Diseases characterized by urethritis and cervicitis

Patients with documented urethritis who do not show Gram-negative intracellular microorganisms in Gram staining, the disease is classified as non-gonococcal urethritis (NSU). C. Trachomatis is the most frequent causative agent of non-gonococcal urethritis (in 23-55% of cases); however, the prevalence of this pathogen is different in different age groups, with the lowest prevalence observed among men of older age groups. The proportion of non-gonococcal urethritis (NSU) caused by chlamydia is gradually decreasing. Complications of non-gonococcal urethritis in men infected with C. Trachomatis are epididymitis and Reiter's syndrome. Chlamydia infection is subject to registration. When it is detected, the partners are examined and treated. The etiology of most cases of non-chlamydial non-gonococcal urethritis is unknown. Ureaplasma urealitycum and, possibly, Mycoplasma genitalium are detected in one third of cases. Specific diagnostic tests to identify these microorganisms are not shown.

Trichomonas vaginalis and HSV can sometimes cause non-gonococcal urethritis. Appropriate methods of diagnosis and treatment are used in the event that conventional therapy of non-gonococcal urethritis is ineffective.

[1], [2], [3]

Confirmed urethritis

The diagnosis of urethritis is confirmed if any of the following symptoms is present:

• sveisto-purulent or purulent discharge;
• in a smear from the secretion of the urethra, stained by Gram, more than 5 leukocytes in the field of vision are detected with microscopy in the oil immersion system. In the diagnosis of urethritis, a smear stained with Gram stain is more preferable than the use of rapid diagnostic methods. Gram staining is a highly sensitive and specific study for the confirmation of urethritis and the identification of gonococcal infection. If a leukocyte and intracellular gram-negative diplococci are found in the study of a Gram-stained smear, then gonococcal infection is confirmed;
• a positive test for leukocyte esterase in the first portion of urine, or detection with microscopy of more than 10 leukocytes at high magnification. If none of the above criteria is found, treatment should be delayed, the patient should be examined for N. Gonorrhoeae and C. Trachomatis and continue monitoring if positive results occur. If, as a result of subsequent tests, N. Gonorrhoeae or C. Trachomatis are detected, appropriate treatment should be prescribed. The sex partners of this patient should also be examined and treated.

Empirical treatment of symptoms without confirmation of the diagnosis of urethritis is recommended only for persons with a high previous risk of infection and with a low probability that these patients will undergo further surveillance, for example, adolescents with multiple partners. When appointing empirical treatment the patient needs to be treated for gonorrhea and chlamydia. Partners of patients receiving empirical treatment should be referred for examination and treatment.

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

Recurrent and chronic urethritis

Before starting antimicrobial treatment, the patient should be identified objective signs of urethritis. Effective treatment regimens for patients with chronic symptoms or frequent recurrences after treatment are not available. Patients with chronic or recurrent urethritis should be re-treated in the same way if they did not complete treatment or were reinfected with an untreated sexual partner. In all other cases, it is necessary to study the wet preparation and conduct a culture examination of the material obtained with the intraurethral tampon on T. Vaginalis. In urological studies, usually, it is not possible to isolate the causative agent of the disease. If the patient complies with the initial treatment regimen and reinfection can be ruled out, the following regimen is recommended:

Management of male patients with urethritis

Urethritis or inflammation of the urethra, caused by infection, is characterized by purulent-mucous or purulent discharge and burning during urination. An asymptomatic infection is widespread. Bacterial pathogens, the clinical significance of which is confirmed in the development of urethritis in men, are N. Gonorrhoeae and C. Trachomatis. It is recommended that a study be conducted to determine the causative agent of the disease, since both of these infections are subject to registration, and also because identification facilitates etiologic treatment and facilitates the identification of sexual partners. If diagnostic methods are not available (eg Gramsci staining microscopy), treatment should be prescribed for both infections. The additional cost of treating a patient with non-gonococcal urethritis from both infections should also prompt the medical worker to conduct a specific diagnosis. New methods of DNA diagnostics make it possible to isolate pathogens in the first portion of urine, and in some cases these tests are more sensitive than the traditional culture method.

