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Background: Mycoplasma genitalium is a major contributor to persistent/recurrent urethritis cases. However, there are limited published studies on recent trends of persistent/recurrent urethritis., Methods: A retrospective analysis was conducted of men presenting with symptomatic urethritis in 16 sexually transmitted disease (STD) clinics from 2015 to 2019. Poisson regression was used to assess trends in the annual proportions of urethritis episodes with follow-up (FU) characterized with persistent/recurrent urethritis symptoms. Results were also stratified by results of chlamydia (CT) and gonorrhea (NG) testing and treatment prescribed., Results: There were 99,897 urethritis episodes, from 67,546 unique men. The proportion of episodes with persistent/recurrent symptomatic FU visits increased 50.8% over a 4-year period (annual percentage change [APC], 11.3%; 95% confidence interval [CI], 6.5-16.3). Similar trends were observed in nonchlamydial nongonococcal urethritis episodes (APC, 12.7%; 95% CI, 6.8-18.9) but increases among those positive for NG (APC, 12.1%; 95% CI, -2.3 to -28.5) or for CT (APC, 7.3%; 95% CI, -6.7 to 23.5) were not statistically significant. Among episodes who received azithromycin as first-line treatment, increases in the proportion of persistent/recurrent FU visits were observed (APC, 12.6%; 95% CI, 8.6-16.7). For episodes where first-line treatment was doxycycline, no significant increases were detected (APC, 4.3%; 95% CI, -0.3 to 9.2)., Conclusions: We found an increase in the proportion of urethritis episodes with persistent or recurrent symptoms over time. Given these observed trends in episodes negative for NG or CT, an etiology not detectable by routine diagnostics was a likely factor in increased persistence, suggesting patients with urethritis may benefit from diagnostic testing for M. genitalium during an initial symptomatic presentation., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2024 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Mycoplasma genitalium (MG) is an emerging sexually transmitted infection. Treatment of MG is complicated by increasing resistance to primary treatment regimens, including macrolides and fluoroquinolones. Understanding the various clinical presentations and relative effectiveness of treatments for MG is crucial to optimizing care., Methods: Patients with a positive MG nucleic acid amplification test between July 1, 2019, and June 30, 2021, at a large health system in New York City were included in a retrospective cohort. Demographics, clinical presentations, coinfections, treatment, and follow-up microbiologic tests were obtained from the electronic medical record. Associations with microbiologic cure were evaluated in bivariate and multivariable logistic regression models., Results: Five hundred two unique patients had a positive MG nucleic acid amplification test result during the study period. Male individuals presented predominantly with urethritis (117 of 187 [63%]) and female individuals with vaginal symptoms (142 of 315 [45%]). Among patients with follow-up testing who received a single antibiotic at the time of treatment, 43% (90 of 210) had persistent infection and 57% (120 of 210) had microbiologic cure. Eighty-two percent of patients treated with moxifloxacin had microbiologic cure compared with 41% of patients receiving azithromycin regimens ( P < 0.001). In multivariable analysis, treatment with moxifloxacin was associated with 4 times the odds of microbiologic cure relative to low-dose azithromycin (adjusted odds ratio [aOR], 4.18; 95% confidence interval, 1.73-10.13; P < 0.01)., Conclusions: Clinical presentations of MG vary, with urethritis or vaginal symptoms in most cases. Among patients who received a single antibiotic, only treatment with moxifloxacin was significantly associated with microbiologic cure relative to low-dose azithromycin., Competing Interests: Conflict of Interest and Sources of Funding: The authors declare they have no conflict of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Sexually Transmitted Diseases Association.)

Background: Sexually transmitted infections (STI) can have severe consequences. In Brazil, case management is recommended by the Clinical Protocol and Therapeutical Guidelines for Comprehensive Care for People with STIs (PCDT-IST). This study assessed the quality of PCDT-IST (2021) and reviewed the main recommendations for the management of STI that cause urethral discharge compared with the World Health Organization (WHO) STI Guidelines., Methods: The PCDT-IST (2021) quality was independently assessed by 4 appraisers using the Appraisal of Guidelines Research and Evaluation instrument, version II (AGREE II). The PCDT-IST (2021) and the WHO Guidelines for the Management of Symptomatic STI (2021) were compared considering 14 different assessment domains., Results: The PCDT-IST (2021) scores in the AGREE II domains were: Rigor of Development (58%), Applicability (35%), Editorial Independence (38%), Scope and Purpose (78%), Stakeholder Involvement (74%), and Clarity and Presentation (82%). The overall score was 67%, and all appraisers recommended the Brazilian guideline. Regarding the PCDT-IST (2021) and the WHO STI Guidelines (2021) comparation, 10 domains would be relevant for further reviewing the Brazilian recommendations: Diagnostic tests; Etiological approach; Treatment for recurrent urethral discharge; Treatment for urethritis without etiological agent identification; Treatment for gonococcal urethritis; Treatment for chlamydial urethritis; Retreatment for gonococcal infections; Treatment for Mycoplasma genitalium urethritis; Treatment for Trichomonas vaginalis urethritis; 10. Flowcharts., Conclusions: The PCDT-IST (2021) has a reasonable degree of quality. However, the domains of Applicability, Rigor of Development, and Editorial Independence must be better ensured. The guidelines comparison will help to select key topics that should be addressed with priority in the following national STI guidelines updates., Competing Interests: Conflicts of interest and Sources of Funding: None declared., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: In South Africa, male urethritis syndrome (MUS) is the most common sexually transmitted infection (STI) syndrome in men. We determined the distribution of STI etiologies and the susceptibility profiles of Neisseria gonorrhoeae isolates from men presenting with MUS to 3 sentinel surveillance health care facilities. Secondary objectives were to determine the seroprevalence of coinfections (HIV, syphilis, herpes simplex virus 2)., Methods: Consecutive, consenting men with symptomatic urethral discharge were enrolled between January 1, 2019, and December 31, 2020. Genital discharge swab and blood specimens were collected and transported to a central STI reference laboratory in Johannesburg, South Africa., Results: Among 769 men enrolled, N. gonorrhoeae was the commonest cause of MUS (674 [87.8%]; 95% confidence interval [CI], 85.2%-89.9%), followed by Chlamydia trachomatis (161 [21.0%]; 95% CI, 18.2%-24.0%). Of 542 cultivable N. gonorrhoeae isolates, all were susceptible to ceftriaxone (modal minimum inhibitory concentration, 0.004 mg/L) and azithromycin (modal minimum inhibitory concentration, 0.128 mg/L). Seroprevalence rates of HIV, syphilis, and HSV-2 were 21.4% (95% CI, 18.5%-24.5%), 2.3%, and 50.1%, respectively. Condom use at last sexual encounter was reported by only 7%, less than 50% had been medically circumcised, and only 66.7% (58 of 87) who self-reported an HIV-positive status were adherent on antiretroviral drugs., Conclusions: Neisseria gonorrhoeae and C. trachomatis were the predominant causes of MUS. Currently recommended dual ceftriaxone and azithromycin therapy are appropriate for MUS syndromic management; however, surveillance must be maintained to timeously detect emerging and increasing gonococcal resistance. Clinic-based interventions must be intensified in men seeing sexual health care to reduce the community transmission and burden of STI and HIV., Competing Interests: Conflict of Interest and Source of Funding: All authors have no conflicts of interest to declare. Funding for this work was obtained from the operational cost center of the Centre for HIV & STI at the National Institute for Communicable Diseases, Johannesburg, South Africa., (Copyright © 2022 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Mycoplasma genitalium (MG) is associated with urethritis in men and could play a role in clinical outcome. We examined clinical improvement of symptoms in men receiving empirical treatment for urethritis and correlated the outcome with Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT), MG, and MG macrolide resistance-associated mutations (MRAM) status., Methods: At the sexually transmitted infection clinic in Amsterdam, the Netherlands, empirical treatment for gonococcal urethritis is 1 g ceftriaxone and for nongonococcal urethritis 1 g azithromycin. In 2018 to 2019, we tested urine samples of men with urethritis for CT, NG, and MG using transcription-mediated amplification assays. Mycoplasma genitalium-positive samples were tested for MRAM using quantitative polymerase chain reaction. Two weeks after receiving therapy, men were sent a text message inquiring after clinical improvement., Results: We evaluated 2505 cases of urethritis. The positivity rates of NG, CT, and MG were 26% (648 of 2489), 29% (726 of 2489), and 23% (522 of 2288), respectively. In 768 of 2288 of the cases (34%), no causative agent was detected. Most cases were infected with a single pathogen: NG, 417 of 2288 (18%); CT, 486 of 2288 (21%); and MG, 320 of 2288 (14%). The prevalence of MRAM among MG-positives was 74% (327 of 439). For 642 (25.6%) cases, we could evaluate clinical improvement after treatment of whom 127 (20%) indicated no improvement; 9% (15 of 174) in NG cases, 18% (35 of 195) in CT cases, 14% (4 of 28) in MG wild-type cases, and 40% (38 of 94) in MG-MRAM cases. Clinical improvement in MG-MRAM cases was significantly lower compared with all other groups (P < 0.001)., Conclusions: Presence of MG-MRAM is associated with lack of clinical improvement in azithromycin-treated nongonococcal urethritis., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Sexually Transmitted Diseases Association.)

