Search

Mycoplasma genitalium (MG) is a common cause of non-gonococcal urethritis, but a role in acute or chronic prostatitis has not been described. We describe the case of a 42-year-old man with recurrent urinary tract infections since 2018 who developed chronic prostatitis despite several and prolonged antibiotic courses. Multiparametric prostatic magnetic resonance showed peripheral inflammatory alterations. A 4-glass Meares-Stamey test detected MG in the third voided bladder (VB3) sample. Moxifloxacin 400 mg daily for 28 days resulted in sustained clinical and microbiological cure., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

We describe an unusual case of a male patient presenting with penile and testicular swelling following an unprotected and traumatic sexual encounter. It was suspected that an isolated penile injury occurred during intercourse; however, ultrasound imaging identified an intact tunical layer and right-sided epididymo-orchitis. Following screening for sexually transmitted infections (STIs), he was discharged with antibiotics and advice to attend the Sexual Health Centre for contact tracing. He represented with a periurethral abscess and an antimicrobial-resistant (AMR) strain of Neisseria gonorrhoea was identified. Appropriate antibiotic treatment was initiated. Examination-under-anaesthesia, following abscess drainage, revealed a contained collection with no urethral fistula; however, a flat urethral lesion was seen during urethroscopy. Repeat urethroscopy and biopsy of the lesion indicated polypoid urethritis. Periurethral abscess secondary to gonococcal urethritis is a rare complication, but one that we should be suspicious of, especially with the growing incidence of AMR-STIs., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Test of cure (TOC) for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) infection is an important tool in the public health management of STIs. However, there are limited data about the optimal time to perform TOC using nucleic acid amplification tests (NAATs) for NG and CT infections. A study was performed to assess the feasibility of a larger study to determine the optimal time to TOC using NAATS., Methods: The Sexually Transmitted Bacteria Reference Unit at Public Health England undertook testing of gonococcal and chlamydial nucleic acids within neat urine stored in different conditions over 25 days to provide evidence of the stability of the nucleic acid prior to recruitment. Individuals diagnosed with uncomplicated NG or CT infection were recruited from three sexual health clinics. Individuals were asked to return nine self-taken samples from the site of infection over a course of 35 days. Survival analyses of time to first negative NAAT result for NG and CT infection and univariate regression analysis of factors that affect time to clearance were undertaken., Results: At room temperature, chlamydial DNA in urine is stable for up to 3 weeks and gonococcal DNA for up to 11 days. We analysed data for 147 infections (81 NG and 66 CT). The median time to clearance of infection was 4 days (IQR 2-10 days) for NG infection and 10 days (IQR 7-14 days) for CT infection. Vaginal CT infections took longer to clear (p=0.031). NG infection in men who have sex with men took longer to clear (p=0.052)., Conclusion: Chlamydial and gonococcal nucleic acids are stable in urine before addition of preservatives, longer than recommended by the manufacturer. The TOC results suggest that it may be possible to undertake TOC for NG and CT infections earlier than current guidelines suggest and that anatomical site of infection may affect time to clearance of infection., Competing Interests: Competing interests: BS is funded through a National Institute for Health Research (NIHR) Doctoral Research Fellowship. NIHR did not have any involvement in the study or manuscript., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

