1
|
Dickson K, Zhou J, Lehmann C. Lower Urinary Tract Inflammation and Infection: Key Microbiological and Immunological Aspects. J Clin Med 2024; 13:315. [PMID: 38256450 PMCID: PMC10816374 DOI: 10.3390/jcm13020315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/13/2023] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
The urinary system, primarily responsible for the filtration of blood and waste, is affected by several infectious and inflammatory conditions. Focusing on the lower tract, this review outlines the physiological and immune landscape of the urethra and bladder, addressing key immunological and microbiological aspects of important infectious/inflammatory conditions. The conditions addressed include urethritis, interstitial cystitis/bladder pain syndrome, urinary tract infections, and urosepsis. Key aspects of each condition are addressed, including epidemiology, pathophysiology, and clinical considerations. Finally, therapeutic options are outlined, highlighting gaps in the knowledge and novel therapeutic approaches.
Collapse
Affiliation(s)
- Kayle Dickson
- Department of Microbiology and Immunology, Dalhousie University, Halifax, NS B3H 4R2, Canada;
| | - Juan Zhou
- Department of Anesthesiology, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS B3H 4R2, Canada;
| | - Christian Lehmann
- Department of Microbiology and Immunology, Dalhousie University, Halifax, NS B3H 4R2, Canada;
- Department of Anesthesiology, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS B3H 4R2, Canada;
- Department of Pharmacology, Dalhousie University, Halifax, NS B3H 4R2, Canada
- Department of Physiology and Biophysics, Dalhousie University, Halifax, NS B3H 4R2, Canada
| |
Collapse
|
2
|
Sutton AJ, Roberts TE, Jackson L, Saunders J, White PJ, Birger R, Estcourt C. Cost-effectiveness of microscopy of urethral smears for asymptomatic Mycoplasma genitalium urethritis in men in England. Int J STD AIDS 2017; 29:72-79. [PMID: 28669322 DOI: 10.1177/0956462417717651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The objective was to determine whether or not the limited use of urethral microscopy to diagnose asymptomatic and symptomatic non-chlamydial, non-gonococcal urethritis (NCNGU) in men is a cost-effective strategy to avert pelvic inflammatory disease (PID), ectopic pregnancy or infertility in female partners. Outputs from a transmission dynamic model of NCNGU in a population of 16-30 year olds in England simulating the number of consultations, PID cases and patients treated over time amongst others, were used along with secondary data to undertake a cost-effectiveness analysis carried out from a health care provider perspective. The main outcome measure was cost per case of PID averted. A secondary outcome measure was cost per major outcome averted, where a major outcome is a case of symptomatic PID, ectopic pregnancy, or infertility. Offering a limited number of asymptomatic men urethral microscopy was more effective than the current practice of no microscopy in terms of reducing the number of cases of PID with an incremental cost-effectiveness ratio of £15,700, meaning that an investment of £15,800 is required to avert one case of PID. For major outcomes averted, offering some asymptomatic men urethral microscopy was again found to be more effective than no microscopy, but here an investment of £49,900 is required to avert one major outcome. Testing asymptomatic men for NCNGU in a small number of genitourinary medicine settings in England is not cost-effective, and thus by maintaining the current practice of not offering this patient group microscopy, this continues to make savings for the health care provider.
