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Few case reports have been published on disseminated gonococcal infection in Japan. We report such a non-HIV case without typical skin rash. A 49-year-old Japanese man living in Thailand on business was seen for fever and multiple arthralgia after returning to Japan. Given the travel history, differential diagnoses included endemic viral infection such as human immunodeficiency virus (HIV), dengue fever, and chikungunya. Diagnosis was based on right-knee arthrocentesis, and synovial fluid culture followed by Neisseria gonorrhoeae polymerase chain reaction (PCR). The isolated strain was sensitive to penicillin. The man was treated with intravenous ceftriaxone and oral levofloxacin. Disseminated gonococcal infection should thus be considered when examining those with classical polyarthralgia symptoms even without a typical skin rash.

About one million Chlamydia trachomatis urogenital infections occur in Japan. Infections of Chlamydia trachomatis or gonococci are associated many clinical syndromes, ranging from urethritis and epididymitis in men to cervicitis, salpingitis, acute urethra syndrome, endometritis, ectopic pregnancy, infertility and pervic inflammatory disease in women. Unfortunately early infected symptoms are often very mild or absent among women. So early diagnosis and treatment are both important in Chlamydia trachomatis and gonococci infection in women. Chlamydial and gonococcal infection are highly prevalent in young sexually active adolescent. With sexually active teens practicing high-risk behavior, frequent testing is ideal and offers multiple opportunities for education and counseling by the care workers.

Oral sex is recently becoming a general sexual behavior among the youths in this country. Oral sex is often performed without a condom because they do not have to worry about pregnancy in oral sex. Chlamydia trachomatis and Neisseria gonorrhoeae which are sexually transmitted diseases are infected with not only the genital tract but also the pharynx. Oral sex attracts attention as a new route of infection of Chlamydia trachomatis and Neisseria gonorrhoeae. It is very imoportant that gential Chlamydia and gonococcal infections should be detected early and treated to protect from re-infection, because these infections are causes of infertility. If Chlamydia trachomatis and Neisseria gonorrhoeae are detected from a genital tract in a youth, pharyngeal Chlamydia trachomatis and Neisseria gonorrhoeae examinations should be performed.

Neisseria gonorrhoeae infections are common bacterial sexually transmitted diseases. Men will usually experience lower urinary tract symptons attributed to urethritis, epididymitis, proctitis, or prostatitis, with associated mucopurulent urethral discharge. Many women are asymptomatic. But, occasionally, they have symptons of vaginal and pelvic discomfort of dysuria, and these infections can lead to pelvic inflammatory disease. Recentry, high prevalence of Neisseria gonorrhoeae isolates resistant to antimicrobial agents is a serious problem in the treatment of gonorrhea. For example, in Fukuoka city, Japan, the proportion of the isolates resistant to ciprofloxacin (CPFX) were 73.4% in 2006 and it was still so high. The proportion of the isolates resistant to tetracycline (TC) was 38.5% in 2006 and that of isolates resistant to penicillin G (PCG) was 17.5%. Owing to this high prevalence of antimicrobial-resistant Neisseria gonorrhoeae in Japan, the clinical efficacy rates of oral antimicrobial agents have become lower. So, as first-line therapy for gonococcal infections, only three parenteral regimens of single doses of ceftriaxone, cefodizime or spectinomycin are recommended by the Japanese Society for Sexually Transmitted Diseases. In the circumstances, we studied in vitro activity of combinations of oral agents such as, beta-lactam and azithromycin, fluoroquinolone and azithromycin, or beta-lactam and fluoroquinolone against Neisseria gonorrhoeae. The cefixime+azithromycin combination demonstrated greater synergy than other combinations.

Guidelines for the diagnosis and treatment of sexually transmitted diseases (STD) have been revised and updated from 1996 in Japan. Revision will be made in the whole content of 2008 version and it will be published in the nearest months. In the diagnosis of gonococcal and chlamydial infection, newer nucleic acid amplification test kit (NAAT), Aptima Combo2 and Probetek ET, was developed and recommended to use. Diagnosis and treatment of gonococcal infection is problematic because of increase of pharyngeal infection and increase of resistant strains against many of antimicrobial agents. Modified Thayer-Martin culture medium or newer NAATs should be used in the diagnosis of pharyngeal gonococcal infection, and single 1 g dose of ceftriaxone should be used in the treatment of gonococcal infection including pharyngeal infection. In young students, increase of chlamydial infection is now main problem in Japan. Screening of chlamydial infection by using NAATs should be done. Much of clinical research to know the proper diagnosis and treatment of STD should be done to verify the evidences described in the guidelines and to make new evidences in the near future.

