis, PID, and genital discomfort. The role as a pathogen in PTD is unclear and future studies are needed to address this issue.

Advances in the Understanding and Treatment of Male Urethritis

Neisseria gonorrhoeae and Chlamydia trachomatis are well-documented urethral pathogens, and the literature supporting Mycoplasma genitalium as an etiology of urethritis is growing. Trichomonas vaginalis and viral pathogens (herpes simplex virus types 1 and 2 and adenovirus) can cause urethritis, particularly in specific subpopulations. New data are emerging regarding the potential role of bacterial vaginosis-associated bacteria in urethritis, although results are inconsistent regarding the pathogenic role of Ureaplasma urealyticum in men. Mycoplasma hominis and Ureaplasma parvum do not appear to be pathogens. Men with suspected urethritis should undergo evaluation to confirm urethral inflammation and etiologic cause. Although nucleic acid amplification testing would detect N. gonorrhoeae and C. trachomatis (or T. vaginalis if utilized), there is no US Food and Drug Administration-approved clinical test for M. genitalium available in the United States at this time. The varied etiologies of urethritis and lack of diagnostic options for some organisms present treatment challenges in the clinical setting.

Urethral inflammatory response to ureaplasma is significantly lower than to Mycoplasma genitalium and Chlamydia trachomatis

A non-syndromic approach to treatment of people with non-gonococcal urethritis (NGU) requires identification of pathogens and understanding of the role of those pathogens in causing disease. The most commonly detected and isolated micro-organisms in the male urethral tract are bacteria belonging to the family of Mycoplasmataceae, in particular Ureaplasma urealyticum and Ureaplasma parvum. To better understand the role of these Ureaplasma species in NGU, we have performed a prospective analysis of male patients voluntarily attending a drop in STI clinic in Oslo. Of 362 male patients who were tested for NGU using microscopy of urethral smears, we found the following sexually transmissible micro-organisms: 16% Chlamydia trachomatis, 5% Mycoplasma genitalium, 14% U. urealyticum, 14% U. parvum and 5% Mycoplasma hominis. We found a high concordance in detecting in turn U. urealyticum and U. parvum using 16s rRNA gene and ureD gene as targets for nucleic acid amplification testing (NAAT). Whilst there was a strong association between microscopic signs of NGU and C. trachomatis infection, association of M. genitalium and U. urealyticum infections in turn were found only in patients with severe NGU (>30 polymorphonuclear leucocytes, PMNL/high powered fields, HPF). U. parvum was found to colonise a high percentage of patients with no or mild signs of NGU (0–9 PMNL/HPF). We conclude that urethral inflammatory response to ureaplasmas is less severe than to C. trachomatis and M. genitalium in most patients and that testing and treatment of ureaplasma-positive patients should only be considered when other STIs have been ruled out.

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.

Prevalence and antimicrobial resistance of Mycoplasmas and Chlamydiae in patients with genital tract infections in Shanghai, China

The infections of Mycoplasmas and Chlamydiae are still severe in patients with genital tract diseases and antimicrobial resistance for these organisms has been changing in recent years. In this study, we reported the prevalence status of Ureaplasma urealyticum, Mycoplasma hominis and Chlamydia trachomatis in 965 patients with genital tract infection in Shanghai from January 2011 to December 2014 and analyzed the antimicrobial resistance of U. urealyticum and M. hominis to 12 kinds of antimicrobial drugs by using commercial kits and SPSS13.0 software. Here, we found the infection of U. urealyticum was the most frequent among these three organisms. The total infection rate for containing any organisms of them was 49.5%, and it has been increasing in recent 4 years. Positive rate in female (53.3%) was higher than male's (34.8%), and the high risk population was 20-39 years old (56.7%). Besides, U. urealyticum and M. hominis displayed relative lower resistance rates to minocycline, doxycycline, josamycin and gatifloxacin (6.5%, 7.2%, 13.5% and 8.6%, respectively). However, for erythromycin, roxithromycin, thiamphenicol and clindamycin, the resistance rates were relatively high (41.9%, 47.2%, 62.3% and 74.9%, respectively). U. urealyticum and M. hominis displayed a declined trend of the antimicrobial resistance to 12 kinds of drugs detected in this study. In total, these preliminary data showed the prevalence of Mycoplasmas and Chlamydiae in patients and the antimicrobial resistance status of Mycoplasmas, which has use for reference on both prevention and treatment of diseases caused by them.