Collapse
Affiliation(s)
- Andrew J Sutton
- 1 Health Economics Unit, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.,2 NIHR Diagnostic Evidence Co-operative Leeds, Leeds, UK
| | - Tracy E Roberts
- 3 Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Louise Jackson
- 3 Health Economics Unit, University of Birmingham, Birmingham, UK
| | - John Saunders
- 4 Centre for Immunology & Infectious Disease, Blizard Institute, Barts & The London School of Medicine & Dentistry, London, UK.,5 Barts Health NHS Trust, London, UK
| | - Peter J White
- 6 MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, School of Public Health, 4615 Imperial College London , London, UK.,7 NIHR Health Protection Research Unit in Modelling Methodology, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK.,8 Modelling and Economics Unit, Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK
| | - Ruthie Birger
- 6 MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, School of Public Health, 4615 Imperial College London , London, UK.,9 Department of Ecology and Evolutionary Biology, 6740 Princeton University , Princeton, NJ, USA
| | - Claudia Estcourt
- 4 Centre for Immunology & Infectious Disease, Blizard Institute, Barts & The London School of Medicine & Dentistry, London, UK.,5 Barts Health NHS Trust, London, UK
| |
Collapse
|
3
|
Estcourt C, Sutcliffe L, Mercer CH, Copas A, Saunders J, Roberts TE, Fuller SS, Jackson LJ, Sutton AJ, White PJ, Birger R, Rait G, Johnson A, Hart G, Muniina P, Cassell J. The Ballseye programme: a mixed-methods programme of research in traditional sexual health and alternative community settings to improve the sexual health of men in the UK. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04200] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BackgroundSexually transmitted infection (STI) diagnoses are increasing and efforts to reduce transmission have failed. There are major uncertainties in the evidence base surrounding the delivery of STI care for men.AimTo improve the sexual health of young men in the UK by determining optimal strategies for STI testing and careObjectivesTo develop an evidence-based clinical algorithm for STI testing in asymptomatic men; model mathematically the epidemiological and economic impact of removing microscopy from routine STI testing in asymptomatic men; conduct a pilot randomised controlled trial (RCT) of accelerated partner therapy (APT; new models of partner notification to rapidly treat male sex partners of people with STIs) in primary care; explore the acceptability of diverse venues for STI screening in men; and determine optimal models for the delivery of screening.DesignSystematic review of the clinical consequences of asymptomatic non-chlamydial, non-gonococcal urethritis (NCNGU); case–control study of factors associated with NCNGU; mathematical modelling of the epidemiological and economic impact of removing microscopy from asymptomatic screening and cost-effectiveness analysis; pilot RCT of APT for male sex partners of women diagnosed withChlamydia trachomatisinfection in primary care; stratified random probability sample survey of UK young men; qualitative study of men’s views on accessing STI testing; SPORTSMART pilot cluster RCT of two STI screening interventions in amateur football clubs; and anonymous questionnaire survey of STI risk and previous testing behaviour in men in football clubs.SettingsGeneral population, genitourinary medicine clinic attenders, general practice and community contraception and sexual health clinic attenders and amateur football clubs.ParticipantsMen and women.InterventionsPartner notification interventions: APTHotline [telephone assessment of partner(s)] and APTPharmacy [community pharmacist assessment of partner(s)]. SPORTSMART interventions: football captain-led and health adviser-led promotion of urine-based STI screening.Main outcome measuresFor the APT pilot RCT, the primary outcome, determined for each contactable partner, was whether or not they were considered to have been treated within 6 weeks of index diagnosis. For the SPORTSMART pilot RCT, the primary outcome was the proportion of eligible men accepting screening.ResultsNon-chlamydial, non-gonococcal urethritis is not associated with significant clinical consequences for men or their sexual partners but study quality is poor (systematic review). Men with symptomatic and asymptomatic NCNGU and healthy men share similar demographic, behavioural and clinical variables (case–control study). Removal of urethral microscopy from routine asymptomatic screening is likely to lead to a small rise in pelvic inflammatory disease (PID) but could save > £5M over 20 years (mathematical modelling and health economics analysis). In the APT pilot RCT the proportion of partners treated by the APTHotline [39/111 (35%)], APTPharmacy [46/100 (46%)] and standard patient referral [46/102 (45%)] did not meet national standards but exceeded previously reported outcomes in community settings. Men’s reported willingness to access self-sampling kits for STIs and human immunodeficiency virus infection was high. Traditional health-care settings were preferred but sports venues were acceptable to half of men who played sport (random probability sample survey). Men appear to prefer a ‘straightforward’ approach to STI screening, accessible as part of their daily activities (qualitative study). Uptake of STI screening in the SPORTSMART RCT was high, irrespective of arm [captain led 28/56 (50%); health-care professional led 31/46 (67%); poster only 31/51 (61%)], and costs were similar. Men were at risk of STIs but previous testing was common.ConclusionsMen find traditional health-care settings the most acceptable places to access STI screening. Self-sampling kits in football clubs could widen access to screening and offer a public health impact for men with limited local sexual health services. Available evidence does not support an association between asymptomatic NCNGU and significant