Comparison of Gram stain and first-voided urine sediment in the diagnosis of urethritis.

The number of polymorphonuclear leukocytes on gram-stained urethral specimens was compared with the number in the sediment of the first-voided urine to determine what constitutes an abnormal number of polymorphonuclear leukocytes in gram-stained specimens. Seventy-three men attending a clinic for sexually transmitted diseases were studied. An attempt was made to select primarily asymptomatic men and men who had minimal symptoms or signs of urethritis because the diagnosis of urethritis is most difficult in these groups. There was a distinct bimodal distribution of the numbers of polymorphonuclear leukocytes by both techniques. Means of four or fewer polymorphonuclear leukocytes per field in five fields (X 1,000) with gram stain and of < 15 polymorphonuclear leukocytes in all of five fields (X 400) in the first-voided urine sediment were considered normal. The results with the two techniques were highly correlated (P = 1.4 x 10(-10)). In the absence of cultures for Neisseria gonorrhoeae, Chlamydia trachomatis, and possibly Ureaplasma urealyticum to detect the presence of urethral infection, a mean of more than four polymorphonuclear leukocytes per field (X 1,000) in a Gram-stained urethral specimen indicates the presence of urethritis.     

利用男性非淋菌性尿道炎患者尿沉渣检测沙眼衣原体

１０２例男性非淋菌性尿道炎患者，以尿道拭式沙眼衣原体培养为金标准，用ＷｅｌｌｃｏｚｙｍｅＣｈｌａｍｙｄｉａ检测清晨首次尿沉渣中沙眼衣原体的敏感性和特异性分别为８９．７％及９２．１％，用ＰＣＲ检测清晨首次尿沉渣中沙 眼衣原体敏感性和特异性分别为９７．４％及９２．１％。     

Observer variation in the interpretation of Gram-stained urethral smears: implications for the diagnosis of non-specific urethritis.

A study was carried out to determine whether the diagnosis of non-specific urethritis was affected by differences in the microscopical interpretation of urethral smears between individual observers (interobserver variation) and the same observer on separate occasions (intraobserver variation). A marked degree of both intraobserver and interobserver variation was found which--depending on the diagnostic criteria adopted--could affect both the diagnosis and treatment of many patients attending a clinic of genitourinary medicine.     

Observer variation in the interpretation of Gram-stained urethral smears: implications for the diagnosis of non-specific urethritis

A study was carried out to determine whether the diagnosis of non-specific urethritis was affected by differences in the microscopical interpretation of urethral smears between individual observers (interobserver variation) and the same observer on separate occasions (intraobserver variation). A marked degree of both intraobserver and interobserver variation was found which--depending on the diagnostic criteria adopted--could affect both the diagnosis and treatment of many patients attending a clinic of genitourinary medicine.     

Staphylococcus saprophyticus in the aetiology of nongonococcal urethritis.

The occurrence of Staphylococcus saprophyticus, Chlamydia trachomatis, and Neisseria gonorrhoeae in urethral specimens of 252 men attending a venereal disease clinic was studied. When using a selective broth medium containing novobiocin and nalidixic acid, Staph. saprophyticus was isolated from 20.8% of 178 men with symptoms of urethritis and from 14.9% of 74 men without such symptoms. Staph. saprophyticus was found significantly less often in controls (7.1% of 56) than in the men with symptoms of urethritis. In the 35 men from whom Staph. saprophyticus was recovered more than 10 leucocytes per high power field in urethral smears occurred more often than in those from whom this organism, or either of the other two agents, were not isolated. No differences were found in the symptoms reported by the men harbouring Staph. saprophyticus or C. trachomatis or those with negative cultures. The results of the present study tend to suggest that Staph. saprophyticus is the aetiological agent of some cases of nongonococcal urethritis.     

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.     

Epidemiological importance of concealed nongonococcal urethritis.

Of the 229 806 new male patients attending venereal disease clinics in England in 1976, 31.9% had recognisable non-specific genital infection (NSGI), which was easily the most common diagnostic category of the sexually transmitted diseases (STDs) and one which had increased more markedly than all the others in the previous 25 years. Many more cases of nongonococcal urethritis (NGU) are concealed under the diagnosis of gonorrhoea, as is clear from the high incidence of post-gonococcal infection following treatment with penicillin. From 44% to 56% of male patients with gonorrhoea can also have non-specific genital infection during the same year. A practical treatment schedule for gonorrhoea which is also effective against simultaneously acquired non-gonococcal urethritis would be of great value.     