Background: The effectiveness of microscopy of Gram-stained smear (GSS) for the detection of male urethral infection is debatable, especially in cases with low inflammation and no visible urethral discharge. This clinical study compared GSS samples collected with the conventional swab method and our new technique, the kissing slide method, together with polymerase chain reaction results to demonstrate the effectiveness of this new method in men with acute urethritis., Methods: The study included 64 men who presented to the urology outpatient clinic with complaints of acute urethritis between October 2019 and January 2020. Two GSS samples were collected from each patient, first using the kissing slide method (applying the slide directly to the urethral mucosa), followed by the conventional method. The results were compared with polymerase chain reaction findings., Results: The patients' mean age was 37.4 ± 7.8 years, and 68.7% had no visible urethral discharge on physical examination. At a GSS threshold of ≥5 polymorphonuclear leukocytes/high-power field, sensitivity values were 60% (95% confidence interval [CI], 42.32%-75.41%) for the kissing slide method and 23.33% (95% CI, 11.79%-40.93%) for the conventional method. At a threshold of ≥2 polymorphonuclear leukocytes/high-power field, sensitivity values with the kissing slide and conventional methods were 80% (95% CI, 62.69%-90.5%) and 50% (95% CI, 33.15%-66.85%) in all patients, and 66.67% (95% CI, 41.71%-84.82%) and 20% (95% CI, 7.047%-45.19%) in cases without visible urethral discharge, respectively., Conclusion: The new kissing slide method is a noninvasive alternative method that may have better sensitivity than the conventional GSS sampling method in the diagnosis of male acute urethritis. Randomized studies are needed to verify these findings.

Identifying pathogen-specific signs or symptoms of nongonococcal urethritis could improve syndromic management accuracy. We evaluated nongonococcal urethritis signs and symptoms in 220 men with single-pathogen infections (Chlamydia trachomatis, Mycoplasma genitalium, Trichomonas vaginalis, or Ureaplasma urealyticum) or idiopathic urethritis. No individual sign or symptom accurately predicted the infectious etiology.

Background: Standard counseling at nongonococcal urethritis (NGU) diagnosis includes advice to abstain from sex for at least 7 days and until symptoms resolve., Methods: From December 2014 to July 2018, we enrolled men who have sex with men and received azithromycin (1 g) for NGU at the Public Health-Seattle and King County STD Clinic. Over 12 weeks of follow-up, participants reported daily urethral symptoms and sexual activity on web-based diaries. Nongonococcal urethritis was defined as urethral symptoms or visible urethral discharge plus 5 or greater polymorphonuclear leukocytes per high-power field. Time of symptom resolution was defined as the first of 5 consecutive asymptomatic days., Results: Of 100 participants with NGU and no Chlamydia trachomatis (CT)/Mycoplasma genitalium (MG) coinfection, 36 (36%), 22 (22%), and 42 (42%) had CT-NGU, MG-NGU, and non-CT/non-MG NGU, respectively. Among men with MG-NGU, 94% had a macrolide resistance mutation. For all etiologies, median time to symptom resolution after azithromycin was 7 days (95% confidence interval [CI], 5-9); 37% had symptoms lasting longer than 7 days. For men with CT-NGU, MG-NGU, and non-CT/non-MG NGU, median time to symptom resolution was 4 days (95% CI, 2-6; 16% >7 days), undefined days (95% CI, 7 to undefined; 60% >7 days), and 7 days (95% CI, 5-11; 46% >7 days), respectively. Median time to first sexual activity (any type) was 12 days (95% CI, 11-17); it was 16 days (95% CI, 12-18) to first urethral sexual exposure. Twenty-seven percent did not avoid urethral exposure for the recommended period., Conclusions: Counseling at NGU diagnosis should educate patients that symptoms may persist more than 7 days, particularly for non-CT NGU, and emphasize the rationale for the 7-day abstinence period.

