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The occurrence of cysts and papulopustules along the midline penile raphe, as a complication of gonococcal urethritis, is considered an exceptional presentation. These lesions are related to developmental abnormalities in the fusion of the lower portion of the ventral abdominal wall during embryogenesis, which create small pathways along the raphe of the penis, prone to secondary infection in the presence of gonococcal urethritis. We present the case of a 25-year-old male who experienced these lesions twice, coinciding with two separate episodes of gonococcal urethritis following unprotected sex. Treatment with intramuscular ceftriaxone resolved both the urethritis and cystic lesions., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: Gonococcal infections with a higher bacterial load may pose a higher risk of transmission. We assessed the association between gonococcal bacterial load and coinfection with Mycoplasma genitalium ., Methods: From September 2015 until May 2018, 200 men and transgender women who have sex with men participated in an HIV pre-exposure prophylaxis (PrEP) demonstration trial in Antwerp, Belgium. They underwent 3-monthly 3-site (anus, urine, and pharynx) molecular testing for N. gonorrhoeae and C. trachomatis and M. genitalium , irrespective of symptoms. Gonococcal bacterial load was determined on remnant DNA extracts using an in-house quantitative PCR. Results were expressed as log 10 transformed copies/mL and analyzed with a linear regression model., Results: Gonococcal bacterial load could be determined for 82 (80.4%) of 102 anal, 17 (73.9%) of 23 urine, and 64 (90.1%) of 71 pharyngeal samples. M. genitalium was detected in five of these anal, two urine, and two pharyngeal samples and C. trachomatis was detected in 16 anal, one urine, and two pharyngeal samples. Gonococcal bacterial load was significantly higher in the presence of M. genitalium (difference 0.92 log copies/mL, 95% CI 0.16-1.67)., Conclusions: Gonococcal bacterial load was higher with M. genitalium coinfection. M. genitalium may thus be a cofactor in gonococcal transmission.

We report a case of Mycoplasma genitalium -positive non-gonococcal urethritis who failed to respond to multiple different courses of antibiotics including azithromycin, minocycline, moxifloxacin and spectinomycin. Extracted M. genitalium DNA from urethral swabs obtained from the patient harbored mutations of 23S rRNA, parC and gyrA . Microbiological cure was eventually achieved by a 14-day course of doxycycline.

National guidelines recommend that male patients presenting with symptoms of urethritis or epididymo-orchitis undergo a urethral swab for microscopy. However, this is resource intensive. The aim of this audit was to determine the proportion of symptomatic patients without urethral discharge who have positive findings on urethral swab microscopy and explore associations between presenting symptoms and microscopy findings. We conducted a retrospective audit of symptomatic male patients who underwent microscopy. There was a significant difference between the percentage of symptomatic patients with positive findings on microscopy in those with and without urethral discharge (67% vs 33%, p < 0.001). In a patient presenting with symptoms other than urethral discharge, the likelihood that positive findings on microscopy would occur in a patient with dysuria was 4.73 times more likely than if they did not have dysuria, when controlling for age, testicular pain or discomfort, and urethral discomfort or penile irritation (p < 0.01). In situations where there are limited resources, patients without urethral discharge presenting with dysuria could be prioritised. However, further research is required to identify and stratify which patients require microscopy.

Mycoplasma genitalium is an emerging sexually transmitted pathogen implicated in urethritis in men and several inflammatory reproductive tract syndromes in women. The prevalence of M. genitalium infections in Cuban patients with urogenital syndromes is unknown. The aim of this study was to analyse the prevalence of M. genitalium infection in sexually-active Cuban men and women with urogenital syndromes as a part of aetiological surveillance of urogenital syndromes in Cuba. Samples from men and women with urogenital syndromes submitted to the Mycoplasma Reference Laboratory for mycoplasma diagnosis from 1 January 2014 to 1 June 2015 were analysed by polymerase chain reaction (PCR) for detection of M. genitalium. A total of 971 samples were received and processed. Of the patients tested, 5.7% (47/824) of women and 27.9% (41/147) of men were positive for M. genitalium. This paper presents the largest study of M. genitalium infections among Cuban patients with urogenital syndromes and is Cuba's first M. genitalium survey. We suggest that M. genitalium should be considered in the Cuban sexually transmitted infection management protocols as an important pathogen, particularly in men.