This case report presents a patient who, while undergoing oral isotretinoin therapy for acne vulgaris, developed onychocryptosis and asymptomatic external urethritis. These uncommon adverse events are not well-documented in medical literature. While his urethritis spontaneously resolved, his onychocryptosis symptoms necessitated surgical intervention. This report illustrates both cosmetic and functional adverse effects of isotretinoin and provides insight into the progression of these reactions over time., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To assess the cost-effectiveness of three testing strategies with or without light microscopic Gram-stained smear (GSS) evaluation for the detection of anogenital gonorrhoea among men who have sex with men (MSM) at the Amsterdam STI clinic using a healthcare payer perspective., Methods: Three testing strategies for MSM were compared: (1) GSS in symptomatic MSM only (currently practised strategy), (2) no GSS and (3) GSS in symptomatic and asymptomatic MSM. The three testing protocols include testing with nucleic acid amplification test to verify the GSS results in (1) and (3), or as the only test in (2). A transmission model was employed to calculate the influence of the testing strategies on the prevalence of anogenital gonorrhoea over 10 years. An economic model combined cost data on medical consultations, tests and treatment and utility data to estimate the number of epididymitis cases and quality-adjusted life years (QALY) associated with gonorrhoea. Incremental cost-effectiveness ratios (ICERs) for the testing scenarios were estimated. Uncertainty and sensitivity analyses were performed., Results: No GSS testing compared with GSS in symptomatic MSM only (current strategy) resulted in nine extra epididymitis cases (95% uncertainty interval (UI): 2-22), 72 QALYs lost (95% UI: 59-187) and €7300 additional costs (95% UI: -€185 000 (i.e.cost-saving) to €407 000) over 10 years. GSS testing in both symptomatic and asymptomatic MSM compared with GSS in symptomatic MSM only resulted in one prevented epididymitis case (95% UI: 0-2), 1.1 QALY gained (95% UI: 0.1-3.3), €148 000 additional costs (95% UI: €86 000 to-€217 000) and an ICER of €177 000 (95% UI: €67 000-to €705 000) per QALY gained over 10 years. The results were robust in sensitivity analyses., Conclusions: GSS for symptomatic MSM only is cost-effective compared with no GSS for MSM and with GSS for both symptomatic and asymptomatic MSM., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The main objective of this study is to determine the prevalence of trichomoniasis in men with and without symptoms of urethritis, with concomitant analysis of sociodemographic and behavioural specificities of both groups. Also, the objective is to evaluate laboratory methods used in the diagnostics of this parasitic disease., Methods: A total of 500 men with and 200 without urethritis symptoms were included in the study. Every respondent filled out a questionnaire asking for some general data, specific information about habits, sexual behaviour and symptoms. Sediment of first void urine was analysed by wet mount microscopy, cultivation in Diamond's medium and real-time PCR., Results: In the symptomatic group, Trichomonas vaginalis infection was documented in 2.4% of respondents by wet mount microscopy, in 4.8% by cultivation and in 8.2% by real-time PCR. In the asymptomatic group, infection was proven using the same methods in 1.0%, 1.5% and 2.0% of the respondents, respectively. Trichomoniasis prevalence was statistically significantly higher in the respondents manifesting urethritis symptoms when cultivation (χ2=4.20, p=0.041) and real-time PCR (χ2=9.20, p=0.002) were used. Several epidemiological risk factors were identified, and greater sensitivity of real-time PCR was found in comparison with microscopy and culture., Conclusions: Trichomonas infection was statistically more frequent in men with urethritis syndrome. Assuming that the samples found positive by any laboratory technique are truly positive, it can be concluded that the real-time PCR showed the greatest sensitivity of all the methods used in this study., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objectives: Gram-stained urethral smear (GSUS), the standard point-of-care test for non-gonococcal urethritis (NGU) is operator dependent and poorly specific. The performance of rapid automated urine flow cytometry (AUFC) of first void urine (FVU) white cell counts (UWCC) for predicting Mycoplasma genitalium and Chlamydia trachomatis urethral infections was assessed and its application to asymptomatic infection was evaluated., Methods: Receiver operating characteristic curve analysis, determining FVU-UWCC threshold for predicting M. genitalium or C. trachomatis infection was performed on 208 'training' samples from symptomatic patients and subsequently validated using 228 additional FVUs obtained from prospective unselected patients., Results: An optimal diagnostic threshold of >29 UWC/µL gave sensitivities and specificities for either infection of 81.5% (95% CI 65.1% to 91.6%) and 85.8% (79.5% to 90.4%), respectively, compared with 86.8% (71.1% to 95%) and 64.7% (56.9% to 71.7%), respectively, for GSUS, using the training set samples. FVU-UWCC demonstrated sensitivities and specificities of 69.2% (95% CI 48.1% to 84.9%) and 92% (87.2% to 95.2%), respectively, when using validation samples. In asymptomatic patients where GSUS was not used, AUFC would have enabled more infections to be detected compared with clinical considerations only (71.4% vs 28.6%; p=0.03). The correlation between UWCC and bacterial load was stronger for M. genitalium compared with C. trachomatis (τ=0.426, p≤0.001 vs τ=0.295, p=0.022, respectively)., Conclusions: AUFC offers improved specificity over microscopy for predicting C. trachomatis or M. genitalium infection. Universal AUFC may enable non-invasive diagnosis of asymptomatic NGU at the PoC. The degree of urethral inflammation exhibits a stronger association with pathogen load for M. genitalium compared with C. trachomatis., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

