Diseases characterized by urethritis and cervicitis

In patients with documented urethritis in whom Gram staining does not reveal Gram-negative intracellular organisms, the disease is classified as non-gonococcal urethritis (NGU). C. trachomatis is the most common causative agent of NGU (in 23-55% of cases); however, the prevalence of this agent varies among age groups, with the lowest prevalence observed in older men. The proportion of NGU caused by chlamydia gradually decreases. Complications of NGU in men infected with C. trachomatis include epididymitis and Reiter's syndrome. Chlamydial infection is notifiable because its detection requires examination and treatment of partners. The etiology of most cases of non-chlamydial NGU is unknown. Ureaplasma urealitycum and possibly Mycoplasma genitalium are detected in one third of cases. Specific diagnostic tests for the identification of these organisms are not indicated.

Trichomonas vaginalis and HSV can sometimes cause non-gonococcal urethritis. Appropriate diagnostic and treatment methods are used when conventional therapy for non-gonococcal urethritis is ineffective.

[ 1 ], [ 2 ], [ 3 ]

Confirmed urethritis

The diagnosis of urethritis is considered confirmed if any of the following signs are present:

• mucopurulent or purulent discharge;
• in a Gram-stained smear of urethral secretion, more than 5 leukocytes are determined per field of vision when examined using an oil immersion microscopy system. When diagnosing urethritis, a Gram-stained smear is preferable to using rapid diagnostic methods. Gram staining is a highly sensitive and specific test for confirming urethritis and identifying gonococcal infection. If leukocytes and intracellular gram-negative diplococci are detected when examining a Gram-stained smear, then gonococcal infection is considered confirmed;
• a positive leukocyte esterase test in the first urine specimen, or microscopic detection of more than 10 leukocytes at high power. If none of the above criteria are found, treatment should be withheld and the patient should be tested for N. gonorrhoeae and C. trachomatis and followed up if positive results occur. If subsequent tests reveal N. gonorrhoeae or C. trachomatis, appropriate treatment should be instituted. Sexual partners of the patient should also be tested and treated.

Empirical treatment of symptoms without confirmation of a diagnosis of urethritis is recommended only for individuals with a high prior risk of infection and a low likelihood of receiving follow-up, such as adolescents with multiple partners. When empirical treatment is initiated, the patient should be treated for gonorrhea and chlamydia. Partners of patients receiving empirical treatment should be referred for evaluation and treatment.

[ 4 ], [ 5 ], [ 6 ], [ 7 ]

Recurrent and chronic urethritis

Before initiating antimicrobial treatment, the patient must have objective evidence of urethritis. There are no effective treatment regimens for patients with chronic symptoms or frequent relapses after treatment. Patients with chronic or recurrent urethritis should be treated again with the same regimen unless they have completed treatment or have been reinfected by an untreated sexual partner. In all other cases, wet mount and intraurethral swab culture for T. vaginalis are necessary. Urologic examinations usually fail to isolate the causative agent. If the patient has complied with the initial treatment regimen and reinfection can be excluded, the following regimen is recommended:

Management of male patients with urethritis

Urethritis, or inflammation of the urethra caused by infection, is characterized by mucopurulent or purulent discharge and burning during urination. Asymptomatic infection is common. Bacterial pathogens that have been clinically documented to cause urethritis in men are N. gonorrhoeae and C. trachomatis. Investigation to identify the causative agent is recommended because both infections are notifiable and because identification facilitates etiologic treatment and facilitates the identification of sexual partners. If diagnostic methods are not available (eg, Gramsci staining or microscopy), treatment for both infections should be considered. The additional cost of treating a patient with nongonococcal urethritis for both infections should also prompt the health care provider to seek specific diagnostic testing. New DNA diagnostics can isolate the pathogen in the first urine sample and are more sensitive than traditional culture in some cases.

Management of patients with non-gonococcal urethritis

All patients with urethritis should be examined for gonococcal and chlamydial infections. Examination for chlamydia is especially recommended, since there are a sufficient number of highly sensitive and specific diagnostic methods that can facilitate successful treatment and identification of partners.

Treatment of urethritis

Treatment should be started immediately after diagnosis.

The single-dose regimen has important advantages, such as a more convenient regimen for taking the medications and the ability to observe the direct effect of therapy. When using multiple-dose regimens, the medications must be given in a clinic or doctor's office. Treatment using the recommended regimens results in symptomatic relief and microbiological cure of the infection.