Background: Symptom awareness, behavioral factors, and other barriers associated with timely sexually transmitted infection (STI) health care provision in men is not well studied., Methods: Men attending an STI clinic answered a questionnaire regarding their symptoms, sexual behavior, and sociodemographic and behavioral characteristics. Characteristics of symptomatic men were compared between those who did and did not delay seeking health care services. Delayed care seeking was defined as clinic attendance longer than 7 days after symptoms, whereas early care seeking was defined as clinic attendance of 7 days or less., Results: Over a quarter (n = 43 [27.7%]) of men with urethritis symptoms (urethral discharge or dysuria) delayed seeking care for more than 7 days. Compared with men who sought treatment within 7 days, those that delayed care worried for longer periods that their symptoms were STI-related, were more likely to attempt self-treatment of STI symptoms, were more likely to continue engaging in sexual activity, and were less likely to use a condom during their last sexual encounter. Conversely, men that delayed care seeking were less likely to have urethral discharge on physical examination, to have 5 or more polymorphonuclear leukocytes, and to test positive for Neisseria gonorrhoeae. When compared with men that sought care earlier, men that delayed care seeking had fewer overall and new partners in the past 30 days., Conclusions: Our data suggest that over a quarter of men aware of STI symptoms delay seeking health services. Interventions that promote better patient understanding of the importance of symptom recognition and that facilitate timely access to care may provide new opportunities to reduce STI transmission.

To evaluate self-reported symptoms to guide urethritis diagnosis, symptomatic men being evaluated for urethritis were asked about 7 symptoms captured during history taking. Discharge and dysuria were significantly associated with urethritis and, when combined with genital irritation and itching, identified 95% of urethritis cases; odor and urinary frequency performed poorly.

Background: Men who have sex with men (MSM) are a key population, particularly vulnerable to sexually transmitted infections (STIs) and HIV, but there are limited data on health programs targeting MSM in Africa. This study aims to describe the utilization of nongovernmental organization-supported sexual health services for MSM at 2 public sector health facilities in Johannesburg, South Africa., Methods: We retrospectively analyzed routine data over the period of January 2014 to June 2016. We report on service utilization for STI syndromes, HIV testing, and the antiretroviral therapy (ART) program., Results: Some 5796 men visited the facilities. Seven thousand one hundred eighty-eight STI episodes were managed, 68.2% (4903 episodes) of which were classified as male urethritis and 9.8% (704 episodes) as genital ulcers. Positivity yield for first-time HIV tests was 38.0% (205 positive test results) in MSM, compared with 14.1% (471 positive test results) in other men. At the end of the study, there were 1090 clients on ART, and 2-year retention was 82% (95% confidence interval, 78%-85%). There was no difference in retention between MSM and other men (P = 0.49)., Conclusions: This study is the first to show that sexual health services targeting MSM in Africa have managed to attract MSM and other men in need of STI and HIV care. The observed high HIV testing yield among MSM illustrates the relevance of MSM-focused services in the South African public health sector, and the good retention on ART demonstrates that high-quality care can be provided to MSM in our setting.

Background: The microscopical diagnosis of male urethritis was recently questioned by Rietmeijer and Mettenbrink, lowering the diagnostic criteria of the diagnosis to ≥2 polymorphonuclear leucocytes (PMNL) per high power field (HPF), and adopted by Centers for Disease Control and Prevention in their 2015 STD Treatment Guidelines. The European Non-Gonococcal Urethritis Guideline advocates a limit of ≥5 PMNL/HPF., Objective: To determine if syndromic treatment of urethritis should be considered with a cutoff value of ≥2 PMNL/HPF in urethral smear., Methods: The design was a cross-sectional study investigating the presence and degree of urethritis relative to specific infections in men attending an STI clinic as drop-in patients., Results: The material included 2 cohorts: a retrospective study of 13,295 men and a prospective controlled study including 356 men. We observed a mean chlamydia prevalence of 2.3% in the 0-9 stratum, and a 12-fold higher prevalence (27.3%) in the strata above 9. Of the chlamydia cases, 89.8% were diagnosed in strata above 9. For Mycoplasma genitalium, the prevalence was 1.4% in the 0-9 stratum and 11.2% in the stratum ≥10, and 83.6% were diagnosed in strata above 9. For gonorrhea, a significant increase in the prevalence occurred between the 0-30 strata and >30 strata from 0.2% to 20.7%. The results of the prospective study were similar., Conclusions: Our data do not support lowering the cutoff to ≥2 PMNL/HPF. However, a standardization of urethral smear microscopy seems to be impossible. The cutoff value should discriminate between low and high prevalence of chlamydia, mycoplasma, and gonorrhea to include as many as possible with a specific infection in syndromic treatment, without overtreating those with few PMNL/HPF and high possibility of having nonspecific or no urethritis.

Background: The aim of this study was to ascertain the clinical characteristics associated with herpes simplex virus (HSV) urethritis in men and to compare those with chlamydial urethritis., Methods: We compared clinical and laboratory data from men diagnosed with polymerase chain reaction confirmed HSV urethritis with those of men with chlamydial urethritis presenting to Melbourne Sexual Health Centre between 2000 and 2015., Results: Eighty HSV urethritis cases were identified: 55 (68%, 95% confidence interval, 58-78) were by HSV-1 and 25 (32%, 95% confidence interval, 22-42) by HSV-2. Compared with chlamydial urethritis, men with HSV urethritis were significantly more likely to report severe dysuria (20% vs 0%, P < 0.01) or constitutional symptoms (15% vs 0%, P < 0.01). Men with HSV urethritis were significantly more likely to have meatitis (62% vs 23%, P < 0.01), genital ulceration (37% vs 0%, P < 0.01), or inguinal lymphadenopathy (30% vs 0%, P < 0.01) but less likely to have urethral discharge (32% vs 69%, P < 0.01). There was no significant difference in the proportion of men who had raised (≥5) polymorphonuclear leukocytes per high-powered field between the two groups (P = 0.46)., Conclusions: The clinical presentation of HSV urethritis in men may differ from those of chlamydial urethritis and guide testing for HSV in men presenting with non-gonococcal urethritis.