We assessed whether urethral microscopy was performed as per clinic protocol for male clinic attendees reporting contact with Neisseria gonorrhoeae (GC), urethral symptoms or given a diagnosis of epididymo-orchitis (EO) over a 12-month period (9732 patients). Prevalence of gonorrhoea in the contacts, urethral symptoms and EO groups was 50, 12.7 and 1.6%, respectively. Microscopy was performed reliably for contacts (96%), those with discharge/dysuria with evidence of urethritis on examination (98%), but not those with EO (43%). We explored the clinical utility of microscopy as a point-of-care test for identifying urethral GC in each subgroup, using the APTIMA Combo 2 CT/GC nucleic acid amplification test as the comparator (1710 patients). Sensitivity of microscopy for each subgroup was good; there was no statistical difference between subgroup sensitivity using Fisher's exact test. Microscopy is valuable to ensure prompt diagnosis and contact tracing. All GC contacts were treated 'epidemiologically'; however, half of GC contacts did not have GC. Microscopy identified the majority of GC cases, including amongst contacts (71% of heterosexual contacts, 66% of contacts reporting sex with men). We propose that epidemiological treatment for GC contacts should be reconsidered on the grounds of antibiotic stewardship, favouring use of microscopy to guide treatment decisions.

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.

A non-syndromic approach to treatment of people with non-gonococcal urethritis (NGU) requires identification of pathogens and understanding of the role of those pathogens in causing disease. The most commonly detected and isolated micro-organisms in the male urethral tract are bacteria belonging to the family of Mycoplasmataceae, in particular Ureaplasma urealyticum and Ureaplasma parvum. To better understand the role of these Ureaplasma species in NGU, we have performed a prospective analysis of male patients voluntarily attending a drop in STI clinic in Oslo. Of 362 male patients who were tested for NGU using microscopy of urethral smears, we found the following sexually transmissible micro-organisms: 16% Chlamydia trachomatis, 5% Mycoplasma genitalium, 14% U. urealyticum, 14% U. parvum and 5% Mycoplasma hominis. We found a high concordance in detecting in turn U. urealyticum and U. parvum using 16s rRNA gene and ureD gene as targets for nucleic acid amplification testing (NAAT). Whilst there was a strong association between microscopic signs of NGU and C. trachomatis infection, association of M. genitalium and U. urealyticum infections in turn were found only in patients with severe NGU (>30 polymorphonuclear leucocytes, PMNL/high powered fields, HPF). U. parvum was found to colonise a high percentage of patients with no or mild signs of NGU (0-9 PMNL/HPF). We conclude that urethral inflammatory response to ureaplasmas is less severe than to C. trachomatis and M. genitalium in most patients and that testing and treatment of ureaplasma-positive patients should only be considered when other STIs have been ruled out.

We sought to investigate the prevalence of Mycoplasma genitalium, Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis in men presenting to a sexually transmitted infection (STI) clinic, with special attention to M. genitalium, its occurrence in Israeli patients, coinfections, and risk factors. In a cross-sectional study, 259 men were successively enrolled in the Tel Aviv Levinsky Clinic for STIs between November 2008 and November 2010. There were 118 men with urethritis and 141 high-risk men without symptoms. M. genitalium, C. trachomatis, N. gonorrhoeae, and T. vaginalis were detected using nucleic acid amplification tests. Demographic characteristics and risk factors were documented. The overall prevalence of infection with M. genitalium, C. trachomatis, N. gonorrhoeae, and T. vaginalis, were 6.6%, 12.7%, 23.1%, and 0%, respectively. Prevalences in men with urethritis were 11.9%, 22%, and 49%, for M. genitalium, C. trachomatis, and N. gonorrhoeae, respectively. Prevalences in men without symptoms were 2.1%, 5.0%, and 1.4%, for M. genitalium, C. trachomatis, and N. gonorrhoeae, respectively. Co-infections were found only in symptomatic individuals, in whom 5.9% were infected concomitantly with C. trachomatis and N. gonorrhoeae, and 2.5% had dual infection with M. genitalium and N. gonorrhoeae. N. gonorrhoeae, C. trachomatis, and M. genitalium were significantly more prevalent in patients with urethritis. M. genitalium was significantly more prevalent in the heterosexual population than in homosexual males. To conclude, we have found that M. genitalium infection is associated with urethritis in Israeli men, and more so in the heterosexual population. Testing men for M. genitalium as a cause of non-gonococcal urethritis is warranted, particularly because of its poor response to doxycycline and possible failure of azithromycin.