We present eight cases and review the literature of concurrent urethritis and conjunctivitis where adenovirus was identified as the causative pathogen. The focus of this review concerns the identification of specific sexual practices, symptoms, signs and any serotypes that seem more commonly associated with such adenovirus infections. We discuss the seasonality of adenovirus infection and provide practical advice for clinicians to give to the patient., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Acute urethritis is among the most common types of sexually transmitted diseases in men. The diagnosis usually requires microscopic evidence of urethritis, but sometimes urethral pathogens are detected in asymptomatic men without such evidence. The aims of this study were to assess the sensitivity of Gram stain in men with urethral symptoms and to relate it to the microorganisms isolated., Methods: Between January 2006 and December 2007, 491 urethral samples were analysed. The authors assessed the presence of leukocytes by Gram stain and tested specifically for Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma hominis and Trichomonas vaginalis, as well as analysing the results of conventional culture., Results: The percentages of positive samples as a function of Gram category were two or less polymorphonuclear leukocytes (PMNLs)/high-power field (HPF) 25% (92/364), three to four PMNLs/HPF 32% (18/57) and five or more PMNLs/HPF 54% (38/70). Classing samples with more than two PMNLs/HPF as positive, the sensitivity, specificity and positive likelihood ratio for Gram stain were 38% (95% CI 30 to 46), 79% (95% CI 75 to 84) and 1.8 (95% CI 1.4 to 2.4), respectively. On the other hand, taking as positive five or more PMNLs/HPF, the sensitivity, specificity and positive likelihood ratio for Gram stain were 26% (95% CI 18 to 33), 91% (95% CI 87 to 94) and 2.7 (95% CI 1.8 to 4.2), respectively. The sensitivity of Gram stain to Neisseria gonorrhoeae, Chlamydia trachomatis and Ureaplasma urealyticum were 80% (95% CI 64 to 96), 23% (95% CI 8 to 39) and 11% (95% CI 2 to 20), respectively., Conclusion: The low sensitivity of Gram stain means that negative results do not exclude the presence of urethritis in symptomatic patients.

Objectives: In the absence of a single nucleic acid amplification test (NAAT) that is both highly specific and sensitive for gonorrhoea, many have put forward the 16S-based assay as a confirmatory test for Neisseria gonorrhoeae. This study was undertaken to evaluate the performance of PCR based on 16S ribosomal gene in comparison with a porA pseudogene-based assay., Methods: The specificity of both the porA pseudogene-based PCR and 16S ribosomal gene PCR was checked against a panel of strains comprising of non N gonorrhoeae Neisseria sp (NgNS) and other gram-negative and gram-positive bacteria. The sensitivity studies were performed using different dilutions of N gonorrhoeae DNA. PCRs were also done on endocervical and urethral swab samples collected from a total of 100 female and 50 male patients presenting to sexually transmitted disease clinics, Dermatology OPD of AIIMS and Safdarjang Hospital, New Delhi, India, recruited as per inclusion criteria., Results: PCR assay based on 16S ribosomal gene showed cross-reactivity with three of six strains of N sicca. The porA pseudogene-based PCR was highly specific. Analytical sensitivity of 16S-based ribosomal assay was more than that of porA pseudogene-based assay. In clinical samples, for female patients, sensitivity, specificity, positive predictive value and negative predictive value of 16S ribosomal assay was 100% (95% CI 51.7% to 100%), 91.5% (95% CI 83.4% to 96%), 42.9% (95% CI 18.8% to 70.4%) and 100% (95% CI 94.7% to 100%), respectively, while for the male patients it was 100% (95% CI 85% to 100%), 95.5% (95% CI 75.1% to 99.8%), 96.6% (95% CI 80.4% to 99.8%) and 100% (95% CI 80.8% to 100%), respectively., Conclusions: The data presented in this report supports use of 16S ribosomal assay as a screening assay only. The porA pseudogene target is highly specific for N gonorrhoeae and may be used as a supplemental assay.

