Urethral trichomoniasis in men

Three hundred twenty-five men with confirmed urethral trichomoniasis were seen at sexually transmitted diseases clinics in Harare, Zimbabwe, in 1983-1984. The mean age of these patients was 30.4 years. The most common symptoms were urethral discharge and urethral irritation. Symptoms in 252 patients (78%) had been present for more than four weeks. Only 1.5% of 5548 patients with nontrichomonal nongonococcal urethritis had had symptoms for this length of time. In most patients with trichomoniasis (99.4%), the discharge was milky white and fluid in nature; when a smear of the discharge was made on a glass slide, small clumps of material were noted. Microscopic examination of the gram-stained smear showed relatively few polymorphonuclear leukocytes but many epithelial cells. Although Trichomonas vaginalis was readily demonstrated by microscopy of both urethral secretions and centrifuged deposits of urine, the organism was cultured only from urethral exudates. Concomitant infection with T. vaginalis was uncommon in patients with proved gonococcal urethritis. Treatment of trichomoniasis in men with a single 2-g dose of metronidazole was unsuccessful in 42.9% of cases. However, treatment with 400 mg of metronidazole thrice daily for five days gave a cure rate of 100%.     

Epidemiologic and clinical studies of Chlamydia trachomatis infection in northeastern Poland

We tested a total of 735 men and women, who either had clinical symptoms of lower urogenital tract infection or were considered for epidemiological reasons to be at high risk for sexually transmitted diseases, for Chlamydia trachomatis infection. Microbiologic examinations were performed by tissue culture with cycloheximide-treated McCoy cells. C. trachomatis infection was diagnosed in approximately 50% of men with nongonococcal urethritis, 23.5% of men with gonococcal urethritis, 69% of men with postgonococcal urethritis, and in 45% of male partners of C. trachomatis-positive women. Among men under 35 years of age with epididymitis, C. trachomatis was isolated from 42%, whereas Neisseria gonorrhoeae was found in only 21 men. C. trachomatis was isolated from 59% of women with nongonococcal cervicitis, 46% of those with gonococcal cervicitis, and 74% of those with postgonococcal cervicitis. Among female partners of men with nongonococcal urethritis, 68% were C. trachomatis-positive, as were 73.5% of the female contacts of C. trachomatis-positive men. In the groups of men and women without clinical or epidemiologic evidence of sexually transmitted infection, C. trachomatis-positive cultures were obtained from 3.8% and 3.6%, respectively. These studies revealed that the prevalence of C. trachomatis infection in northeastern Poland is high and is similar to that reported in Western countries.     

Value of the gram-stained urethral smear in the management of men with urethritis

The value of the gram-stained urethral smear in clinical decision-making was assessed in a study of 250 men attending a clinic for sexually transmitted diseases. Of the 250 men, 132 (52.8%) had objective evidence of urethritis. Neisseria gonorrhoeae and/or Chlamydia trachomatis was isolated from 94 patients (37.6%). No pathogens were isolated from 38 patients (15.2%) who were diagnosed as having urethritis. Although the specificity (0.95) and positive predictive value (0.95) of the gram smear for culture-proved urethral infection was high, the relatively low sensitivity (0.66) and negative predictive value (0.63), led us to conclude that the test was of limited value in diagnosis and therapeutic decision-making when the patient was first seen. The decision to treat a patient should be based on a reliable history of dysuria and/or a urethral discharge in a patient at risk of infection, with or without an observable urethral discharge. Nevertheless, a gram smear should be done for all patients who are diagnosed presumptively as having urethritis, because it may be the only objective evidence of urethritis.     