Epidemiological importance of concealed nongonococcal urethritis.

Of the 229 806 new male patients attending venereal disease clinics in England in 1976, 31.9% had recognisable non-specific genital infection (NSGI), which was easily the most common diagnostic category of the sexually transmitted diseases (STDs) and one which had increased more markedly than all the others in the previous 25 years. Many more cases of nongonococcal urethritis (NGU) are concealed under the diagnosis of gonorrhoea, as is clear from the high incidence of post-gonococcal infection following treatment with penicillin. From 44% to 56% of male patients with gonorrhoea can also have non-specific genital infection during the same year. A practical treatment schedule for gonorrhoea which is also effective against simultaneously acquired non-gonococcal urethritis would be of great value.     

Staphylococcus saprophyticus in the aetiology of nongonococcal urethritis.

The occurrence of Staphylococcus saprophyticus, Chlamydia trachomatis, and Neisseria gonorrhoeae in urethral specimens of 252 men attending a venereal disease clinic was studied. When using a selective broth medium containing novobiocin and nalidixic acid, Staph. saprophyticus was isolated from 20.8% of 178 men with symptoms of urethritis and from 14.9% of 74 men without such symptoms. Staph. saprophyticus was found significantly less often in controls (7.1% of 56) than in the men with symptoms of urethritis. In the 35 men from whom Staph. saprophyticus was recovered more than 10 leucocytes per high power field in urethral smears occurred more often than in those from whom this organism, or either of the other two agents, were not isolated. No differences were found in the symptoms reported by the men harbouring Staph. saprophyticus or C. trachomatis or those with negative cultures. The results of the present study tend to suggest that Staph. saprophyticus is the aetiological agent of some cases of nongonococcal urethritis.     

Use of Kova-Slide II with grid and uncentrifuged segmented urine specimens in the diagnosis of nongonococcal urethritis: a quantitative technique

An attempt was made to use uncentrifuged segmented urine specimens and Kova-Slide II with grid as a quantitative technique for the diagnosis of nongonococcal urethritis. Of the 100 men with urethral symptoms, 54 had fewer than five polymorphonuclear leukocytes per high-power field (x1000) in their gram-stained urethral smear. On the basis of examination of segmented urine and Kova-Slide test, 41 of these 54 patients were diagnosed as having nongonococcal urethritis. None of the 13 patients considered to be free of urethritis on the basis of segmented urine tests had a Chlamydia trachomatis--positive culture, and all became asymptomatic without treatment. All 46 patients who had more than five polymorphonuclear leukocytes per high-power field (x1000) also had positive segmented urine tests. The rate of isolation of C. trachomatis was similar for both groups of tests. This study revealed that patients with lower polymorphonuclear leukocyte counts in the first 10 ml of urine passed (voided-bladder urine 1) also had cultures positive for C. trachomatis. None of the 50 patients in the control group had polymorphonuclear leukocytes in either voided-bladder urine 1 or in the midstream specimen (voided-bladder urine 2). All controls had cultures negative for C. trachomatis.     