adverse clinical outcomes for men or their sexual partners but the literature is of poor quality. Similarities in characteristics of men with and without NCNGU precluded development of a meaningful clinical algorithm to guide STI testing in asymptomatic men. The mathematical modelling and cost-effectiveness analysis of removing all asymptomatic urethral microscopy screening suggests that this would result in a small rise in adverse outcomes such as PID but that it would be highly cost-effective. APT appears to improve outcomes of partner notification in community settings but outcomes still fail to meet national standards. Priorities for future work include improving understanding of men’s collective behaviours and how these can be harnessed to improve health outcomes; exploring barriers to and facilitators of opportunistic STI screening for men attending general practice, with development of evidence-based interventions to increase the offer and uptake of screening; further development of APT for community settings; and studies to improve knowledge of factors specific to screening men who have sex with men (MSM) and, in particular, how, with the different epidemiology of STIs in MSM and the current narrow focus on chlamydia, this could negatively impact MSM’s sexual health.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
Collapse
Affiliation(s)
- Claudia Estcourt
- Centre for Immunology and Infectious Disease, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK
- Barts Health NHS Trust, London, UK
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Lorna Sutcliffe
- Centre for Immunology and Infectious Disease, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK
| | - Catherine H Mercer
- Research Department of Infection and Population Health, University College London, London, UK
| | - Andrew Copas
- Research Department of Infection and Population Health, University College London, London, UK
| | - John Saunders
- Centre for Immunology and Infectious Disease, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK
- Barts Health NHS Trust, London, UK
| | - Tracy E Roberts
- Health Economics Unit, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Sebastian S Fuller
- Centre for Immunology and Infectious Disease, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK
- Public Health England, London, UK
| | - Louise J Jackson
- Health Economics Unit, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Andrew John Sutton
- Health Economics Unit, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Peter J White
- Medical Research Council Centre for Outbreak Analysis and Modelling, Imperial College London, London, UK
- National Institute for Health Research Health Protection Research Unit in Modelling Methodology, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
- Modelling and Economics Unit, Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK
| | - Ruthie Birger
- Medical Research Council Centre for Outbreak Analysis and Modelling, Imperial College London, London, UK
- National Institute for Health Research Health Protection Research Unit in Modelling Methodology, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
| | - Greta Rait
- PRIMENT Clinical Trials Unit, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Anne Johnson
- Research Department of Infection and Population Health, University College London, London, UK
| | - Graham Hart
- Research Department of Infection and Population Health, University College London, London, UK
| | - Pamela Muniina
- Research Department of Infection and Population Health, University College London, London, UK
| | - Jackie Cassell
- Division of Primary Care and Public Health, Brighton and Sussex Medical School, University of Brighton, Brighton, UK
| |
Collapse
|
4
|
Horner P, Blee K, O'Mahony C, Muir P, Evans C, Radcliffe K. 2015 UK National Guideline on the management of non-gonococcal urethritis. Int J STD AIDS 2015; 27:85-96. [PMID: 26002319 DOI: 10.1177/0956462415586675] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Accepted: 04/14/2015] [Indexed: 11/16/2022]
Abstract
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.
Collapse
Affiliation(s)
- P Horner
- School of social and Community Medicine, University of Bristol, Bristol, UK Bristol Sexual Health Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - K Blee
- Bristol Sexual Health Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - C O'Mahony
- Chester Sexual Health, Countess of Chester NHS Foundation Trust, Cheshire, UK
| | - P Muir
- Public Health Laboratory, Public Health England, Bristol, UK
| | - C Evans
- West London Centre for Sexual Health, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - K Radcliffe
- Whittall Street Clinic, Birmingham Sexual Health, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | |
Collapse
|
5
|
Pallawela SNS, Sonnex C, Burdett J, Cooper D, Nethercott K, Thomas CM, Goon P, Webb H, Carne C. Testing for 'threads' and leucocyte esterase in first-void urine to exclude the diagnosis of non-specific urethritis in asymptomatic men. Sex Health 2014; 11:283-4. [PMID: 24717166 DOI: 10.1071/sh13190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Accepted: 02/14/2014] [Indexed: 11/23/2022]
Abstract
Recent evidence suggests that asymptomatic nonspecific urethritis (NSU), which is not routinely tested for, is a clinically significant pathology.The aim of this pilot study was to determine if testing for urinary threads, leucocyte esterase (LE) or both in asymptomatic men is a good screening tool for NSU. Of the126 asymptomatic men, 8% met microscopic criteria for the diagnosis of NSU. The positive predictive value for NSU was 71% (95% confidence interval (CI): 29.3-95.5%) and the negative predictive value was 96% (95% CI: 92.8-99.5%). The absence of threads and negative LE makes urethritis highly unlikely, making urinary chlamydia (Chlamydia trachomatis) and gonorrhoea (Neisseria gonorrhoeae) testing sufficient. Incidental findings of further pathology occurred in 7%.