Objectives: To determine the prevalence of urethritis pathogens amongst male symptomatic urethritis (MUS) patients, genital ulcer (GUS) patients without urethritis symptoms and men requesting HIV testing at a voluntary counselling and testing (VCT) clinic., Methods: A prospective study was conducted in Johannesburg, South Africa. Men from the three groups were screened for urethritis pathogens using molecular tests. Culture for Neisseria gonorrhoeae and, initially, trichomoniasis was performed. Antimicrobial susceptibility testing was undertaken for ciprofloxacin on all gonococcal isolates; ciprofloxacin resistant isolates were screened for ceftriaxone resistance., Results: 664 participants were recruited (438 MUS, 76 GUS and 158 VCT) over 2 years. Gonorrhoea was detected in 62.3% MUS, 15.8% GUS and 3.2% VCT participants. Chlamydial infection was detected in 19.3% MUS, 13.2% GUS and 8.2% VCT participants. Trichomoniasis was detected in 4.9% MUS, 19.7% GUS and 3.8% VCT participants. Mycoplasma genitalium infection was detected in 14.4% MUS, 13.2% GUS and 7.0% VCT participants. Ciprofloxacin resistance increased from 13.0% in the first year to 26.3% in the second year; all resistant isolates were susceptible to ceftriaxone., Conclusions: Urethritis pathogens, including Trichomonas vaginalis, should be covered in syndromic management treatment of genital ulcers in the absence of clinical urethritis. Consideration should be given to adding metronidazole to existing MUS treatment. Ciprofloxacin can no longer be relied upon to treat presumptive gonococcal infections in South Africa.

Objectives: To study the prevalence, symptoms, and signs of Mycoplasma genitalium and Chlamydia trachomatis infections in women attending a Swedish STD clinic, accessible for both sexes, and in a group of young women called in the cervical cancer screening programme., Methods: A cross sectional study among female STD clinic attendees in Orebro and a study among women called for Papanicolaou smear screening. Attendees were examined for urethritis and cervicitis. First void urine and endocervical samples were tested for M genitalium and C trachomatis., Results: The prevalence of C trachomatis and M genitalium in the STD clinic population was 10% (45/465) and 6% (26/461), respectively. Dual infection was diagnosed in four women. In the cancer screening group of women the corresponding prevalence was 2% (1/59) and 0%, respectively. Among the STD clinic attendees there were no significant differences in symptoms (32% v 23%, RR 1.4, 95% CI 0.6 to 3.4) or signs (71% v 50%, RR 1.4, 95% CI 0.9 to 2.3) between C trachomatis and M genitalium infections. Microscopic signs of cervicitis were significantly more common among M genitalium and C trachomatis infected women than in the cancer screening group of women. 56% (15/27) of male partners of M genitalium infected women were infected with M genitalium compared to 59% of male partners of C trachomatis infected women who were infected with C trachomatis (p = 0.80)., Conclusions: M genitalium is a common infection associated with cervicitis and with a high prevalence of infected sexual partners supporting its role as a cause of sexually transmitted infection.

Objectives: To determine the reliability of the diagnosis of non-gonococcal urethritis (NGU), and the variation between and within microscopists, from urethral smears at a large London genitourinary medicine clinic., Methods: A senior microscopist (SM) preselected 60 Gram stained urethral smear slides, 20 negative (<5 polymorphs/hpf), 20 low grade NGU (5-20 p/hpf), and 20 high grade NGU (>20 p/hpf). Ten experienced microscopists, blinded to these initial grades, examined all slides giving each a polymorph score. After relabelling and randomly changing their order, the slides were re-examined by the same microscopists. Finally, the SM determined whether the study had resulted in loss of cells from any of the slides. The SM's initial grading and the consensus among microscopists provide two gold standards for analysis., Results: Nine low grade and five high grade slides were removed from analysis because of loss of cells. By SM standard, considering microscopists' readings as simply non-NGU (<5 p/hpf) or NGU (>or=5 p/hpf), 97% from negative slides were correct (variation 93-100 across microscopists), 68% from low grade slides (45-95), and 94% from high grade slides (83-100). Consistency between repeat readings by the same microscopist was 96% for negatives, 75% for low grade and 89% for high grade slides. Results were similar by consensus standard., Conclusions: There was considerable variation between and within microscopists in the diagnosis of NGU. Sensitivity was strongly related to grade of urethritis, with an appreciable proportion of low grade urethritis falsely diagnosed as negative. With increasing attendances for sexual health screening, a false positive rate of only 3% may lead to many false diagnoses.