We present the updated International Union against Sexually Transmitted Infections (IUSTI) guideline for the management of non-gonococcal urethritis in men. This guideline recommends confirmation of urethritis in symptomatic men before starting treatment. It does not recommend testing asymptomatic men for the presence of urethritis. All men with urethritis should be tested for Chlamydia trachomatis and Neisseria gonorrhoeae and ideally Mycoplasma genitalium using a nucleic acid amplification test (NAAT) as this is highly likely to improve clinical outcomes. If a NAAT is positive for gonorrhoea, a culture should be performed before treatment. In view of the increasing evidence that azithromycin 1 g may result in the development of antimicrobial resistance in M. genitalium, azithromycin 1 g is no longer recommended as first line therapy, which should be doxycycline 100 mg bd for seven days. If azithromycin is to be prescribed an extended course of 500 mg stat, then 250 mg daily for four days is to be preferred over 1 g stat. In men with persistent NGU, M. genitalium NAAT testing is recommended if not previously undertaken, as is Trichomonas vaginalis NAAT testing in populations where T. vaginalis is detectable in >2% of symptomatic women., (© The Author(s) 2016.)

Inflammation of the urethra defined by an excess of polymorphonuclear leukocytes in the absence of sexually transmitted Chlamydia trachomatis and Neisseria gonorrhoeae is called non-chlamydial non-gonococcal urethritis (NCNGU). Although Mycoplasma genitalium is now recognised as causing a sexually transmitted infection, the clinical significance of the other Mollicute species is less clear. This study used specific real-time quantitative polymerase chain reaction assays to detect and quantify four Mollicute species, M. genitalium, M. hominis, Ureaplasma urealyticum and U. parvum, in urine specimens from men with and without NCNGU. A total of 165 urine specimens from male patients attending a genitourinary medicine clinic were eligible for the study, with microscopy-confirmed (≥5 polymorphonuclear leukocytes in urethral swab) NCNGU in 75 (45.5%) and non-confirmed NCNGU in 90 (54.5%). Chi-squared statistical analysis indicated a significantly higher prevalence of U. parvum (17.3% vs. 5.6%; p = 0.03) and M. genitalium (12% vs. 0%; p < 0.001) in NCNGU. In a subset analysis, M. genitalium was also significantly (p = 0.03) higher in men who have sex with men (MSM; 13.5%) compared to non-MSM (3.1%). No significant associations were reported for U. urealyticum and M. hominis In conclusion, this study supports a clinically significant role in NGNCU for both U. parvum and M. genitalium., (© The Author(s) 2015.)

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., (© The Author(s) 2015.)

Ureaplasma parvum, which has been recognised as a coloniser in the male urethra, is detected in some men with non-gonococcal urethritis. In this study, we quantified the 16 S rRNA genes of U. parvum by a real-time polymerase chain reaction-based assay in first-voided urine from 15 symptomatic and 38 asymptomatic men who were positive only for U. parvum. We also determined the leukocyte counts by automated quantitative urine particle analysis in their first-voided urine. Positive correlations were observed between copies of the 16 S rRNA genes of U. parvum/ml and the leukocyte counts/µl in first-voided urine (p = 0.0019). The loads of ≥10(4) copies of the 16 S rRNA gene/ml, corresponding to ≥5 × 10(3) cells of U. parvum/ml, were significantly associated with the presence of ≥12.5 leukocytes/µl in first-voided urine that might document the presence of inflammatory responses in the urethra. However, a large portion of the subjects (83.0%) had bacterial loads of <5 × 10(3) cells of U. parvum/ml, and 79.5% of them showed <12.5 leukocytes/µl. The ambiguity of the pathogenic role of U. parvum in non-gonococcal urethritis could, in part, be due to its low bacterial loads, which might not give rise to inflammatory responses in the male urethra., (© The Author(s) 2015.)