Etiology of symptomatic urethritis in men and association with sexual behaviors

INTRODUCTION

Gonorrhea and chlamydia are sexually transmitted infections (STI) that are the most common causes of urethritis in men. The role of specific sexual behaviors and presentation of urethritis is often overlooked.

METHODS

Data was retrospectively reviewed on all men presenting at the major STI clinic in Providence, Rhode Island. Predictors of gonorrhea and chlamydia infection were modeled using a generalized model assuming a binary distribution.

RESULTS

Of the men with urethritis, 27% had chlamydia, 13% gonorrhea, 3% both, and 63% neither (non-gonococcal, non-chlamydial urethritis). MSM were more likely to test positive for gonorrhea than MSW (25% of MSM versus 6% of MSW; p<0.01).

CONCLUSIONS

MSM with urethritis were much more likely to test positive for gonorrhea which may be due to increased risk behaviors and spread within concentrated sexual networks. A large number of both MSM and MSW had non-gonococcal, non-chlamydial urethritis, which suggests the need for improved diagnostic testing. [Full article available at http://rimed.org/rimedicaljournal-2016-06.asp, free with no login].

Polymerase chain reaction-hybridization method using urease gene sequences for high-throughput Ureaplasma urealyticum and Ureaplasma parvum detection and differentiation

In this article, we discuss the polymerase chain reaction (PCR)-hybridization assay that we developed for high-throughput simultaneous detection and differentiation of Ureaplasma urealyticum and Ureaplasma parvum using one set of primers and two specific DNA probes based on urease gene nucleotide sequence differences. First, U. urealyticum and U. parvum DNA samples were specifically amplified using one set of biotin-labeled primers. Furthermore, amine-modified DNA probes, which can specifically react with U. urealyticum or U. parvum DNA, were covalently immobilized to a DNA-BIND plate surface. The plate was then incubated with the PCR products to facilitate sequence-specific DNA binding. Horseradish peroxidase-streptavidin conjugation and a colorimetric assay were used. Based on the results, the PCR-hybridization assay we developed can specifically differentiate U. urealyticum and U. parvum with high sensitivity (95%) compared with cultivation (72.5%). Hence, this study demonstrates a new method for high-throughput simultaneous differentiation and detection of U. urealyticum and U. parvum with high sensitivity. Based on these observations, the PCR-hybridization assay developed in this study is ideal for detecting and discriminating U. urealyticum and U. parvum in clinical applications.

Prevalence of M. genitalium and U. urealyticum in urine tested for C. trachomatis

BACKGROUND

Mycoplasma genitalium and Ureaplasma urealyticum cause sexually transmitted infections. While M. genitalium is an established aetiological agent, U. urealyticum is still controversial as a pathogen. Testing for these microbes is not yet widely available in Norway, and knowledge of their prevalence is limited. In this study we have investigated the prevalence of M. genitalium and U. urealyticum in a heterogeneous population from Vestfold and Telemark.

MATERIAL AND METHOD

Urine samples (n = 4,665) received by the laboratory for testing for Chlamydia trachomatis in the period from February 2011 to January 2012 were subsequently tested for M. genitalium and U. urealyticum. Samples were analysed using an in-house PCR protocol.

RESULTS

The prevalence of C. trachomatis, M. genitalium and U. urealyticum was 11.9%, 3.6% and 17.9% respectively. M. genitalium was found most frequently in women aged 20-24 years (5.1%), while the proportion of samples positive for U. urealyticum was greatest in persons aged 15-24 years (22.8%).

INTERPRETATION

M. genitalium was highly prevalent in urine samples submitted for C. trachomatis testing. M. genitalium testing was requested for only a minority of the samples analysed, suggesting limited knowledge of this microbe. U. urealyticum was the most predominant microbe in the study, which may indicate that it is largely non-pathogenic.

Antibiotic Resistance among Clinical Ureaplasma Isolates Recovered from Neonates in England and Wales between 2007 and 2013

Ureaplasma spp. are associated with numerous clinical sequelae with treatment options being limited due to patient and pathogen factors. This report examines the prevalence and mechanisms of antibiotic resistance among clinical strains isolated from 95 neonates, 32 women attending a sexual health clinic, and 3 patients under investigation for immunological disorders, between 2007 and 2013 in England and Wales. MICs were determined by using broth microdilution assays, and a subset of isolates were compared using the broth microdilution method and the Mycoplasma IST2 assay. The underlying molecular mechanisms for resistance were determined for all resistant isolates. Three isolates carried the tet(M) tetracycline resistance gene (2.3%; confidence interval [CI], 0.49 to 6.86%); two isolates were ciprofloxacin resistant (1.5%; CI, 0.07 to 5.79%) but sensitive to levofloxacin and moxifloxacin, while no resistance was seen to any macrolides tested. The MIC values for chloramphenicol were universally low (2 μg/ml), while inherently high-level MIC values for gentamicin were seen (44 to 66 μg/ml). The Mycoplasma IST2 assay identified a number of false positives for ciprofloxacin resistance, as the method does not conform to international testing guidelines. While antibiotic resistance among Ureaplasma isolates remains low, continued surveillance is essential to monitor trends and threats from importation of resistant clones.