Objectives: This study was conducted to examine the variation in clinical practice in genitourinary medicine clinics in the United Kingdom in early 2002., Methods: Questionnaires were sent to all 234 consultants in charge of genitourinary medicine clinics in the United Kingdom in March-May 2002. The questions concerned clinical practice in respect of asymptomatic patients presenting for an infection screen, and practice in respect of some specific sexually transmitted and other genitourinary infections., Results: The test for infection least likely to be offered to heterosexuals is an HIV test (71% and 70% of clinics routinely offer this to male and female heterosexuals respectively). The practice of permitting "low risk" patients to telephone for their HIV results now extends to 24% of clinics. 34% of clinics do not require patients with non-specific urethritis to attend for follow up. 41% of clinics routinely ask patients treated for Chlamydia trachomatis to return for a follow up chlamydia detection test. 25% of clinics routinely offer two tests of cure to all patients with gonorrhoea. 6% of clinics do not routinely offer syphilis serology to heterosexuals. Other significant variations in clinical practice were documented., Conclusions: Overall, our findings indicate the need for further evidence to guide clinical practice and a wider knowledge and debate of national guidelines.

Objectives: To compare endourethral swabs and urine as diagnostic specimens for the detection of genital Chlamydia trachomatis infection using the polymerase chain reaction (PCR), in male patients attending a genitourinary clinic and to assess whether the first endourethral swab used solely for diagnosing gonococcal infection could be used for C trachomatis detection as well., Methods: Two endourethral swabs were taken from 80 male patients, in whom the likelihood of genital C trachomatis infection was high. The first swab was used for microscopy and culture for Neisseria gonorrhoeae, before being used for C trachomatis detection. First voided urine specimens were collected from 61 of these patients. All three specimens were processed for C trachomatis DNA detection using the Roche Cobas Amplicor PCR. A diagnosis of genital C trachomatis infection was made if any one of the specimens tested reproducibly positive. Samples from 13 patients showing discrepant PCR results between swabs and/or urine were retested by ligase chain reaction (LCR)., Results: Chlamydia trachomatis DNA was detected in 35 (43.8%) of the 80 patients. In 17 of the 35 patients (48.6%), all the genital specimens were positive. However, in 18 (51.4%) patients, one or more of the genital specimens had negative PCR results. Among the 18 patients with discrepant results, urine was found to be a more sensitive diagnostic specimen than the second urethral swab picking up 13 out of 16 positives (81.3%) as opposed to five out of 18 (27.8%). There was no significant difference between the two swabs. Retesting by LCR, of the samples from 13 of the 18 patients with discrepant PCR results confirmed them all as true positives, although as with PCR, not all specimens in the set were concordantly positive. LCR detected all the 13 positives in urine, while there was no difference in the detection rate between the first and the second urethral swabs., Conclusions: Urine appeared to be a better diagnostic specimen than the conventional second endourethral swab for C trachomatis detection by PCR in this cohort of male patients. There was no difference between the first swab, intended primarily for N gonorrhoeae testing and the second swab intended for C trachomatis detection. This raises questions over the need for the conventional second swab for detecting C trachomatis.

A practical protocol using the polymerase chain reaction (PCR) was designed for detecting Chlamydia trachomatis in clinical samples. DNA was extracted from material collected on urethral swabs and used as substrate for the PCR. The target was a 600 basepair DNA segment of the multicopy plasmid that is common to all strains of the bacterium. Negative samples were checked for loss of DNA or presence of polymerase inhibitors by a second PCR, targeted to a conserved segment of the human genome. The whole procedure was tested on 216 men with non-gonococcal urethritis (NGU). All patients were independently assessed by tissue culture isolation (60 positive samples) and a commercial immunoenzymatic assay. The PCR protocol, while sufficiently simple for routine application, was reliable and, for the diagnosis of urethritis, at least as good as tissue culture isolation.

In a clinical study of 190 men with non-gonococcal urethritis, Chlamydia trachomatis inclusions were sought in cycloheximide-treated McCoy cells by an indirect immunofluorescent antibody technique. The method was consistently reliable over a period of two years, and the results were obtained within 24 hours of a patient's attendance. The results correlated with those obtained by Giemsa staining in 91.6% of patients, and the new method was at least as sensitive as the established Giemsa-staining method.