Background: To determine if female partners of men with pathogen-negative non-gonococcal urethritis (NGU) are at risk of genital infection., Methods: Secondary data analysis using health records from a large sexually transmitted disease clinic in Melbourne of 1710 men and their female partners attending on the same day from January 2006 to April 2015. Proportions of female partners with symptoms suggesting genital infection or pelvic inflammatory disease (PID) were determined for: (1) men with NGU and no Chlamydia trachomatis or Mycoplasma genitalium (referred to as pathogen-negative NGU) (n = 91); 2) men with urethral C. trachomatis (n = 176); 3) men with urethral M. genitalium (n = 26); and 4) asymptomatic men (n = 652)., Results: Female partners of men with pathogen-negative NGU experienced deep pelvic pain (adjusted odds ratio [AOR], 2.2; 95% confidence interval [CI], 1.1-4.4), post coital bleeding (AOR, 2.4; 95% CI, 1.2-4.9), and dysuria (AOR, 3.7; 95% CI, 1.6-8.6) more commonly and were diagnosed with PID more commonly (AOR, 4.8; 95% CI, 2.1-11.3) than the female partners of asymptomatic men. Pelvic inflammatory disease was not more likely to be diagnosed in the female partners of men with genital warts (AOR, 1.4; 95% CI, 0.5-4.4) or candidiasis (AOR, 1.2; 95% CI, 0.4-3.5) than the female partners of asymptomatic men. The female partners of men with chlamydia experienced post coital bleeding more (AOR, 1.9; 95% CI, 1.0-3.6) and were more likely to be diagnosed with PID (AOR, 3.6; 95% CI, 1.6-8.0)., Conclusions: The female partners of men with pathogen-negative NGU may be at increased risk of genital infection, even if a recognised pathogen is not identified in the man.

Background: This study was done to diagnose Mycoplasma genitalium infection based on bacterial load in urine specimens from symptomatic and asymptomatic men., Methods: Urine specimens from 94 men with visible urethral discharge, 206 with burning on micturition and 75 without symptoms presenting to a family practitioner were tested for M. genitalium as well as Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis by transcription-mediated amplification assays. A quantitative polymerase chain reaction assay was used to determine the bacterial load for all specimens in which M. genitalium was the only organism detected., Results: Among the 375 specimens collected, M. genitalium was detected in 59 (15.7%) men (both symptomatic and asymptomatic) using the transcription-mediated amplification assay, and in 45 (12.0%) of the total population, it was the only pathogen detected. One or more pathogens were detected in 129 (43%) of the symptomatic men, with N. gonorrhoeae in 50 (16.7%); C. trachomatis in 37 (12.3%) and T. vaginalis present in 24 (8.0%) patients. Among the 17 patients where mixed infections were detected, M. genitalium with N. gonorrhoeae was the most common (11/17; 64.7%). Patients with visible urethral discharge had significantly higher M. genitalium concentrations than those with burning on micturition. The median M. genitalium load in symptomatic men was significantly higher than that in asymptomatic men., Conclusions: This study confirms the high prevalence of M. genitalium among men with urethritis in South Africa and demonstrates that there is a strong association with M. genitalium bacterial load and clinical urethritis. As the number of organisms increased, the severity of the symptoms increased, an indication of the role that the organism plays in disease progression.

Corynebacterium propinquum is usually considered part of the normal human oropharyngeal flora and is rarely responsible for clinical infection. We report here what seems to be the first case of acute purulent urethral discharge in a young Iranian man with urethritis acquired after orogenital contact. Attention should be devoted to less common nondiphtheriae Corynebacterium species for differential diagnosis.

Background: Given recent increasing case rates of Chlamydia trachomatis infection, we evaluated trends in chlamydia rates and related health outcomes in women and men aged 15 to 44 years who were enrolled in a Pacific Northwest health plan., Methods: We identified chlamydia, pelvic inflammatory disease (PID), ectopic pregnancy, and male urethritis cases occurring annually during 1997-2007 using computerized health plan databases, calculating rates per 100,000 person-years (py) by gender and 5-year age groups. We also calculated annual chlamydia testing rates., Results: In women, chlamydia testing rates increased by approximately 23% (220 tests per 1000 py in 1997 to 270 tests per 1000 in 2007). Chlamydia diagnosis rates rose from 449 cases/100,000 py in 1997 to 806/100,000 in 2007, a 79% increase (P = 0.01). Increases were greatest during 2005-2007, also the period of major conversion to nucleic acid amplification test. PID rates in this interval declined steadily from 823 cases/100,000 py to 473/100,000 (P < 0.01). Ectopic pregnancy rates remained unchanged. In men, chlamydia testing rates increased nearly 3.5-fold, from 12 to 42 tests per 1000 py. Chlamydia rates for men also rose significantly throughout the study interval (from 91 cases/100,000 py to 218/100,000; P < 0.01) as did urethritis diagnosis rates (P < 0.01)., Conclusion: Between 1997 and 2007, annual health plan chlamydia rates increased significantly for both women and men. These trends may be due in part to increased testing rates and increased use of more sensitive tests, but they likely do not explain the increased urethritis rates. During this same interval, we observed steady declines in PID rates, consistent with other national data sources.

We describe herein a case of uropathogenic Escherichia coli urethritis and orchiepididymitis in a heterosexual man, which he had acquired sexually from his girlfriend. The identity of the genital isolates from both partners was confirmed by pulsed-field gel electrophoresis.

Background: Criteria for diagnosis of male urethritis based on a Gram-stained smear (GSS) of urethral discharge were developed before the era of nucleic acid amplification testing (NAAT) for Neisseria gonorrhoeae (Ng) and Chlamydia trachomatis (Ct) and may be too stringent when considering the higher sensitivity of NAAT., Objective: To evaluate Ct and Ng positivity at different strata of polymorphonuclear cells (PMN) per high power field (hpf) GSS microscopy., Methods: A retrospective analysis of the electronic medical record system of the Denver Metro Health Clinic between March 1, 2005 and December 31, 2010; all men with a GSS test during this period had an NAAT for Ct and Ng and had GSS results recorded at 1 PMN/hpf increments., Results: A total of 13,520 GSS were available for analysis. For Ct, a statistically significant trend was observed along the PMN/hpf incremental spectrum, and a significant increase in positivity was observed between the 1 and 2 PMN/hpf strata (from 6.5% to 16.2%). For men diagnosed with Ng, no such trend was observed, and >95% of GSS results fell in the >10 strata. A subanalysis to control for laboratory technician variance and difference in NAAT technology showed similar results., Conclusion: Our data support lowering the diagnostic criteria of the GSS diagnosis of male urethritis to ≥2 PMN/hpf. At this level, the Ct positivity (16.2%) is similar or higher than positivity in men who receive presumptive chlamydia treatment as a contact to patients diagnosed with gonorrhea, pelvic inflammatory disease, or mucopurulent cervicitis.