Ureaplasma parvum and Mycoplasma genitalium are found to be significantly associated with microscopy-confirmed urethritis in a routine genitourinary medicine setting

Inflammation of the urethra defined by an excess of polymorphonuclear leukocytes in the absence of sexually transmitted Chlamydia trachomatis and Neisseria gonorrhoeae is called non-chlamydial non-gonococcal urethritis (NCNGU). Although Mycoplasma genitalium is now recognised as causing a sexually transmitted infection, the clinical significance of the other Mollicute species is less clear. This study used specific real-time quantitative polymerase chain reaction assays to detect and quantify four Mollicute species, M. genitalium, M. hominis, Ureaplasma urealyticum and U. parvum, in urine specimens from men with and without NCNGU. A total of 165 urine specimens from male patients attending a genitourinary medicine clinic were eligible for the study, with microscopy-confirmed (≥5 polymorphonuclear leukocytes in urethral swab) NCNGU in 75 (45.5%) and non-confirmed NCNGU in 90 (54.5%). Chi-squared statistical analysis indicated a significantly higher prevalence of U. parvum (17.3% vs. 5.6%; p = 0.03) and M. genitalium (12% vs. 0%; p < 0.001) in NCNGU. In a subset analysis, M. genitalium was also significantly (p = 0.03) higher in men who have sex with men (MSM; 13.5%) compared to non-MSM (3.1%). No significant associations were reported for U. urealyticum and M. hominis In conclusion, this study supports a clinically significant role in NGNCU for both U. parvum and M. genitalium.

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.

Ureaplasma parvum and Ureaplasma urealyticum detected with the same frequency among women with and without symptoms of urogenital tract infection

There is mounting evidence stating that Ureaplasma urealyticum causes non-gonococcal urethritis in males, whereas Ureaplasma parvum does not seem to be of clinical significance. However, the clinical role of U. parvum and U. urealyticum in lower urogenital tract infections in females remains unclear. The aim of the study was to determine the frequency of U. parvum and U. urealyticum among 145 Ureaplasma spp. culture-positive women with symptoms of lower urogenital tract infection (n = 75) and those without (n = 70), and to determine possible associations between the detection of U. parvum and U. urealyticum with selected characteristics. Endocervical, urethral, and vaginal swabs, and first voided urine were obtained. Polymerase chain reaction (PCR) was performed to differentiate ureaplasmas. No significant association between the detection of U. parvum or U. urealyticum and symptom status was found. Significantly more women aged 25 years and younger were infected with U. urealyticum (23.4 %) compared to those aged above 25 years (9.2 %) [odds ratio (OR) 3.0 (1.1; 8.1); p = 0.03] and significantly less women aged 25 years and younger (83.5 %) were infected with U. parvum compared to those aged above 25 years (95.5 %) [OR 0.2 (0.1; 0.9); p = 0.03]. The detection of Chlamydia trachomatis was significantly associated to both U. parvum and U. urealyticum (p = 0.021), and to U. parvum alone with borderline significance (p = 0.063). Although neither U. parvum nor U. urealyticum seem to cause symptoms in females, their role in the female urogenital tract remains unknown, taking into account their ubiquity, possible augmentation of the urogenital microenvironment, and ascending capability to the sterile upper reproductive tract.

Efficacy of standard therapies against Ureaplasma species and persistence among men with non-gonococcal urethritis enrolled in a randomised controlled trial

OBJECTIVE

Ureaplasma urealyticum biovar 2 (UU-2), but not Ureaplasma parvum (UP), has been associated with non-gonococcal urethritis (NGU), but little is known about species-specific responses to standard therapies. We examined species-specific treatment outcomes and followed men with treatment failure for 9 weeks.