Mycoplasma genitalium in males with nongonococcal urethritis: prevalence and clinical efficacy of eradication

BACKGROUND: Mycoplasma genitalium is regarded as a potential pathogen of the human urogenital tract based on prevalence findings of several European studies. GOAL: To determine the prevalence of M genitalium in urethral specimens of symptomatic patients with nongonococcal urethritis and from asymptomatic patients attending a sexually transmitted disease clinic in Milan, and to verify the clinical efficacy of M genitalium eradication by antibiotic treatment. STUDY DESIGN: From May 1998 to late April 1999, a routine analysis for M genitalium by DNA amplification (polymerase chain reaction) was performed in patients attending the Institute of Dermatological Science in Milan. The authors examined urethral swabs from 178 symptomatic and 23 asymptomatic males. M genitalium-positive patients were clinically and microbiologically tested after treatment with either doxycycline or azithromycin. RESULTS: Among males with nongonococcal urethritis, M genitalium was detected in 14.0% of patients as the only agent; in 15.1% of patients in association with Chlamydia trachomatis and/or Ureaplasma urealyticum; and in 1 asymptomatic patient. In all symptomatic M genitalium-positive patients, antibiotic treatment eradicated the infection and cured clinical symptoms. CONCLUSION: These data reveal the high prevalence of M genitalium in symptomatic patients, the rarity of asymptomatic carriers, the high susceptibility to antibiotic treatment, and the clinical efficacy of M genitalium eradication. Moreover, data confirm the etiologic role of M genitalium in inflammatory processes of the human urogenital tract in the Mediterranean area.     

Urine-based screening for Chlamydia trachomatis in men attending sexually transmitted disease clinics

BACKGROUND: Nucleic acid-amplified tests for Chlamydia trachomatis are accurate but costly. Screening strategies for asymptomatic men are needed. GOAL: To assess C trachomatis screening strategies for asymptomatic males. STUDY DESIGN: Men attending a sexually transmitted disease clinic were tested for C trachomatis with ligase chain reaction and culture, and for urethral inflammation with urine leukocyte esterase and urethral Gram stain. RESULTS: C trachomatis prevalence was 5.5% among 1,625 asymptomatic men. Ligase chain reaction increased detection by 49% among men without urethral inflammation. An age of younger than 25 years and urethral inflammation were associated with positive ligase chain reaction results. The negative predictive value of urine leukocyte esterase was highest among older men, but urethral Gram stain was equally sensitive in predicting infection regardless of age. An age of younger than 30 years or urethral inflammation identified the highest proportion of infections (92%) and reduced the percentage of men screened by 43%. CONCLUSIONS: Urine ligase chain reaction increased C trachomatis detection, particularly among men without urethral inflammation. Testing all asymptomatic men younger than 30 years is optimal, whereas negative urine leukocyte esterase or urethral Gram stain results in men 30 years or older support no testing.     

Effect of prior sexually transmitted disease on the isolation of Chlamydia trachomatis

In developed nations, Chlamydia trachomatis is the most common sexually transmitted pathogen. To determine whether prior disease affects the probability of subsequent chlamydial infection, we took culture specimens from 2,546 men and 1,998 women attending a sexually transmitted diseases clinic. The men had nongonococcal urethritis and the women were contacts of men who had a positive chlamydial culture or nongonococcal urethritis. Significantly lower isolation rates for those with a history of sexually transmitted diseases were found for both men (29% vs. 38%; P less than 0.0001) and women (27% vs. 36%; P less than 0.0001). In addition, both men and women with previously documented chlamydial infections had a lower isolation rate at the index visit, if the previous infection occurred less than, as opposed to more than, six months earlier (men: 20% vs. 41%; P = 0.0006; women: 14% vs. 35%; P = 0.003). These relationships were found to be independent of age. However, the effect of partial immunity due to prior infection could not be distinguished from that of prior antibiotic therapy, and if such immunity does confer protection against reinfection, that protection appears to be both partial and of relatively short duration.     

Evaluation of urethral culture for Neisseria gonorrhoeae in the routine investigation of men attending a STD clinic.