The study attempts to determine the prevalence of organisms associated with urethritis in men in rural southwestern Haiti and to determine the association with demographic, clinical and laboratory variables. A standardised verbal interview was conducted; genital examinations were done; urethral swabs were collected for nucleic acid amplification testing, and first void urine was obtained for urinalysis. The mean participant age was 54; 88.8% lived in a rural area. Swabs were positive for Trichomonas vaginalis in 13.7% (28/205), Mycoplasma genitalium in 6.3% (13/205), Chlamydia trachomatis in 4.4% (9/205) and Neisseria gonorrhoeae in 0% (0/205). Subjects who never reported using condoms were nearly 3.5 times more likely to have any positive swab result (OR: 3.46, 95% CI 1.31-9.14). Subjects who reported their partners had other sexual partners or were unsure were more than three times likely to have any positive swab result (OR: 3.44, 95% CI 1.33-8.92). Infections with Trichomonas vaginalis and Mycoplasma genitalium were the most common., (© The Author(s) 2014.)

We conducted a study to determine the prevalence of Trichomonas vaginalis (TV), Mycoplasma genitalium (MG) and Ureaplasma urealyticum (UU) in men with urethritis, attending an urban sexual health clinic, in order to inform screening and treatment policies. Men attending an urban sexual health clinic between June 2011 and January 2012 were evaluated. Urine samples were collected from men with urethritis and tested for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (GC) and TV using transcription-mediated amplification and for MG and UU using polymerase chain reaction. Eighty-three samples were analysed. The prevalence of CT was 33.7% (28/83), GC was 16.8% (14/83), TV was 3.6% (3/83), MG was 12.0% (10/83) and UU was 4.8% (4/83). Fifteen men had recurrent urethritis. Of these, three were found to have had TV, five to have had MG and none to have had UU, at initial presentation. Given the prevalence of MG in this study, there is an urgent need for further larger studies looking at optimal treatment regimens and screening strategies in urethritis., (© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Mycoplasma genitalium (M. genitalium)was first isolated from the urethral swabs of two symptomatic men with urethritis in 1980. Published prevalence rates vary greatly between populations studied. A number of urogenital conditions have been ascribed toM. genitalium, which is recognised to cause a sexually transmitted infection. The association of M. genitalium with non-specific urethritis is now well established, but the evidence supporting its role in both male and female infertility remains inconclusive. Laboratory methods are challenging and there is a lack of test standardisation. The recommended treatment of the infection is azithromycin as a single 1 gm dose. However, in recent years macrolide resistance has been observed. More studies are required to establish the clinical importance of M. genitaliumin urogenital conditions, particularly infertility, and to establish the role for screening and treatment in high-risk populations., (© The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Ureaplasma urealyticum could be a pathogen of non-gonococcal urethritis (NGU) in men. However, ureaplasma is often detected in men without NGU, and the proportion of cases possibly attributable to this pathogen is still undefined. We attempted to determine the bacterial loads of U. urealyticum significantly associated with NGU. The 16S rRNA genes of U. urealyticum were quantified by a real-time polymerase chain reaction-based assay in first-void urine (FVU) from 26 asymptomatic and 25 symptomatic men positive for U. urealyticum. The leucocyte counts in first-void urine (FVU) were determined as an objective measure of inflammatory response to ureaplasma in the hosts by automated quantitative urine particle analysis. Positive correlations were observed between copies of the 16S rRNA genes of U. urealyticum per ml and the leucocyte counts per µl in FVU (r = 0.49, p = 0.0003). Loads of ≥10(4) copies of the 16S rRNA gene of U. urealyticum/ml, corresponding to ≥5 × 10(3) cells of U. urealyticum/ml in FVU, were significantly associated with the presence of urethritis symptoms (p < 0.0001) and with higher leukocyte counts in FVU (p < 0.0001). The bacterial load of U. urealyticum, possibly of ≥5 × 10(3) cells of U. urealyticum/ml in FVU, could be significantly associated with the development of symptomatic NGU.

A 27-year-old man who has sex with men presented with a painful lesion at the urethral meatus. A diagnosis of genital herpes was suspected, and initial tests for sexually transmitted infections (STIs), including syphilis serology, were negative. However, a polymerase chain reaction (PCR) swab for Treponema pallidum from the lesion was positive, and a diagnosis of chancre of primary syphilis at the meatus was made. Subsequently, the patient required urological surgery due to the formation of a urethral stricture. Chancre at the meatus and development of stricture are unusual complications of syphilis that may become more common in the future with increasing case numbers. We also discuss the development of PCR as a useful test for early primary syphilis.