In Japan, STD has widely spread especially in big cities and number of infected people have been increasing with HIV infection. Clinicians have to diagnose, treat STDs appropriately and educate the patients to cease the new infection. So I want to review how to use these tests as a screening or more specific situation.

Sexually transmitted diseases diagnosed and treated exclusively in urology clinics are male urethritis and epididymitis caused by Neisseria gonorrhoeae and Chlamydia trachomatis. Although recent developments in diagnostic tools have made it possible to detect these microorganisms with extremely high sensitivities, the screening of Neisseria gonorrhoeae using the microscopic observation of intraleucocyte diplococci stained by methylene blue or gram staining in the first voided urine sediment or urethral smears still the key point in the diagnosis and treatment of gonococcal urethritis. In recent years, mycoplasmas and ureaplasmas have been supposed to be possible pathogens of prostatitis as well as urethritis. The objective diagnosis of genital skin lesions caused by herpes simplex virus and human papillomavirus are remained to be developed.

Among sexually transmitted diseases, Chlamydia trachomatis and Neisseria gonorrhoeae infections are found most frequently. Recently, their incidence in youths has increased. The rate of infection by human immunodeficiency virus is increased in patients who have been infected by Chlamydia trachomatis. In view of this, early detection and treatment of Chlamydia trachomatis infection appear to be important. Asymptomatic infections by Chlamydia trachomatis and Neisseria gonorrhoeae are not rare among gynecological patients. However, in patients infected by both of these pathogens it is difficult to detect microbial antigens using specific antibodies. Therefore, patients suspected of infection by these pathogens should receive precise genetic testing for Chlamydia trachomatis and Neisseria gonorrhoeae, and the results of such tests should be evaluated carefully.

We evaluated the usefulness of urine sediment from male gonorrhea patients for detecting gonococcal antigens by enzyme immunoassay, Gonozyme (Abbott Laboratories). Experiments for dilution rate of urine sediment with buffer provided in a kit indicated that dilution of sediment at 1:4-6 would be practical in performing Gonozyme. All urine sediment specimens from 18 gonorrhea patients showed positive by Gonozyme, and 68, except for 3, culture-negative control urine sediments, including 8 sediments from patients with chlamydial urethlitis, were negative. Based on comparing results of Gonozyme with those of culture, sensitivities and specificity were 88.9-100% and 95.6%, respectively. During storage of urine sediment at 5 degrees C for 7 days, absorbance values were stable. Therefore, urine sediment could be preserved or transported. We conclude that urine sediment is useful for diagnosis of gonococcal urethritis in males by Gonozyme.

Neisseria gonorrhoeae was detected from first-voided urine sediments of male patients with urethritis by polymerase chain reaction (PCR). Urine and urinary sediment were treated with proteinase K, and DNA was further purified by phenol extraction. Two oligonucleotides based on sequences within a ribosomal RNA gene from N. gonorrhoeae were used as primers for the PCR. A DNA fragment of 206 bp specific for N. gonorrhoeae was amplified by PCR and detected by agarose gel electrophoresis. In 19 specimens of urine sediments collected from 21 patients in whom N. gonorrhoeae was isolated from urethral swab by culture, 206 bp DNA fragment was amplified by PCR. In all specimens of urine sediments from 24 patients in whom cultures for N. gonorrhoeae were negative, no DNA was amplified by the PCR. The overall coincidence rate between the PCR for detecting N. gonorrhoeae in first-voided urine sediments and culture in urethral swab was 95.6% (43/45). PCR procedure for detection of pathogens from first-voided urine sediments would be noninvasive and would be applied for the diagnosis of gonococcal urethritis and chlamydial urethritis.

From January through June 1983, 178 male patients with urethritis were investigated on the etiology and epidemiological and clinical features. By using Chlamydia trachomatis direct specimen test (Micro Trak), C. trachomatis was detected in 60 (47.2%) among 127 patients with non-gonococcal urethritis, while it was detected 8 (15.7%) among 51 patients with gonococcal urethritis. The source of infection was a non-prostitute in 30% of chlamydial urethritis, while in gonorrheal urethritis only one patient was infected from a non-prostitute. Mean incubation period of chlamydial and gonorrheal urethritis was 28.5 and 9.2 days, respectively. In chlamydial urethritis, 33.3% of patients did not complain of urination pain and 20.4% showed no urethral discharge. Symptoms of chlamydial urethritis were milder than those of gonorrheal urethritis.