Urethral gonorrhoea was diagnosed by culture in 957 (18.8%) of 5076 new male patients attending a sexually transmitted diseases clinic; the infection was asymptomatic in 38 (4%) of these patients. The diagnosis in only six (0.3%) out of 2159 men with urethral gonorrhoea but with no symptoms or signs of urethritis would have been missed if urethral cultures had not been performed.     

Evaluation of urethral culture for Neisseria gonorrhoeae in the routine investigation of men attending a STD clinic.

Urethral gonorrhoea was diagnosed by culture in 957 (18.8%) of 5076 new male patients attending a sexually transmitted diseases clinic; the infection was asymptomatic in 38 (4%) of these patients. The diagnosis in only six (0.3%) out of 2159 men with urethral gonorrhoea but with no symptoms or signs of urethritis would have been missed if urethral cultures had not been performed.     

Study of STDs in patients attending venereal disease clinics in Khartoum, Sudan.

During the period October 1976 to January 1978, 290 patients were examined for sexually transmitted diseases in three venereal clinics in Khartoum Providence. Clinical and laboratory findings showed that nongonococcal urethritis was the commonest STD in men (35.1%), with gonorrhoea the second commonest (25.9%). Most of the patients with STDs were aged between 20 and 30 years. Of the infected men, 49.3% had acquired their infections from prostitutes.     

Study of STDs in patients attending venereal disease clinics in Khartoum, Sudan

During the period October 1976 to January 1978, 290 patients were examined for sexually transmitted diseases in three venereal clinics in Khartoum Providence. Clinical and laboratory findings showed that nongonococcal urethritis was the commonest STD in men (35.1%), with gonorrhoea the second commonest (25.9%). Most of the patients with STDs were aged between 20 and 30 years. Of the infected men, 49.3% had acquired their infections from prostitutes.     

Sexually transmitted infections in Bangladeshis resident in the UK: a case-control study

OBJECTIVE: To evaluate the prevalence of sexually transmitted infections (STIs) and mode of presentation in patients originating from Bangladesh and resident in the United Kingdom in comparison with non-Bangladeshi patients attending an inner London genitourinary medicine (GUM) clinic. METHODS: A retrospective, cross sectional study with comparator group was carried out at an open access GUM clinic in east London. 104 consecutive newly attending Bangladeshi men were compared with 199 consecutive newly attending non-Bangladeshi men and 115 consecutive newly attending Bangladeshi women were compared with 218 consecutive newly attending non-Bangladeshi women. Any diagnosed sexually transmitted infections, sexual history characteristics, reasons for presentation, and referral patterns were noted. RESULTS: Bangladeshi men (28.8% compared with 7.5%; p<0.0001) and women (42.7% compared with 12.8%; p<0.0001) were more likely to be referred by their general practitioners or other medical services. Bangladeshi men were more likely to present with sexual dysfunction (12.5% compared with 2.5%; p=0.001). The prevalence of STIs was broadly similar across the study groups; however, syphilis was significantly more common in the Bangladeshi men (10.9% compared with 4%; p=0.04) and nongonococcal urethritis (NGU) in the control men (35% compared with 20.2%; p=0.02). Bacterial vaginosis was an infrequent diagnosis in the Bangladeshi women (3.5% compared with 22.4%; p<0.0001). CONCLUSIONS: STI prevalence in Bangladeshis attending GUM services is similar to other populations although patterns of presentation and referral do show variation. Bangladeshi men are more likely to access GUM clinics for psychosexual services. The presence of STIs in Bangladeshis particularly those imported from Bangladesh provides an opportunity for HIV transmission between the United Kingdom and Bangladesh.     

Male carriage of Gardnerella vaginalis

The prevalence of Gardnerella vaginalis in the urethra of 430 men attending a clinic for sexually transmitted disease was 11·4%; it was significantly higher in heterosexuals (14·5%) than in homosexuals (4·5%). There was no evidence of rectal or subpreputial carriage of G vaginalis, and urethral carriage was not associated with symptoms of urethritis.     

Urethritis in women attending an STD clinic.