The objective was to determine the occurrence of four urethral pathogens in urine specimens from symptomatic men using transcription mediated amplification (TMA) assay. Urethral swab and urine specimens from 300 men presenting to a family practitioner were Gram stained and tested for Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis and Mycoplasma genitalium using three TMA assays respectively. Except for T. vaginalis, the other recognized pathogens viz. N. gonorrhoeae, C. trachomatis and M. genitalium were detected in significantly larger numbers of patients with urethral discharge than in those with burning on micturition (BOM). The overall prevalences were 16.7% for N. gonorrhoeae, 12.3% C. trachomatis, 8.0% T. vaginalis and 17.3% M. genitalium. With regard to microscopic evidence of urethritis, significant associations were found for N. gonorrhoeae and C. trachomatis, but not for M. genitalium and T. vaginalis. This study demonstrated that in symptomatic men attending family practice, M. genitalium and T. vaginalis are also important aetiological agents of urethritis and hence treatment strategies be they syndromic management or laboratory directed should cover for these causative agents. The microscopic diagnosis of urethritis may not be important for treatment strategies. The current syndromic treatment guidelines for developing countries including South Africa need modification.

Male urethritis is one of the most common sexually transmitted infections (STIs). However, the aetiology is still unclear in many cases. In this study the prevalences of Epstein-Barr virus (EBV), herpes simplex virus type 1 (HSV-1), HSV-2, cytomegalovirus (CMV), adenovirus, Chlamydia trachomatis, Mycoplasma genitalium and Ureaplasma urealyticum (including subtyping) were investigated. Samples from 112 male STI attendants with microscopically verified urethritis and from a control group of 103 men without clinical or microscopic signs of urethritis were analysed. Prevalences in the urethritis group compared with the controls were as follows: EBV 21%, 6% (P < 0.01); C. trachomatis 15%, 3% (P < 0.01); M. genitalium 6%, 1% (P = 0.067) and U. urealyticum 10%, 10% (ns). The results for HSV-1, HSV-2, CMV and adenovirus were negative in patients, and therefore not analysed in the controls. EBV was shown to be an independent predictor of urethritis and may play a role in its pathogenesis.

Urethral specimens from 172 men who attended sexually transmitted disease clinics in the Moscow Oblast were examined for Neisseria gonorrhoeae, Chlamydia trachomatis and Mycoplasma genitalium by nucleic acid amplification tests. N. gonorrhoeae was detected in the urethra of 41 (24%) of the 172 men and C. trachomatis in 57 (33%). The latter occurred in 15 (36%) of the 41 men who were infected by N. gonorrhoeae and in 42 (32%) of 131 uninfected by gonococci. Of the 42 men uninfected by gonococci but chlamydia infected, 39 (93%) had symptoms and/or signs of urethritis. M. genitalium was detected in 45 (26%) of the 172 men, in nine (22%) of the 41 men infected with N. gonorrhoeae and in 12 (21%) infected with C. trachomatis. M. genitalium was detected alone in 25 (28%) of the 89 men uninfected by either gonococci or C. trachomatis. Of these 25 men, 24 (96%) had urethral symptoms and signs of inflammation, a proportion significantly more than experienced by the 64 men uninfected by any of the microorganisms. Of the 31 men who apparently had no symptoms or signs of urethritis, only three (10%) were infected by M. genitalium. The data provide evidence for the pathogenicity and frequent occurrence of M. genitalium in men in Moscow and presumably elsewhere in Russia.

This study was performed to identify possible factors associated with penile wetness, defined as the observation of a diffuse homogenous film of moisture on the surface of the glans and coronal sulcus, in men attending a sexually transmitted infection clinic. Genital examination was undertaken in 422 uncircumcised men and any degree of subpreputial wetness observed was recorded. The degree of visibility of the urinary meatus on direct inspection was also assessed. Subjects were asked whether they retracted the foreskin while urinating and how long since they had last passed urine. Penile wetness was observed in 13.0% of the men and was more common in those whose foreskin covered the urinary meatus on direct inspection (17.4% vs. 4.9%) and those with balanitis (33.3%). On multivariate analysis, penile wetness was independently associated with balanitis, non-specific urethritis/chlamydia, reporting sex with another man and having a visible urinary meatus on direct inspection. Penile wetness was not associated with retracting the foreskin while passing urine or duration since last passed urine. Men with a foreskin covering the urinary meatus on direct observation should be advised about the benefits of good genital hygiene if penile wetness was observed.