Collapse
Affiliation(s)
- Sanjeeva N S Pallawela
- Department of GU Medicine, Clinic 1 A, Cambridge University Hospitals NHS Trust, Addenbrookes Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Christopher Sonnex
- Department of GU Medicine, Clinic 1 A, Cambridge University Hospitals NHS Trust, Addenbrookes Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Julia Burdett
- Department of GU Medicine, Clinic 1 A, Cambridge University Hospitals NHS Trust, Addenbrookes Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Dawn Cooper
- Department of GU Medicine, Clinic 1 A, Cambridge University Hospitals NHS Trust, Addenbrookes Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Katrina Nethercott
- Department of GU Medicine, Clinic 1 A, Cambridge University Hospitals NHS Trust, Addenbrookes Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Catherina M Thomas
- Department of GU Medicine, Clinic 1 A, Cambridge University Hospitals NHS Trust, Addenbrookes Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Peter Goon
- Department of GU Medicine, Clinic 1 A, Cambridge University Hospitals NHS Trust, Addenbrookes Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Hayley Webb
- Department of GU Medicine, Clinic 1 A, Cambridge University Hospitals NHS Trust, Addenbrookes Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Christopher Carne
- Department of GU Medicine, Clinic 1 A, Cambridge University Hospitals NHS Trust, Addenbrookes Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| |
Collapse
|
6
|
Asymptomatic urethritis is common and is associated with characteristics that suggest sexually transmitted etiology. Sex Transm Dis 2013; 40:271-4. [PMID: 23407472 DOI: 10.1097/olq.0b013e31827c9e42] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
Collapse
|
7
|
Saunders JM, Mercer CH, Sutcliffe LJ, Cassell JA, Estcourt CS. Factors associated with asymptomatic non-chlamydial non-gonococcal urethritis in heterosexual men: findings from a case-control study. Int J STD AIDS 2013; 24:627-31. [DOI: 10.1177/0956462413477554] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Summary The significance of asymptomatic non-chlamydial non-gonococcal urethritis (NCNGU) is unclear. Organisms associated with NCNGU, e.g. Mycoplasma genitalium, for which there is no widely available test, are linked to reproductive sequelae in women but UK guidance no longer recommends urethral smear microscopy to screen for asymptomatic NCNGU. This case-control study of heterosexual male genitourinary (GU) medicine clinic attenders aimed to identify clinical, demographic and sexual behaviour factors associated with asymptomatic NCNGU so that we could determine whether the presence or absence of symptoms provides a rational basis for deciding to whom we should offer microscopy and whom we should treat. Men with asymptomatic NCNGU were very similar to men with symptomatic NCNGU, except for more consistent condom use. Asymptomatic and symptomatic NCNGU could be different ends of the same clinical syndrome. Until the microbiological basis of NCNGU is understood, we recommend treatment of men with NCNGU irrespective of symptoms.
Collapse
Affiliation(s)
- J M Saunders
- Blizard Institute, Barts and the London Queen Mary's School of Medicine & Dentistry, Barts Health NHS Trust, Barts Sexual Health Centre, St Bartholomew's Hospital, West Smithfield, London EC1A 5BE
| | - C H Mercer
- Institute of Epidemiology and Health, Faculty of Population Health, University College, London
| | - L J Sutcliffe
- Blizard Institute, Barts and the London Queen Mary's School of Medicine & Dentistry, London
| | - J A Cassell
- Division of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton
| | - C S Estcourt
- Blizard Institute, Barts and the London Queen Mary's School of Medicine & Dentistry, and Barts Health NHS Trust, London, UK
| |
Collapse
|