Of an unselected group of 159 women attending a sexually transmitted diseases (STD) clinic 20% (32) had symptoms of urethritis. A positive correlation existed between the finding of more than 10 polymorphonuclear leucocytes (PMNL) per high-power field in the Gram-stained urethral smear and the presence of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis. Conversely, these organisms were rarely isolated if no PMNL were present. Fewer cultures gave positive results for these organisms if micturition had occurred less than four hours before examination. C trachomatis was recovered from the urethra or endocervix in 29/150 (19 . 3%) and from the urethra alone in six women. In contrast, N gonorrhoea was never recovered from the urethra in the absence of endocervical infection. Of the 159 women 10% had bacteriuria due to non-sexually transmissible agents; 50% had asymptomatic bacteriuria. All, however, had other urethral pathogens isolated as well. Thus, sexually transmitted disease agents are highly prevalent in women attending an STD clinic who have signs and symptoms of urethritis. As in non-gonococcal urethritis in men, C trachomatis may be an important cause of urethritis in women.     

Urethritis: an underestimated clinical variant of genital herpes in men?

Two men had a first clinical episode of genital herpes presenting as nongonococcal urethritis in the absence of any penile lesions. Data on the etiologic function of herpes simplex in patients with nongonococcal urethritis are scarce and conflicting. Considering our cases, the large amount of nongonococcal urethritis of unknown origin, and the high frequency of unrecognized genital herpes, herpes simplex virus may be a significant etiologic agent of nongonococcal urethritis and warrants necessary laboratory investigations in patients with clear mucoid urethral discharge.     

High prevalence of trichomoniasis in rural men in Mwanza, Tanzania: results from a population based study

OBJECTIVES: To measure the prevalence of urethral infections including trichomoniasis in rural Tanzanian men, to assess the prevalence of symptoms and signs among men with Trichomonas vaginalis, and to analyse the risk factors for trichomoniasis. DESIGN: A cross sectional study of 1004 men aged 15-54 years in a rural community in north west Tanzania. METHODS: Participants were interviewed about sexual behaviour and symptoms of sexually transmitted diseases. First fraction urine samples and urethral swabs were collected and used to test for T vaginalis by wet preparation and culture, Neisseria gonorrhoeae by culture, Chlamydia trachomatis by ligase chain reaction and non-specific urethritis by Gram stain. Urine was also tested for the presence of leucocytes using a leucocyte esterase dipstick. Men were re-interviewed 2 weeks later to document new symptoms and signs of urethritis. RESULTS: Complete laboratory results were available on 980 men. One in four men had laboratory evidence of urethritis. T vaginalis was found in 109 individuals (11%), gonorrhoea in eight (0.8%), and chlamydial infection in 15 (1.5%). Over 50% of men with urethritis were asymptomatic. The prevalence of signs and symptoms was similar among men with T vaginalis alone compared with men with other urethral infections. The sensitivity and specificity of the leucocyte esterase dipstick (LED) test for detecting T vaginalis were 80% and 48% respectively in symptomatic men and 60% and 68% in asymptomatic men. Factors associated with trichomoniasis included religion, type of employment, and marital status. CONCLUSIONS: A high prevalence of urethritis was found in men in this community based study. More than half of the urethral infections detected were asymptomatic. The most prevalent pathogen was T vaginalis. Studies are needed on the prevalence of trichomoniasis in men presenting to health services with complaints suggestive of urethritis since treatment for T vaginalis is not included in the syndromic management of urethritis in most countries. The performance of the LED test as a screening test for trichomoniasis was unsatisfactory in both symptomatic and asymptomatic men. Improved screening tests are urgently needed to identify urethral infections that are asymptomatic and which are not covered by current syndromic management algorithms.     