There is currently a debate as to whether microscopy is necessary in asymptomatic men presenting for a sexual health screen. Arguments favouring microscopy include finding chlamydia in a significant proportion of sexual partners of men with non-specific urethritis (NSU) in studies that included symptomatic men. We aimed to investigate the proportion of partners of men with asymptomatic NSU who were diagnosed with a sexually transmitted infection. A retrospective case-note review was carried out for all men diagnosed with asymptomatic pathogen-negative NSU, and their traced sexual contacts, during a nine-month period. As a result of contact-tracing, we identified 42 partners who attended the clinic. Only one partner (2.4%) tested positive for chlamydia. A further two partners were diagnosed with a viral sexually transmitted infection (STI). The low level of chlamydia and other STIs in partners of asymptomatic men with pathogen-negative NSU does not support the routine use of microscopy to identify these patients.

The aim of this study was to ascertain how sexual health physicians in Australia and New Zealand manage men with chlamydia-negative non-gonococcal urethritis (NGU), particularly in relation to the notification of their female sexual partners. In July 2006, a cross-section survey was sent out to all the members of the Australasian Chapter of Sexual Health Medicine. Seventy-three percent of sexual health physicians believed that female partners of men who present with chlamydia-negative NGU were at risk of adverse reproductive health outcomes. At least 62% usually initiated some form of partner notification of female partners of men with chlamydia-negative NGU. However, only 19% (21/111) of sexual health physicians routinely tested for, and only 65% sometimes tested for, pathogens other than Neisseria gonorrhoeae and Chlamydia trachomatis in men presenting with NGU. These included Mycoplasma genitalium, herpes simplex virus, ureaplasma species, Trichomonas vaginalis and adenoviruses.

The purpose of this study is to determine the prevalence of asymptomatic male patients with urethral infections attending a government sexually transmitted infection clinic in Hong Kong and their microbiological profile. A total of 274 consecutive male patients without any symptoms for urethral infections were recruited. A questionnaire was used to record the symptoms, sexual history and demographics. Further assessment, including urethral smear for Gram stain, gonococcal culture and polymerase chain reaction (PCR) for Chlamydia trachomatis (CT), Mycoplasma genitalium (MG) and Ureaplasma urealyticum (UU) were performed. In 274 asymptomatic patients, 36 patients had non-gonococcal urethritis (NGU) and two patients had positive gonococcal culture. Among the asymptomatic patients with NGU, there were 6 (16.6%), 10 (22.8%) and five (13.9%) patients with positive PCR for CT, UU and MG, respectively. In addition, there were 14 asymptomatic patients with positive PCR for CT but without evidence of NGU. In conclusion, urethral infections were identified in a significant number of asymptomatic male patients and therefore, routine screening for this group is warranted.

Leucocyte esterase (LE) in first-voided urine (FVU) and presence of leucocytes in urethral and cervical smears were evaluated to identify Mycoplasma genitalium infection in 416 men and 417 women attending Department of Genitourinary Medicine. M. genitalium was diagnosed in FVU specimens by realtime polymerase chain reaction. The prevalence of M. genitalium was 6.5% in women and 6.7% in men. In total, 88.5% (23/26) of M. genitalium-infected men were identified by a combination of urethral smear and the LE test. In women, the combination of urethral and/or cervical smears and/or a positive LE test identified 91.3% (21/23) of M. genitalium-infected patients. Organism load in FVU correlated significantly with presence of urethritis (> or =4 leucocytes per high-power field) in men. A combination of LE testing of urine and urethral and/or cervical smears can be used as screening tests to select patients for specific M. genitalium testing. By this strategy, about 10% of infected individuals will remain undetected.

Resistant Neisseria gonorrhoeae has been evolving. This study assessed the antimicrobial susceptibility profile of isolates in the Pretoria region, South Africa. Isolates of N. gonorrhoeae from men with urethritis were tested for susceptibility to eight antimicrobial agents by disc diffusion, Etest and agar dilution methods. Chromosomal resistance to penicillin was found in 16% of isolates, 16% showed plasmid-mediated resistance and decreased susceptibility was seen in 73% of isolates. For the first time, there is evidence of high-level tetracycline resistance (36%). Ciprofloxacin resistance emerged at 7%. All isolates remained susceptible to ceftriaxone. In view of these findings of the emergence of quinolone-resistant N. gonorrhoeae, national treatment guidelines for syndromic management of sexually transmitted infections need to be urgently reviewed. The injectable preparation, ceftriaxone has to be considered as a first-line agent for the management of gonococcal infections. Overall, the gonococcal isolates in the Pretoria region remain susceptible to ceftriaxone, cefoxitin, cefpodoxime and spectinomycin.