Management of patients with non-gonococcal urethritis

All patients with urethritis should be examined for gonococcal and chlamydial infection. Inspection for chlamydia is particularly recommended, because There is a sufficient number of highly sensitive and specific diagnostic methods that can contribute to successful treatment and identification of partners.

Treatment of urethritis

Treatment should be started immediately after diagnosis.

The single-dose regimen has important advantages, consisting of a more convenient mode of taking medications and the ability to observe the direct effect of therapy. When using multiple regimens, medication should be given at the clinic or in the doctor's office. Treatment using recommended regimens leads to the elimination of symptoms and the microbiological cure of the infection.

Recommended schemes

Azithromycin 1 g orally, once,

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

Alternative schemes

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

Or Erythromycin ethyl succinate 800 mg orally 4 times a day for 7 days.

Or

Ofloxacin 300 mg 2 times a day for 7 days.

If only erythromycin is used and the patient does not tolerate the high doses of erythromycin that are assigned to it, one of the following schemes can be used:

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

Or Erythromycin ethyl succinate 400 mg orally 4 times a day for 14 days.

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

Follow-up for all patients with urethritis

Patients should be warned about the need for re-examination if the clinical symptoms do not improve or repeat after the completion of therapy. The presence of only symptoms, in the absence of signs or laboratory confirmation of the presence of urethral inflammation, is not a sufficient basis for re-treatment. Patients should be instructed to abstain from sexual intercourse until treatment is complete.

[13], [14], [15]

Notification of partners

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

Recommended regimen for the treatment of recurrent / persistent urethritis

Metronidazole 2 grams, orally, in a single dose

A plus

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

Or Erythromycin ethinyl succinate 800 mg orally 4 times a day for 7 days.

Special Remarks

HIV infection

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

Management of patients with mucopurulent cervicitis

Muco-purulent cervicitis (CGS) is characterized by the presence of purulent or fusiform purulent discharge visible in the endocervical canal or on a tampon with endocervical examination. Some experts also diagnose on the basis of the easily caused bleeding of the cervix. One of the diagnostic criteria is an increase in the number of polymorphonuclear leukocytes in a cervical smear stained with Gram stain. However, this criterion is not standardized, has a low degree of positive predictive value (PPP), and is not used in some clinics. Many women have no symptoms, although some have unusual vaginal discharge and abnormal vaginal bleeding (eg, after intercourse). The cause of this disease can be Neisseria gonorrhoeae and Chlamydia trachomatis, although in most cases it is not possible to isolate either one or the other microorganism. In some cases, mucopurulent cervicitis acquires a chronic form, despite repeated courses of antimicrobial therapy. Relapse or reinfection of C. Trachomatis or N. Gonorrhoea does not explain the occurrence of chronic course. Other non-microbiological factors, such as inflammation in the ectropion may play a role in mucopurulent cervicitis. Patients with mucopurulent cervicitis should be examined in C. Trachomatis and N. Gonorrhoeae, using the most sensitive and specific tests. However, mucopurulent cervicitis is not an accurate predictor of these infections; in most women with C. Trachomatis and N. Gononhoeae, mucopurulent cervicitis is not detected.

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 by both microorganisms or the likelihood that the patient will not return for treatment. Empirical treatment of gonorrhea and chlamydia should be recommended in the event that

• in medical institutions of one geographic area, the incidence data differ by more than 15% and
• there is a low probability that the patient will return for treatment.

The management of patients with persistent mucopurulent cervicitis, if it is not caused by relapse or reinfection, has not been developed. In these cases, additional antimicrobial treatment will be of little use.

Follow-up

It is recommended to monitor for infections that the patient is receiving treatment for. If symptoms persist, women should be instructed to return for re-examination and to refrain from having sex, even if they have completed the treatment.

[16], [17], [18]

Management of sexual partners

The management of sexual partners of women with mucopurulent cervicitis should correspond to the detected or suspected STDs. Sex partners should be notified, and also examined and treated from identified or suspected STDs in the indicated patient.

Patients should be instructed that they should abstain from sexual intercourse until both the patient and his partner are cured. Since cure control is usually not recommended, patients should abstain until the therapy is completed (ie 7 days after taking the medication in a single dose or after completing the 7-day course of treatment).

Special Remarks

HIV infection

Individuals with HIV infection and HHC should receive the same treatment as patients without HIV infection.