A study on non-specific urethritis in males

31,042 cases of sexually transmitted disease (STD) were seen among male soldiers at the Command Hospital in Pune during the period 1980-89. All presented with the complaint of urethral discharge with or without dysuria. Among the 4823 cases of urethritis, 3881 men presented with gonorrhea and 942 with nonspecific urethritis. The incidence of nonspecific urethritis was therefore 3.03% of all STDs. 68% of the patients were aged 20-29 years and 72% were single. Urethral discharge was present at the first attendance in 96% of cases. The authors note that among the various types of STDs, the incidence of nonspecific urethritis has risen more rapidly than that of gonorrhea in the world and it is now recognized as the most common STD in Western countries.     

Symptomatic urethritis is more prevalent in men infected with Mycoplasma genitalium than with Chlamydia trachomatis

OBJECTIVES: To study the prevalence, symptoms, and signs of Mycoplasma genitalium and Chlamydia trachomatis infections in men attending a Swedish STD clinic and to study the criteria for urethritis. METHODS: A cross sectional study among STD clinic attendees in Orebro, Sweden. Attendees were examined for microscopic urethritis and first void urine (FVU) was tested for M genitalium and C trachomatis. RESULTS: The prevalence of M genitalium and C trachomatis was 7% (34/512) and 12% (61/512), respectively. Dual infection was diagnosed in four men. In both infections 90% of the patients had signs of microscopic urethritis. M genitalium positive men had symptomatic urethritis significantly more often than those infected with C trachomatis (73% v 40%, RR 1.8; 95% CI 1.2 to 2.7). 63% of female partners of men infected with M genitalium were infected with M genitalium compared with chlamydial infection in 67% of female partners of men infected with C trachomatis. Non-chlamydial non-gonococcal urethritis without evidence of M genitalium infection was diagnosed in 180 men (35%). Symptoms and/or visible discharge were reported in 49% in this group. CONCLUSIONS: M genitalium is a common infection associated with symptomatic urethritis and with a high prevalence of infected sexual partners supporting its role as a sexually transmitted infection.     

Oral sex as a risk factor for Chlamydia-negative ureaplasma-negative nongonococcal urethritis

We present a case-control study that evaluated the association of Chlamydia-negative, Ureaplasma-negative nongonococcal urethritis with oral and/or anal sex. The study population was composed of 120 patients diagnosed as having nongonococcal urethritis in the Diagnostic Center for sexually transmitted diseases (STD) of the Medical School of Seville. Cases were 56 men suffering from nonogonococcal urethritis from whom neither Chlamydia trachomatis nor Ureaplasma urealyticum was isolated; the remaining 64 males with cultures positive for these agents were considered as controls. Insertive genital-oral intercourse significantly increased the risk of Chlamydia-negative, Ureaplasma-negative nongonococcal urethritis (odds ratio, 11.400; 95% confidence interval, 2.357-75.057). This association was still very strong (odds ratio, 8.882) after adjustment for homosexuality. Insertive anal intercourse appears not to increase the risk of Chlamydia-negative, Ureaplasma-negative nongonococcal urethritis. We conclude that insertive oral sex can be an important risk factor in the development of nongonnococcal urethritis in which the microbial agent is still unknown.     

Comparative rates of sexually transmitted diseases among heterosexual men, homosexual men, and heterosexual women

The prevalences of several sexually transmitted diseases (STD) among patients attending a public STD clinic were determined in a prospective study. Rates of gonorrhea, syphilis, genital herpes, trichomoniasis, nongonococcal urethritis, pediculosis pubis, scabies, and venereal warts were ascertained according to sex, sexual preference, and race. Numbers of cases of diseases not routinely reported to most public health agencies exceeded numbers of cases of diseases that are routinely reported. Rates of gonorrhea were higher among men than among women and higher among blacks than among whites. Syphilis was most common among homosexual men. Trichomoniasis was three times more frequent among blacks than among whites. Rates of nongonococcal urethritis among heterosexual men were almost twice those among homosexual men. Whites were more likely than blacks to have pediculosis pubis, scabies, and venereal warts. STD not routinely reported to most public health agencies are commonly seen in public clinics, and rates vary according to sex, sexual preference, and race.