A case of heterosexual transmission of Moraxella catarrhalis by fellatio, which resulted in acute purulent urethritis mimicking gonorrhoea in the male partner, is described. In male patients with urethritis due to M. catarrhalis, orogenital contact with a sexual partner carrying the organism in his/her oropharynx is the probable route of transmission.

With the increasing pressure to achieve the government's 48 hour access target for departments of genitourinary (GU) medicine better utilization of resources must be part of the solution. The leucocyte esterase (LE) test has been shown to perform as well as a urethral smear in asymptomatic men in identifying chlamydia-positive individuals and is likely to perform better in detecting genitalium-positive individuals than chlamydia-positive men. The LE test, which is both inexpensive and non-invasive, offers an interim, evidence-based, solution to the issue of whether asymptomatic men attending departments of GU medicine should be screened for the presence of urethral inflammation.

The majority of cases of chlamydial conjunctivitis are thought to result from autoinoculation by the patient of infected genital secretions from themselves or their sexual partners. We noted that some patients had developed symptoms following direct ejaculation into the affected eye. We describe four cases of chlamydial conjunctivitis following ejaculation of semen directly into the eye, which have not been previously described. In only one case was chlamydia detected in the genital tract. In three cases, there was no evidence of genital chlamydial infection; the sources of the eye infection being either from infected genital material of their sexual partners transferred by hands to the eyes, or more likely from direct ejaculate inoculation. It is likely that this mode of transmission is underestimated as a history of ejaculation into the conjunctiva is not normally asked for.

In order to further investigate the epidemiology of Mycoplasma genitalium, 680 men attending departments of genitourinary medicine in Bristol, Bath and Truro were studied. M. genitalium was detected in 36 men (5.3%) and was present at all three clinics. Clinically, both urethritis and the presence of a urethral discharge and/or dysuria, but not penile irritation were independently associated with the detection of M. genitalium, the former being with the strongest association (odds ratio [OR] 10.76, 95% confidence interval [CI] [3.10-37.29], P < 0.0001; OR 3.01, 95% CI [1.28-7.05], P = 0.011 and OR 1.28, 95% CI [0.61-2.69], P = 0.51, respectively). In men with urethritis, those with a discharge and/or dysuria were more likely to have M. genitalium detected (OR 2.61, 95% CI [1.09-6.25], P = 0.032). We found no association with younger age or a recent change of sexual partner. In conclusion, M. genitalium is associated with symptomatic urethritis.

An audit of all cases of chlamydial infection diagnosed in men at the Edinburgh genitourinary (GU) medicine clinic over a six-month period from January 2003 is reported. In all, 189 men identified as requiring treatment for possible chlamydial infection on first attendance (because of contact with a partner with chlamydia or the diagnosis of non-gonococcal urethritis [NGU] on microscopy), who later proved chlamydia-positive by polymerase chain reaction (PCR), were compared with 83 men in whom infection was identified only on receipt of a PCR result. Treatment rates were 100% in the first group and 97.6% in the second group (chi(2) 0.046, P<0.05). In men presumptively diagnosed and treated, 88.6% of contacts identified were confirmed as traced, compared with 90% confirmed as traced in the group diagnosed by PCR alone. Our audit suggests that identifying men with chlamydial NGU by routine microscopy may carry a small but significant advantage in increasing treatment rates, but makes no difference to contact-tracing success rate.

It has recently been advocated that non-invasive testing with first-catch urine specimens using nucleic acid amplification techniques, to detect Chlamydia trachomatis and Neisseria gonorrhoeae, should replace routine microscopy on asymptomatic men. Although it is assumed that this strategy will be cost effective, the available evidence suggests that this will result in fewer sexually transmitted infections being averted than continuing the current practice of screening for urethritis and testing for both microorganisms in asymptomatic men. This review article summarizes the available evidence and argues that research is urgently needed in order to properly evaluate the cost-effectiveness of detecting urethritis in asymptomatic men.