METHODS

From May 2007 to July 2011, men aged ≥16 attending a sexually transmitted disease (STD) clinic in Seattle, Washington, with NGU (urethral discharge or urethral symptoms plus ≥5 polymorphonuclear leucocytes /high-powered field) enrolled in a double-blind, randomised trial. Participants received active azithromycin (1 g) + placebo doxycycline or active doxycycline (100 mg twice a day ×7 days) + placebo azithromycin. Ureaplasma were detected in culture followed by species-specific PCR. Outcomes were assessed at 3, 6 and 9 weeks. At 3 weeks, men with persistent Ureaplasma detection received 'reverse therapy' (e.g., active doxycycline if they first received active azithromycin). At 6 weeks, persistently positive men received moxifloxacin (400 mg×7 days).

RESULTS

Of 490 men, 107 (22%) and 60 (12%) were infected with UU-2 and UP, respectively, and returned at 3 weeks. Persistent detection was similar for UU-2-infected men initially treated with azithromycin or doxycycline (25% vs. 31%; p=0.53), but differed somewhat for men with UP (45% vs. 24%; p=0.11). At 6 weeks, 57% of UU-2-infected and 63% of UP-infected men who received both drugs had persistent detection. Failure after moxifloxacin occurred in 30% and 36%, respectively. Persistent detection of UU-2 or UP was not associated with signs/symptoms of NGU.

CONCLUSIONS

Persistent detection after treatment with doxycycline, azithromycin and moxifloxacin was common for UU and UP, but not associated with persistent urethritis.

TRIAL REGISTRATION NUMBER

NCT00358462.

Are Ureaplasma spp. a cause of nongonococcal urethritis? A systematic review and meta-analysis

Background

Nongonococcal urethritis (NGU) is the most common male reproductive tract syndrome. Ureaplasmas spp. including U. urealyticum and U. parvum, have been increasingly reported to be implicated in NGU. However, there are still many contradictions about their pathogenic role in NGU.

Aims

The goals of this study were to evaluate the association of Ureaplasmas spp. with NGU, and to compare the prevalence of Ureaplasmas spp. infection in China relative to the world average.

Methods

A systematic review and meta-analysis was conducted following standard guidelines for meta-analysis. The quality of included studies was assessed by Newcastle-Ottawa scale.

Results

A total of seven studies involving 1,507 NGU patients and 1,223 controls were eligible for meta-analysis. There was no significant difference in the Ureaplasma spp. positive rate between the NGU and control groups. However, the U. urealyticum positive rate was significantly higher in NGU patients compared to controls; the U. parvum positive rate was significantly higher in controls compared to NGU patients. Furthermore, within the NGU patient group, the positive rate of U. urealyticum was significantly higher than that of U. parvum, whereas within the control group, the opposite trend was observed. Compared to the world average, a significantly higher positive rate of Ureaplasma spp. was observed in both the NGU and control groups in China.

Conclusions

Our analysis supports that U. urealyticum, but not U. parvum, is an etiological agent in NGU. More detailed studies of these two species in China and the world could contribute to a better understanding of the epidemiology and pathogenesis, and facilitate the development of better strategies for treatment and prevention of NGU.

Comparison between culture and a multiplex quantitative real-time polymerase chain reaction assay detecting Ureaplasma urealyticum and U. parvum

A novel multiplex quantitative real-time polymerase chain reaction (qPCR) for simultaneous detection of U. urealyticum and U. parvum was developed and compared with quantitative culture in Shepard's 10 C medium for ureaplasmas in urethral swabs from 129 men and 66 women, and cervical swabs from 61 women. Using culture as the gold standard, the sensitivity of the qPCR was 96% and 95% for female urethral and cervical swabs, respectively. In male urethral swabs the sensitivity was 89%. The corresponding specificities were 100%, 87% and 99%. The qPCR showed a linear increasing DNA copy number with increasing colour-changing units. Although slightly less sensitive than culture, this multiplex qPCR assay detecting U. urealyticum and U. parvum constitutes a simple and fast alternative to the traditional methods for identification of ureaplasmas and allows simultaneous species differentiation and quantitation in clinical samples. Furthermore, specimens overgrown by other bacteria using the culture method can be evaluated in the qPCR.

Bacterial vaginosis-associated bacteria in men: association of Leptotrichia/Sneathia spp. with nongonococcal urethritis

BACKGROUND

Approximately 45% of nongonococcal urethritis cases have no identified etiology. Novel bacteria recently associated with bacterial vaginosis (BV) in women may be involved. We evaluated the association of idiopathic nongonococcal urethritis and 5 newly described BV-associated bacteria (BVAB).