We compared a simple, one-step staining procedure using a mixture of methylene blue and gentian violet to Gram stain for the detection of gonococcal urethritis. The sensitivity and specificity of both Gram stain and methylene blue/gentian violet stain were 97.3% and 99.6%, respectively. There was a 100% correlation between the 2 methods.

Background: Timely notification and treatment of sex partners exposed to a sexually transmitted disease (STD) is essential to reduce reinfection and transmission. Our objectives were to determine factors associated with patient-initiated notification of sex partners and preferences regarding standard partner referral versus expedited partner therapy (EPT)., Methods: Participants diagnosed with gonorrhea, chlamydia, trichomoniasis, or nongonococcal urethritis within the previous year were administered a baseline survey asking about demographics, sexual history, and partner treatment preferences (standard partner referral vs. EPT). They identified up to 4 sex partners within the past 2 months, and answered questions on relationship characteristics, quality, and notification self-efficacy. At follow-up, participants with a current STD were asked whether they notified their partners. Generalized estimating equations were used to evaluate the associations between predictor variables and partner notification., Results: Of the 201 subjects enrolled, 157 had a current STD diagnosis, and 289 sex partners were identified. The rate of successful partner notification was 77.3% (157/203 sex partners). Partner notification was increased if the subject had a long-term relationship with a sex partner (odds ratio: 3.07; 95% confidence interval: 1.43, 6.58), considered the partner to be a main partner (odds ratio: 2.53; 95% confidence interval: 1.43, 6.58), or had increased notification self-efficacy. Overall, participants did not prefer EPT over standard referral; however, females, those with higher education levels, and those with a prior STD preferred EPT., Conclusions: Patient-initiated partner referral is more successful in patients with increased self-efficacy who have stronger interpersonal relationships with their sex partners.

An adult male presented to the Hawaii Health Department with a purulent urethral discharge. Urethral Gram stain examination led to a presumptive gonorrhea diagnosis even though his sexual history was nonsupportive. Culture results identified Neisseria meningitidis. This case report highlights the clinical similarities and differing epidemiology of these Neisseria urethritides.

In a sexually transmitted disease clinic-based sample of men who have sex with women, positivity for urethral Chlamydia trachomatis and Neisseria gonorrhoeae was 3.5% and 3.1%, respectively, among patients whose only urethral exposure in the previous 3 months was receiving fellatio from a woman. Urethral infections acquired by fellatio might contribute to ongoing disease spread.

Background: The Centers for Disease Control and Prevention recommends that men who have sex with men (MSM) be screened annually for gonorrhea (GC) infection at the urethral, pharyngeal, or rectal site based on recent sexual exposure. This evaluation estimated the proportion of GC infections in MSM that would be missed if only urethral or urine specimens were tested., Methods: Culture of specimens from all sites and urethral (or urine) nucleic acid amplification test (NAAT) results for gonorrhea were reviewed for all identified MSM attending the San Diego County STD Clinic during 1997-2003., Results: During the 7-year period, 7333 MSM were tested for GC and 1157 (15.8%) had a positive test result at > or =1 sites. Overall, 10.8% of urethral, 9.8% of rectal, and 4.0% of pharyngeal tests were positive. Among 5812 patients who had a urethral and a rectal or pharyngeal specimen tested, 970 were positive and among those, 369 (38%) had a negative test result in their urethral or urine specimen. Among 163 patients who had only a rectal and/or pharyngeal specimen tested for GC, 16 (9.8%) were positive. If the clinic had tested only urethral or urine specimens, 33% of total gonorrhea cases among MSM [385 (369 + 16) of 1157] would have been missed., Conclusion: GC screening strategies for MSM should include testing of rectal and pharyngeal specimens based on exposure. Given the decline of culture availability, efforts are needed to encourage laboratories to validate NAATs for rectal/pharyngeal specimens, which will likely increase exposure-based screening of MSM.

Background: Gram stain is used to detect urethral inflammation, suggestive of infection, in men and guide therapeutic decisions. In the absence of signs, symptoms, or polymorphonuclear leukocytes (PMNs) on urethral Gram stain, treatment and sometimes testing is deferred., Goal: Determine the proportion of men with chlamydia or gonorrhea diagnosed by nucleic acid amplification testing (NAAT) or culture who lack Gram stain evidence of inflammation and compare their clinical characteristics to men with inflammation., Methods: Records from 2629 men presenting for routine sexually transmitted disease care with urethral PMN count and NAAT data were retrospectively analyzed. A subpopulation tested by NAAT and culture was analyzed. Men receiving antibiotics within the prior month or those reporting a sexual partner with trichomoniasis were excluded., Results: Among 2266 eligible men, 353 (16%) had chlamydia and 462 (20%) had gonorrhea. Among chlamydia-infected men, PMNs per oil-immersion field (oif) on Gram stain were > or =5 in 291 (82%), 1 to 4 in 20 (6%), and none in 42 (12%). In men with gonorrhea, PMNs/oif were > or =5 in 433 (94%), 1 to 4 in 6 (1%), and none in 23 (5%). Urethral symptoms, discharge, and/or > or =5 PMNs/oif were absent in 47 (13%) and 22 (5%) of chlamydial and gonococcal infections, respectively (including no PMNs/oif and 1-4 PMNs/oif). None of these 47 chlamydial-infected men and only 4 of 22 men with gonorrhea received therapy at the time of initial examination., Conclusions: Twelve percent of chlamydial and 5% of gonococcal infections had no Gram stain evidence of urethral inflammation. Absence of symptoms and discharge is not uncommon in chlamydial infection detected by NAAT, and without testing, many infections will go untreated, furthering the possibility of complications or partner transmission.