Recommended schemes

Azithromycin 1 g orally, single dose,

Or Doxycycline 100 mg orally 2 times a day for 7 days.

Alternative schemes

Erythromycin base 500 mg orally 4 times a day for 7 days,

Or Erythromycin ethylsuccinate 800 mg orally 4 times daily for 7 days.

Or

Ofloxacin 300 mg 2 times a day for 7 days.

If erythromycin alone is used and the patient cannot tolerate the high doses of erythromycin prescribed, one of the following regimens may be used:

Erythromycin base 250 mg orally 4 times a day for 14 days,

Or Erythromycin ethylsuccinate 400 mg orally 4 times daily for 14 days.

[ 8 ], [ 9 ], [ 10 ], [ 11 ], [ 12 ]

Follow-up for all patients with urethritis

Patients should be advised to return for re-examination if clinical symptoms do not improve or recur after completion of therapy. Symptoms alone, without evidence or laboratory confirmation of urethral inflammation, are not sufficient grounds for re-treatment. Patients should be instructed to abstain from sexual intercourse until completion of therapy.

[ 13 ], [ 14 ], [ 15 ]

Notification to partners

Patients should bring all sexual partners with whom they have had sexual contact in the last 60 days for examination and treatment. Etiological diagnostics can help identify partners. Therefore, testing for gonorrhea and chlamydia is recommended.

Recommended treatment regimen for recurrent/persistent urethritis

Metronidazole 2 grams, orally, in a single dose

Plus

Erythromycin base 500 mg orally 4 times a day for 14 days,

Or Erythromycin ethinylsuccinate 800 mg orally 4 times daily for 7 days.

Special Notes

HIV infection

Gonococcal urethritis, chlamydial urethritis, and nongonococcal non-chlamydial urethritis contribute to HIV infection. Patients with HIV infection and NGU should be treated in the same way as patients without HIV infection.

Management of patients with mucopurulent cervicitis

Mucopurulent cervicitis (MPC) is characterized by the presence of purulent or mucopurulent discharge visible in the endocervical canal or on a swab during endocervical examination. Some experts also base the diagnosis on easy cervical bleeding. One of the diagnostic criteria is an elevated polymorphonuclear leukocyte count on a Gram-stained cervical smear. However, this criterion is not standardized, has a low positive predictive value (PPV), and is not used in some clinics. Many women are asymptomatic, although some have unusual vaginal discharge and abnormal vaginal bleeding (eg, after intercourse). Neisseria gonorrhoeae and Chlamydia trachomatis may be involved, although neither organism can be isolated in most cases. In some cases, mucopurulent cervicitis becomes chronic despite repeated courses of antimicrobial therapy. Recurrence or reinfection with C. trachomatis or N. gonorrhoea does not explain the chronic course. Other nonmicrobiologic factors, such as inflammation in the ectropion, may play a role in mucopurulent cervicitis. Patients with mucopurulent cervicitis should be tested for C. trachomatis and N. gonorrhoeae using the most sensitive and specific tests. However, mucopurulent cervicitis is not an accurate predictor of these infections; most women with C. trachomatis and N. gonorrhoeae do not have mucopurulent cervicitis.

Treatment

The need for treatment should be determined based on the results of sensitive tests for C. trachomatis and N. gonorrhoeae, such as DNA amplification tests, unless there is a high probability of infection with both organisms or the patient is unlikely to return for treatment. Empirical treatment for gonorrhea and chlamydia should be recommended if

• in medical institutions of the same geographic area, data on morbidity differ by more than 15% and
• the likelihood that the patient will return for treatment is low.

Tactics for managing patients with persistent mucopurulent cervicitis, unless the cause is relapse or reinfection, have not been developed. In these cases, additional antimicrobial treatment will bring little benefit.

Follow-up observation

Monitoring of infections for which the patient is being treated is recommended. If symptoms persist, women should be instructed to return for re-examination and to abstain from sexual intercourse, even if they have completed treatment.

[ 16 ], [ 17 ], [ 18 ]

Management of sexual partners

Management of sexual partners of women with mucopurulent cervicitis should be consistent with the STDs identified or suspected in them. Sexual partners should be notified and examined and treated for STDs identified or suspected in the patient.

Patients should be instructed to abstain from sexual intercourse until both the patient and their partner are cured. Since testing of cure is not generally recommended, patients should abstain until therapy is completed (i.e., 7 days after taking a single dose of medication or after completing a 7-day course of treatment).

Special Notes

HIV infection

Persons with HIV infection and SGC should receive the same treatment as patients without HIV infection.