METHODS

Heterosexual men 16 years or older attending a sexually transmitted disease clinic in Seattle, Washington, from May 2007 to July 2011 and negative for Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Mycoplasma genitalium, and Ureaplasma urealyticum-biovar2 were eligible. Cases had urethral discharge or 5 or more polymorphonuclear leukocytes per high-power field in urethral exudates. Controls had no urethral discharge and less than 5 polymorphonuclear leukocytes per high-power field. Urine was tested for Atopobium spp., BVAB-2, BVAB-3, Megasphaera spp., and Leptotrichia/Sneathia spp. using quantitative taxon-directed polymerase chain reaction.

RESULTS

Cases (n = 157) and controls (n = 102) were of similar age, education, and income, and most were white. Leptotrichia/Sneathia spp. was significantly associated with urethritis (24/157 [15.3%] vs. 6/102 [5.9%], P = 0.03). BVAB-2 was more common in cases than in controls (7/157 [4.5%] vs. 1/102 [1.0%], P = 0.15), and BVAB-3 (n = 2) and Megasphaera spp. (n = 1) were only detected in men with urethritis, but these bacteria were found only in men who also had Leptotrichia/Sneathia spp. Atopobium spp. was not associated with urethritis. The quantity of bacteria did not differ between cases and controls. Among treated cases, doxycycline was more effective than azithromycin for clinical cure of men with Leptotrichia/Sneathia spp. (9/10 vs. 7/12, P = 0.16) and BVAB-2 (3/3 vs. 0/3, P = 0.10).

CONCLUSIONS

Leptotrichia/Sneathia spp. may be urethral pathogens or contribute to a pathogenic microbiota that can also include BVAB-2, BVAB-3, and Megasphaera spp. Doxycycline may be more effective than azithromycin against these newly identified bacteria.

Characteristics of acute nongonococcal urethritis in men differ by sexual preference

Nongonococcal urethritis (NGU) is a common clinical syndrome, but no etiological agent is identified in a significant proportion of cases. Whether the spectrum of pathogens differs between heterosexual men (MSW) and men who have sex with men (MSM) is largely unstudied but of considerable clinical relevance. A retrospective review was done using the electronic medical record database of Melbourne Sexual Health Centre, Australia. Cases were first presentations of symptomatic acute NGU with ≥ 5 polymorphonuclear leukocytes (PMNL)/high-powered field (HPF) on urethral Gram stain between January 2006 and December 2011. First-stream urine was tested for Chlamydia trachomatis and Mycoplasma genitalium by PCR. Demographic, laboratory, and behavioral characteristics of cases were examined by univariate and multivariable analyses. Of 1,295 first presentations of acute NGU, 401 (32%; 95% confidence interval [CI] of 29 to 34%) had C. trachomatis and 134 (11%; 95% CI of 9 to 13%) had M. genitalium detected. MSM with acute NGU were less likely to have C. trachomatis (adjusted odds ratio [AOR] = 0.4; 95% CI of 0.3 to 0.6) or M. genitalium (AOR = 0.5; 95% CI of 0.3 to 0.8) and more likely to have idiopathic NGU (AOR = 2.4; 95% CI of 1.8 to 3.3), to report 100% condom use for anal/vaginal sex (AOR = 3.6; 95% CI of 2.7 to 5.0), or to have engaged in sexual activities other than anal/vaginal sex (AOR = 8.0; 95% CI of 3.6 to 17.8). Even when C. trachomatis or M. genitalium was detected, MSM were more likely than MSW to report consistent condom use (OR = 4.7; 95% CI of 2.6 to 8.3). MSM with acute NGU are less likely to have the established bacterial sexually transmitted infections (STIs) and more likely to report protected anal sex or sexual activity other than anal sex prior to symptom onset than MSW. These data suggest that the etiologic spectrum of pathogens differs between MSM and MSW in acute NGU and that relatively low-risk practices are capable of inducing acute NGU.

Prevalence, clinical features and quantification of genital non-viral infections

We conducted a study of the prevalence, clinical features and microscopy findings, by retrospective case-notes survey, of six non-viral organisms, among 1718 attendees at a genitourinary (GU) medicine clinic in England. An in-house assay for six non-viral infections was used and quantitation of ureaplasmas performed. The prevalences of the six organisms were: Chlamydia trachomatis (CT), 7.1%; Neisseria gonorrhoeae (NG), 0.6%; Mycoplasma genitalium (MG), 1.0%; Trichomonas vaginalis, 0.2%; Ureaplasma urealyticum, 16.1%; Ureaplasma parvum, 35.6%. Among men (but not women) there were significantly raised odds ratios compared with that for U. parvum, for the symptom of discharge with CT, 7.30; MG, 6.43; NG 19.29; dysuria with CT, 5.89 and MG, 5.95; and the microscopy finding of >4 pus cells per high power field with: CT, 7.22; MG, 4.58 and NG 22.31. Evaluation of a possible link between quantitation of U. urealyticum and urethritis did not confirm research findings elsewhere.