Etiology and treatment of nongonococcal urethritis

The significant progress of the last decade in determining the etiology of nongonococcal urethritis is reviewed, and current treatments are assessed. Convincing evidence that Chlamydia trachomatis is the cause of 30-50% of cases of nongonococcal urethritis has been developed by many groups from isolation data, serologic studies, urethral inoculation of monkeys, and studies of postgonococcal urethritis. Other evidence that C. trachomatis is a urethral pathogen is that its selective eradication results in alleviation of urethritis in C. trachomatis-infected men. The cause of nongonococcal urethritis when C. trachomatis infection cannot be proven by isolation or serologic testing is unclear. The most likely cause of a significant proportion of the C. trachomatis-negative cases is Ureaplasma urealyticum. Although studies of the role of U. urealyticum as a urethral pathogen have been complicated by the fact that in health the rate of urethral colonization is strongly correlated with an individual's total number of sex partners, and serologic studies have not supported a role for U. urealyticum, other evidence is consistent with such a role, including treatment studies and experimental inoculation. Assuming both C. trachomatis and U. urealyticum are etiologic agents, in another 20% of men with the disease neither organism is initially isolated. False-negatives probably account for some of the cases, but poor response to treatment for the 2 pathogens suggests they constitute another group. Although the incidence of gonorrhea has tended to stabilize recently, that of nongonococcal urethritis continues to rise sharply. Management requires diagnosis of urethritis, exclusion of urethral infection with Neisseria gonorrheae, choosing an appropriate antimicrobial for the patient, treatment of sexual contacts, and follow-up of the patient. When the patient is symptomatic, has a readily expressible discharge, and the exudate contains many polymorphonuclear leukocytes but not gram-negative diplococci, diagnosis is easy. However, when symptoms or signs are minimal, arbitrary criteria must be utilized in diagnosis. In individual cases it is impossible to distinguish between gonorrheal and nongonococcal urethritis on clinical grounds, and the final diagnosis requires laboratory examination for N. gonorrheae. Tetracyclines, erythromycins, and a combination of sulfonamides and an aminocyclitol, which almost always eradicate C. trachomatis, were recognized as the most effective therapies by the 1950s. Although many studies have been done, the optimal drug dose and duration of therapy have not been determined.     

Tetracycline in nongonococcal urethritis. Comparison of 2 g and 1 g daily for seven days.

In a previous study treatment with minocycline 100 mg orally every day for seven days was as effective for nongonococcal urethritis (NGU) as 200 mg for seven days or 100 or 200 mg for 21 days. In this prospective, randomised study men with NGU received tetracycline either 500 mg or 250 mg four times daily for seven days. of 200 men initially enrolled, Chlamydia trachomatis was isolated from 40% and Ureaplasma urealyticum from 48%. Eight of 10 homosexual men compared with 39 (21%) of 190 bisexual or heterosexual men had negative culture results for both C trachomatis and U urealyticum (x2 = 15.5, P < 0.0005). U urealyticum was isolated more frequently from chlamydia-negative men and from men with 10 or fewer sex partners during their lifetime. Both regimens were equally effective in their in-vivo activity against C trachomatis and U urealyticum. Failure rates were similar with the two regimens. More obvious failure with purulent or profuse mucoid discharge and pyuria occurred more frequently with the 250-mg regimen (20% of 76 men on the 250-mg regimen compared with 7% of 67 men on the 500-mg regimen; x2 = 4.45, P < 0.05). Failure occurred more frequently in men who were initially chlamydia-negative and in men in whom U urealyticum persisted after medication. Thus, the 250-mg regimen appeared to be as effective as the 500-mg regimen in the initial treatment of NGU. However, one-third of men had persistent or recurrent urethritis with these regimens, and there is a need for antimicrobial agents with greater in-vivo activity, especially against chlamydia-negative NGU.     

Serotypes of Ureaplasma urealyticum isolated from patients with nongonococcal urethritis and gonorrhea and from asymptomatic urethral carriers

Ureaplasma urealyticum strains isolated from urethral specimens of 112 patients with nongonococcal urethritis, 17 with gonorrhea, and 33 asymptomatic carriers (controls) were tested by the growth-inhibition test with standard ureaplasma antisera (serotypes 1-8). Cases with more than one serotype (two to four types) were encountered in 36.6% of patients with nongonococcal urethritis, 29.4% of those with gonorrhea, and 21.2% of controls. The most frequently recovered serotypes were type 4 from patients with nongonococcal urethritis (57.1%) and type 2 from patients with gonorrhea and controls (35.2% and 36.3%, respectively). The difference in frequency of serotype 4 between patients with nongonococcal urethritis and controls was statistically significant (P less than .001). An additional serotyping with types 9 and 10 antisera of the nontypable strains from patients with nongonococcal urethritis and controls (17.8% and 21.2%, respectively) revealed three type-9 strains. The results show a need for utilization of serotyping of U. urealyticum in studies of the epidemiology and transmissibility of genital infections with U. urealyticum.