Objective: The objective of this study was to compare urogenital swab specimens and first void urine (FVU) specimens from male and female patients at a sexually transmitted disease clinic for the detection of Mycoplasma genitalium and Chlamydia trachomatis infections using in-house, inhibitor-controlled polymerase chain reaction (PCR)., Study Design: Urethral swabs and FVU were collected from 1856 men and 753 women who also had a cervical swab collected. A positive diagnosis of infection was made if any 1 of the specimens tested positive and were confirmed in a second PCR assay targeting independent genes., Results: M. genitalium DNA and C. trachomatis DNA were detected in 126 (6.8%) and 246 (13.3%) of the male sample sets and in 51 (6.8%) and 73 (9.7%) of the female specimen sets, respectively. Using our in-house PCR and sample preparation methods, FVU was found to be the most sensitive diagnostic specimen for both pathogens, but for optimal sensitivity, it should be supplemented with a cervical specimen in women. In a small subset of female FVUs, storage at -20 degrees C led to false-negative M. genitalium PCR results in 27% of specimens found positive when a sample preparation was performed before freezing. The age-specific prevalence of M. genitalium in men was almost constant between 18 and 45 years of age in contrast to C. trachomatis infections, which were more common in younger men., Conclusion: Urine appeared to be a better diagnostic specimen than the urethral swab for M. genitalium and C. trachomatis detection by PCR in this cohort of sexually transmitted disease clinic attendees but should be supplemented with a cervical specimen in women.

Background: Noninvasive urine samples have been used to diagnose Chlamydia trachomatis infections, with the assumption that the first-void urine (FVU), defined as the first 20 to 30 ml at any micturition, would be the optimal collection. We compared testing technologies on first, second, and third volumes for diagnosis., Goal: The goal was to test in nonculture assays three sequential volumes of urine from men also undergoing urethral swabbing for C trachomatis culture specimens., Study Design: A total of 237 men attending an STD clinic (C trachomatis prevalence, 11%) collected three containers of urine (each containing 20-30 mL) for testing in four nonculture assays. A urethral swab specimen was tested in cell culture., Results: The numbers of men positive by testing of FVU with nucleic acid amplification (LCx chlamydia), nucleic acid hybridization (PACE 2), enzyme immunoassay (Chlamydiazyme), and a leukocyte esterase dipstick were 26, 7, 14, and 11, respectively; urethral culture identified 6 of the infected men. Comparative testing of all voids from the 26 men positive by the FVU assays demonstrated a reduction of LCx-positives. Non-amplified-test positivity declined precipitously in subsequent voids, approaching zero in the third void. The presence of symptoms and time of last void up to 8 hours had little effect on the number of positives detected by LCx of FVU., Conclusion: Amplified testing of FVU was most effective for diagnosing infection in these men.

Background: Cost containment has led to a concern that health maintenance organization-insured patients presenting with complaints of urethritis may be treated without being tested., Goal: To determine the proportion of men presenting with symptoms of urethritis who are tested for Chlamydia trachomatis and Neisseria gonorrhoeae., Study Design: Reviews were performed on 196 randomly selected patient records with an outpatient visit and a diagnostic code consistent with urethritis between 1995 and 1997. Data were collected on demographics, diagnostic testing, and treatment., Results: Diagnostic testing for C trachomatis and N gonorrhoeae was performed, respectively, in 92.3% and 83.2% of the men presenting at an initial visit with complaints of urethritis. Altogether, 98.2% of the patients who met the Centers for Disease Control criteria for documenting urethritis were tested for C trachomatis and N gonorrhoeae., Conclusion: Diagnostic testing for C trachomatis and N gonorrhoeae is nearly universal in this multispecialty group practice setting, facilitating surveillance and public health efforts.

Background: The leukocyte esterase (LE) test has a limited role in determination of empiric therapy for male patients screened for urethritis because of its poor positive predictive value in low (< 5%) prevalence settings. The recent advent of nucleic acid amplification testing of first-void urine (FVU) has dramatically increased the ease with which widespread screening for Chlamydia trachomatis and Neisseria gonorrhoeae can be performed, but the costs of such testing may be prohibitive. The LE test may therefore have a role in management of urethritis because of its high negative predictive value., Objectives: To determine the sensitivity, specificity, and positive and negative predictive value of LE testing for the diagnosis of N. gonorrhoeae and C. trachomatis in male FVU specimens in a low-prevalence urban setting using a commercial polymerase chain reaction (PCR) as the gold standard., Methods: Data were obtained on men presenting to an urban sexually transmitted disease clinic over a 16-month period. Patients were included if an FVU had been tested for the presence of LE using a rapid dipstick, read by an automated urine analyzer, and the sample (either an FVU or urethral swab) had then been processed for the detection of N. gonorrhoeae and C. trachomatis by PCR., Results: Of 301 assessable patients, there were 14 cases of gonorrhoea, 21 cases of chlamydia, and 1 case of dual infection detected by PCR. Most men (245/301; 81.4%) were asymptomatic, of whom 12 of 245 (4.9%) had an infection detected compared with 24 of 56 (42.9%) in the symptomatic men (P < 0.001). Using a "< or = trace" cutoff, the overall value for the sensitivity of the LE test was 77.8% (95% confidence interval, 60.4-89.3), specificity 80.8% (75.4-85.2), positive predictive value 35.4% (25.2-47.1), and negative predictive value 96.4% (92.8-98.3)., Conclusions: The negative predictive value of the LE test may be of use in determining which patients should proceed to specific diagnosis by nucleic amplification methods (e.g., PCR or ligase chain reaction). By limiting testing to patients with positive LE results, cost savings may be made, enabling the technology to be used in a wider community setting. The value of the LE test in higher prevalence populations with access to nucleic amplification testing remains to be established.

Background and Objectives: A quick and highly sensitive diagnostic test would be valuable in the diagnosis of Chlamydia trachomatis., Goal of This Study: We compared a new polymerase chain reaction (PCR) technique to Chlamydiazyme (Abbott, North Chicago, IL) in the detection of male chlamydial urethritis, and evaluated the performance of PCR on urine samples., Study Design: Urethral samples for analysis by PCR and Chlamydiazyme were obtained from 474 unselected patients attending a sexually transmitted diseases (STD) clinic. Urine samples were analyzed by PCR from 362 of these patients., Results: Twenty seven (5.7%) urethral samples were positive by Chlamydiazyme, while 64 (13.5%) were positive by PCR. After resolution of discrepant results, the sensitivity of PCR on urethral swabs was 98.4% and the specificity was 99.0%, with positive and negative predictive values of 93.8% and 99.8%, respectively. These same measures for Chlamydiazyme were 43.5%, 100%, 100%, and 92.2%, respectively. The sensitivity of PCR on urine samples was 87.1%, the specificity was 98.0%, and the positive and negative predictive values were 90.0% and 97.4%, respectively., Conclusions: This PCR test is more sensitive than Chlamydiazyme in detecting male urethral chlamydial infections in an STD clinic population, and appears to be equally efficacious on urethral swabs and urine samples.