Bacterial loads of Ureaplasma urealyticum contribute to development of urethritis in men

Ureaplasma urealyticum could be a pathogen of non-gonococcal urethritis (NGU) in men. However, ureaplasma is often detected in men without NGU, and the proportion of cases possibly attributable to this pathogen is still undefined. We attempted to determine the bacterial loads of U. urealyticum significantly associated with NGU. The 16S rRNA genes of U. urealyticum were quantified by a real-time polymerase chain reaction-based assay in first-void urine (FVU) from 26 asymptomatic and 25 symptomatic men positive for U. urealyticum. The leucocyte counts in first-void urine (FVU) were determined as an objective measure of inflammatory response to ureaplasma in the hosts by automated quantitative urine particle analysis. Positive correlations were observed between copies of the 16S rRNA genes of U. urealyticum per ml and the leucocyte counts per µl in FVU (r = 0.49, p = 0.0003). Loads of ≥10(4) copies of the 16S rRNA gene of U. urealyticum/ml, corresponding to ≥5 × 10(3) cells of U. urealyticum/ml in FVU, were significantly associated with the presence of urethritis symptoms (p < 0.0001) and with higher leukocyte counts in FVU (p < 0.0001). The bacterial load of U. urealyticum, possibly of ≥5 × 10(3) cells of U. urealyticum/ml in FVU, could be significantly associated with the development of symptomatic NGU.

Asymptomatic urethritis is common and is associated with characteristics that suggest sexually transmitted etiology

We evaluated 236 asymptomatic men for urethritis, assessed sexual behaviors, and tested urine for pathogens. Asymptomatic urethritis was present in 38 (16.1%). Of these, nearly half (42.1%) had a previously unrecognized discharge on examination; only 18.4% had a known pathogen. Correlates included black race, anal intercourse, and number of sex partners.

Standard treatment regimens for nongonococcal urethritis have similar but declining cure rates: a randomized controlled trial

BACKGROUND

Azithromycin or doxycycline is recommended for nongonococcal urethritis (NGU); recent evidence suggests their efficacy has declined. We compared azithromycin and doxycycline in men with NGU, hypothesizing that azithromycin was more effective than doxycycline.

METHODS

From January 2007 to July 2011, English-speaking males ≥16 years, attending a sexually transmitted diseases clinic in Seattle, Washington, with NGU (visible urethral discharge or ≥5 polymorphonuclear leukocytes per high-power field [PMNs/HPF]) were eligible for this double-blind, parallel-group superiority trial. Participants received active azithromycin (1 g) + placebo doxycycline or active doxycycline (100 mg twice daily for 7 days) + placebo azithromycin. Urine was tested for Chlamydia trachomatis (CT), Mycoplasma genitalium (MG), Ureaplasma urealyticum biovar 2 (UU-2), and Trichomonas vaginalis (TV) using nucleic acid amplification tests. Clinical cure (<5 PMNs/HPF with or without urethral symptoms and absence of discharge) and microbiologic cure (negative tests for CT, MG, and/or UU-2) were determined after 3 weeks.

RESULTS

Of 606 men, 304 were randomized to azithromycin and 302 to doxycycline; CT, MG, TV, and UU-2 were detected in 24%, 13%, 2%, and 23%, respectively. In modified intent-to-treat analyses, 172 of 216 (80%; 95% confidence interval [CI], 74%-85%) receiving azithromycin and 157 of 206 (76%; 95% CI, 70%-82%) receiving doxycycline experienced clinical cure (P = .40). In pathogen-specific analyses, clinical cure did not differ by arm, nor did microbiologic cure differ for CT (86% vs 90%, P = .56), MG (40% vs 30%, P = .41), or UU-2 (75% vs 70%, P = .50). No unexpected adverse events occurred.

CONCLUSIONS

Clinical and microbiologic cure rates for NGU were somewhat low and there was no significant difference between azithromycin and doxycycline. Mycoplasma genitalium treatment failure was extremely common. Clinical Trials Registration.NCT00358462.