Background and Objectives: The detection of asymptomatic urethritis using a leukocyte esterase (LE) strip may have a role in primary care screening to select men who need diagnostic testing for Chlamydia trachomatis and Neisseria gonorrhoeae., Study Design: Eight-hundred and eighty-two men, 16 to 35 years of age were studied when they attended their family physician or university health clinic for nongenitourinary complaints. First void urine (FVU) was tested by an LE strip (Chemstrip 2 LN, Boehringer Mannheim Corp., Indianapolis, IN), Chlamydiazyme (Abbott Laboratories, N. Chicago, IL) enzyme immunoassay with confirmatory blocking and polymerase chain reaction (PCR) with chlamydial plasmid primers., Results: Forty-five men (5.1%) were positive (> trace) by LE strip. Of the LE-positive urines, 9 (20.0%) were positive by EIA or PCR, and none of the LE-negatives were positive by EIA or PCR. Twenty-three LE positives (5 EIA/PCR-positive; 1 PCR-positive; 17 EIA/PCR-negative) were able to be followed with a second urine and 2 urethral swabs. All of the 6 chlamydia-positives who had follow-up tests were positive by both immunoassay and PCR on urine. Based on the FVU results, the prevalence of asymptomatic chlamydial infection was 1.0% (9/88) (95% CL, 0.5 to 1.9) for which the LE urine strip was 100% (9/9) sensitive and 95.9% (837/873) specific. Analyses based on screening 1,000 men, 16 to 25 years of age, showed that the cost per case detected was $192.00 using the LE strip (> 1+) to select urine specimens for EIA testing, compared to $1,326.00 using the EIA to test all urine specimens., Conclusion: In this low prevalence, primary care setting, the LE urine strip was an accurate screening test, which if used to preselect urine specimens for subsequent chlamydial testing, would be less costly per case detected than assaying each specimen for chlamydia.

To characterize the problem of unsuspected Chlamydia trachomatis infection in heterosexual men attending a sexually transmitted diseases (STD) clinic, the authors assessed risk factors for infection and the value of screening for infection by gram-stained smears and urinalysis in 438 men who did not have conventional clinical indications for chlamydial treatment at their initial visit. Evaluations included urethral swabs for gram-stained smears and Neisseria gonorrhoeae and C. trachomatis cultures and microscopy of first-catch urine sediment. C. trachomatis was isolated from 29 subjects (6.6%) and N. gonorrhoeae from 6 subjects (1.3%), (P less than .05). The only demographic or clinical factors that were associated with C. trachomatis were age younger than 21 years and five or more lifetime sexual partners. Screening for C. trachomatis with urethral gram stain and urine sediment examination had sensitivities of only 23% and 35%, respectively. Risk factor assessment and screening with standard microscopic procedures do not adequately predict infection in this group, which accounts for almost 25% of the C. trachomatis burden in heterosexual men who visit an STD clinic. More specific chlamydia detection methods are needed for effective control programs.

In areas such as Los Angeles, California, where penicillin-resistant Neisseria gonorrhoeae accounts for 1% or more of all gonorrhea strains isolated, third-generation cephalosporin agents have replaced penicillin as standard therapy. Ceftriaxone, the agent recommended by CDC guidelines, or ceftizoxime, an alternative agent have excellent activity against all strains of N. gonorrhoeae. One hundred seventy-five male patients with clinically and microbiologically confirmed gonococcal urethritis were treated with single-dose ceftizoxime 250 mg IM (50 patients) or 500 mg IM (125 patients). Cure was demonstrated clinically by repeat cultures of urethral discharge in all patients, including those with infections from penicillinase-producing strains of bacteria. None of the patients experienced complications or allergic reactions to ceftizoxime. Given the lower unit-of-use cost of ceftizoxime, its routine in place of ceftriaxone could result in substantial cost savings in those institutions that treat large numbers of patients with uncomplicated gonococcal urethritis.

Polymorphonuclear leukocytes (PMNs) in the gram-stained urethral smears of 236 consecutive sexually active men without gonorrhea were analyzed quantitatively. The frequency distribution of the highest count of PMNs per high-power field (hpf) showed a count of four PMNs to be the "cut-off" point separating men with urethritis from those without urethritis. This cut-off point correlated well with the presence of Chlamydia trachomatis as well as with turbid urine. However, the PMN count in the gram-stained urethral smear was found to be more sensitive than the appearance of the urine in the diagnosis of urethritis among those with minimal symptoms and signs and not harboring C. trachomatis. This study also demonstrated a close similarity as regards clinical features and PMN count in gram-stained urethral smears between those harboring Ureaplasma urealyticum and those with no organisms.

The diagnostic sensitivity of the numbers of leukocytes in the sediment of first-voided urine and in gram-stained smears of urethral secretions was evaluated by a study of 62 men with symptoms of nongonococcal urethritis. Fifty-one patients (82.3%) had pyuria (defined as ten or more leukocytes per high-power field) in the sediment of first-voided urine, whereas 8 (45.2%) had more than four leukocytes per oil-immersion held in gram-stained urethral smears. Frequencies of positive first-voided urine sediments and urethral smears were similar in Chlamydia trachomatis--positive and -negative cases. Results of cultures, urinalyses, and urethral smears were not affected by recent micturition. Pyuria in the first-voided urine but not a positive urethral smear is a sensitive sign of urethritis whether or not urethral discharge is evident. Specimens of urethral secretions were subjected to different storage conditions to determine the effect on subsequent isolation of C. trachomatis. Equal rates of isolation were demonstrated for specimens that had been held at 4 degrees C for either four or 20-24 hr or frozen to -70 degrees C for one week prior to culture.

First-catch urine specimens were obtained before clinical examination from 101 sexually active men who attended a sexually transmitted diseases clinic with a complaint of urethral discharge. Urethral swab specimens were used for preparation of smears and were then cultured on Martin-Lewis medium. Enzyme immunoassay (EIA) tests were performed on (1) uncentrifuged urine, (2) urine sediment, and (3) urine sediment diluted 1:6 with detergent buffer. Urethral cultures from 65 (64%) of the 101 men were positive for N. gonorrhoeae. EIA performed on urine sediment diluted 1:6 yielded the highest sensitivity: 98.5% (64/65). Sensitivity of EIA for uncentrifuged urine was only 66% (43/65). Specificity of all samples tested exceeded 97.2%. Overall agreement between results of EIA on diluted urine sediment and culture was 98% (99/101). Discordant culture and EIA results were unrelated to urine volume, time since prior urination, quantity of gonococcal growth on Martin-Lewis medium, duration of urine storage (less than 72 hours) before testing, or immunotype. EIA tests using urine sediment are highly sensitive and specific, and they offer an alternative means of diagnosing gonorrhea in men who refuse urethral manipulation. They also provide a means of screening men at high risk for gonorrhea who have submitted a urine specimen for other reasons.

The rate of isolation of Chlamydia trachomatis from cervical and urethral specimens from 99 culture-positive female partners of men with nongonococcal urethritis who were attending a gynecological outpatient clinic was correlated with the clinical status of the women. The agent was recovered from both sites in 46 women, from the cervix only in 28, and from the urethra only in 25 women. Urethral symptoms were reported by 38 (54%) of those with positive urethral cultures, as compared with six (21%) of those with positive cervical cultures only (P less than 0.01). Significant bacteriuria was found in only three patients with urethral symptoms; two of them had negative urethral cultures for C. trachomatis. Frequencies of cervicitis, rises in titer of antibody, and geometric mean titers of immunofluorescent antibody to C. trachomatis did not differ significantly among the three groups.

Specimens of urethral exudate from 200 men with uncomplicated urethritis were tested for Neisseria gonorrhoeae by the limulus amebocyte lysate assay, culture on modified Thayer-Martin medium, and gram-stained smear. As compared with cultures, the sensitivity and specificity of the limulus assay were 94.8% and 89.3%, respectively, while the sensitivity and specificity of the gram stain were 98.8% and 100.0%, respectively. The accuracy of prediction of the presence of N. gonorrhoeae was significantly better by gram-stained smear than by the limulus assay. Unless the limulus assay is modified, as it was in this study, it does not appear to have a role in the presumptive diagnosis of the gonorrhea in men at a clinic for sexually transmitted diseases.

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.

Chlamydia trachomatis infection is easy to treat but laborious to diagnose by culture. An antigen-detecting enzyme immunoassay (EIA; Chlamydiazyme, Abbott Laboratories, North Chicago, IL), suitable for testing many samples, was compared with the conventional iodine-stained, one-passage culture. A total of 471 duplicate samples from 218 men (urethra) and 128 women (urethra and cervix) attending a sexually transmitted disease clinic were examined by both tests. The overall sensitivity, specificity, and predictive value of positive and negative results were 80.3%, 96.7%, 86.4%, and 95.0%, respectively. No difference between male and female patients was observed. A remarkable difference between sensitivities of female urethral (60.0%) and cervical (95.5%) samples was found. This difference is clearly important in cases of women with urethral infection only (19% in our study) and points to the need for further improvement of this EIA.

Branhamella (Neisseria) catarrhalis was recovered from urethral exudates of three men with acute urethritis. In all cases gram stain of the urethral exudates revealed intracellular gram-negative diplococci morphologically compatible with Neisseria gonorrhoeae. Branhamella (Neisseria) catarrhalis should be considered as a potential cause of acute urethritis in men with urethral discharge microscopically consistent with, but culture-negative for, N. gonorrhoeae.

Of 609 male patients seen for sexually transmitted disease, 94 (15.4%) admitted to having had orogenital intercourse; 30 (5%) had practiced it during their last contact. Ten of the 30 patients admitting to fellatio during their last exposure had gonococcal urethritis. Three of these men practiced fellatio exclusively with prostitutes, and their cases demonstrate the inherent risk of oral-to-genital transfer of sexually transmitted disease. All three patients responded favorably to therapy with ampicillin and probenecid.

Nongonococcal urethritis was identified as a major reason that men attended our Venereal Disease Clinic. The prevalence of several agents that might cause nongonococcal urethritis was determined. Attempts were made to isolate gonococci; chlamydiae, Ureaplasms urealyticum, trichmonads, Candida sp., and Corynebacterium vaginale from urethral swabs from 307 men. Chlamydiae were recovered from 31% of the 67 men with nongonococcal urethritis compared to only 4% of 86 asymptomatic men without pyuria. Unexpectedly, cultures from only 4% of the 99 men with gonorrhea also yielded chlamydiae. Ureaplasma urealyticum was recovered from 9 of 27 asymptomatic men (33%), 16 of 30 men with nongonococcal urethritis (53%) and 16 of 68 men with gonorrhea (42%). These differences were not statistically significant. However, when chlamydiae-positive men were excluded from the analysis urethritis. Twelve of 18 (76%) men with nononchlamdial nongonococcal urethritis yielded the organism compared to 8 of 26 (31%) men without urethritis. The other organisms sought were recovered infrequently and could not be associated with nongonococcal 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.

When a standard method for grading urethral discharge that is based on quantity (profuse, moderate, or scant) and quality (purulent, cloudy, or clear) is used, the optimal performance of the clinical diagnosis of gonorrhea is 73%. This performance (true positives over true plus false positives) is dependent not only on the sensitivity, specificity, and prevalence of gonorrhea but also on the components of that prevalence, i.e., the specific mix of patients who attend a clinical service. Optimal performance, as determined through use of a relative operating characteristics curve, will vary from setting to setting depending upon certain patient variables, such as race and sexual preference. Clinics with full diagnostic service would not employ clinical diagnosis as a screening tool directly, but rather as an epidemiologic device for helping to characterize patient populations at risk. Areas with less developed clinic facilities might apply these observations for clinical decision making in the absence of laboratory support.

The clinical and laboratory features of nongonococcal urethritis were studied in 96 patients. Data from previous episodes of urethritis were obtained from 88 men; histories of previous urethritis were obtained from 46 (52%) of the 88 men. Prostatic enlargement (and often tenderness) was found on rectal examination of 22 men (23%) and correlated with a history of previous episodes(s) of urethritis (P less than 0.01). Chlamydia trachomatis was recovered from 19 patients (20%), Ureaplasma urealyticum from 58 (60%), and neither organism from 27 (28%). Results of serologic test for C. trachomatis correlated with cultural findings and demonstrated a high prevalence of preexisting antibody. In comparison with those patients whose urethral smears showed greater purulence, patients with five or fewer polymorphonuclear leukocytes (per 1,000 x field) on the urethral smear had similar frequencies of recovery of C. trachomatis, prostatic abnormalities, and responses to therapy, but had lower frequencies of urethral discharge and recovery of U. urealyticum. A 14-day course of either tetracycline hydrochloride or doxycycline hyclate was successful in eradicating both symptoms and pathogens, except for cases for cases in which initial isolates of U. urealyticum showed in-vitro resistance.