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We describe a case of urethritis caused by group B streptococci. The diagnosis was confirmed by examination of a Gram stained smear, isolation of the organism from the urethral discharge, and also by the clinical response to treatment with phenoxymethyl penicillin.

Of an unselected group of 159 women attending a sexually transmitted diseases (STD) clinic 20% (32) had symptoms of urethritis. A positive correlation existed between the finding of more than 10 polymorphonuclear leucocytes (PMNL) per high-power field in the Gram-stained urethral smear and the presence of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis. Conversely, these organisms were rarely isolated if no PMNL were present. Fewer cultures gave positive results for these organisms if micturition had occurred less than four hours before examination. C trachomatis was recovered from the urethra or endocervix in 29/150 (19 . 3%) and from the urethra alone in six women. In contrast, N gonorrhoea was never recovered from the urethra in the absence of endocervical infection. Of the 159 women 10% had bacteriuria due to non-sexually transmissible agents; 50% had asymptomatic bacteriuria. All, however, had other urethral pathogens isolated as well. Thus, sexually transmitted disease agents are highly prevalent in women attending an STD clinic who have signs and symptoms of urethritis. As in non-gonococcal urethritis in men, C trachomatis may be an important cause of urethritis in women.

In a retrospective study of clinic records containing accurate information on the dates of infection and onset of symptoms, the mean (+/- SEM) incubation period of gonorrhea in men was 6.2 +/- 3.8 days and the mean duration of symptoms (3.1 +/- 2.3 days. For non-specific urethritis the mean (+/- SEM) figures were 7.7 +/- 4.1 and 4.0 +/- 3.4 days respectively; both were significantly longer than for gonorrhoea. Patients with a first episode of urethritis had longer than average incubation periods and duration of symptoms. Past experience of urethritis shortened the duration of symptoms; this was more significant in gonorrhoeae than in non-specific urethritis. "Anxious" men who had attended previously of their own accord when no abnormality had been found had the shortest times. The most notable factor in determining the interval between infection and attendance, however, was whether or not the sexual contact was known. Infections by known contacts were associated with prolonged duration of symptoms which negated the benefit of past experience and, to some extent, of anxiety. Thus, patients should be made more generally aware that known contacts may be a source of infection, especially after a break in a relationship, and that they should return to the clinic as soon as symptoms develop. Furthermore, doctors should examine carefully even the most persistently "neurotic" patients, because they may eventually become infected.

Chronic non-bacterial prostatitis is a difficult condition to diagnose accurately either by symptoms and signs or by investigations. Four groups of patients were assessed for the number of leucocytes and the presence of pathogens in expressed prostatic secretions before and after treatment with co-trimoxazole two tablets twice daily for three months. The pretreatment findings suggest that the upper limit of normal for the number of leucocytes in expressed prostatic secretions is about five per microscope field (X 40 magnification) and that for the cell count about 0.5 X 10(9)/l using the method described. Increased microscopical cell estimations and cell counts in the expressed prostatic secretions of patients with symptoms of prostatitis and those with recurrent non-specific urethritis seem to indicate the presence of prostatitis.

A study was carried out to determine whether the diagnosis of non-specific urethritis was affected by differences in the microscopical interpretation of urethral smears between individual observers (interobserver variation) and the same observer on separate occasions (intraobserver variation). A marked degree of both intraobserver and interobserver variation was found which--depending on the diagnostic criteria adopted--could affect both the diagnosis and treatment of many patients attending a clinic of genitourinary medicine.

Chlamydia trachomatis was isolated from the uretha of 125 (52%) of 238 men with non-gonococcal urethritis (NGU). Repeat isolation attempts in 155 of these patients were successful in eight men in whom results had been negative on the initial visit, but they were unsuccessful in eight men who initially had had positive cultures. We must assume that with our present isolation techniques we are missing, at any single visit, at least 9% of chlamydial infections. C. trachomatis was also found in 32 (23%) of 139 men with gonorrhoea. Positive cultures were obtained from 15 (79%) of 19 men, who later developed post-gonococcal urethritis (PGU). Thiamphenicol, used for the treatment of gonorrhoea, was shown to have very little effect on C. trachomatis, which could still be recovered after treatment in 76% of the patients who initially had had a combined infection. The typing of 35 genital isolates by micro-immunofluorescence confirms the previously reported distribution of chlamydial serotypes. In this study a social profile is given of our patients with urethritis and a comparison is made of the duration of symptoms and the nature of discharge in men with gonococcal, chlamydial, and non-specific urethritis. We were able to show a clear difference in clinical symptoms in men with gonorrhoea and NGU, taken as a whole, but found only a slight difference between men with chlamydial and non-specific urethritis.

In an evaluation of the limulus assay as a method for detecting endotoxin in urethral exudates, positive results of urethral samples at a 1/200 dilution were obtained from 73 out of 73 patients with culture-positive gonococcal urethritis while negative results were obtained from 26 out of 27 patients with cuture-negative urethral specimens. A specimen from one patient, which gave negative results on Gram stain and culture, gave positive results to the limulus test. The overall accuracy of the limulus test for predicting culture results was 99% (p less than 0.001). Thus, in preliminary studies of otherwise healthy men, the results of the limulus assay correlated with those of biological methods for diagnosing urethral gonorrhoea; the test may, therefore, be of use in identifying cases of nongonococcal urethritis.

Data previously collected on the facilities and diagnostic criteria used in clinics for sexually transmitted diseases in England and Wales were reanalysed to established how different consultant policies affected the management of individual cases. Several discrepancies were found between conclusions based on percentages of clinics and those based on numbers of cases. Full-time facilities for contact tracing were available to more cases than previously suggested and rectal sampling in women was more widespread. Laboratory facilities were limited and cultural facilities lacking in small clinics, which thus affected only a small number of cases. Previous indications that diagnostic criteria were fairly standardised in the diagnosis of non-specific urethritis were found to be invalid. Variation in the management of individual cases was found to lead to inconsistencies in the notification of STDs to the Department of Health and Social Security.

In a study of 157 men and 141 women with gonorrhoea post-gonococcal urethritis (PGU) in men was significantly more common among chlamydia-positive (76%) than among chlamydia-negative (22.5%) patients. Clinical investigations of PGU detected 95% of the patients infected with C trachomatis. PGU was, however, asymptomatic in over half of the patients and a careful follow-up for 3-6 weeks was necessary to detect between 80% and over 90% of cases. PGU was not related to age, past history of gonorrhoea or non-gonococcal urethritis, severity of gonococcal infection, or chlamydial inclusion count. Although post-gonococcal cervicitis (PGC) in women was an identifiable entity, it was detected in only one-third of chlamydia-positive patients. PGC was significantly associated with the 20-29 year-old age group but was not related to symptoms or chlamydial inclusion count. In the absence of facilities for culturing chlamydia, selection on an epidemiological basis of all female consorts of men with PGU, together with the remaining women with PGC, would have resulted in some unnecessary treatments and left untreated up to 30% of those harbouring C trachomatis.

A substantial number of problems are associated with the present notification system on sexually transmitted diseases. Since a comprehensive and uniform system is vitally important to all clinicians in indicating changes in disease incidence and patterns, some modifications are proposed to make the system of more direct clinical relevance.

A retrospective study on early morning smears confirmed the value of this investigation for diagnosing urethritis in men. In 200 patients 108 new infections were diagnosed.

The current methods of diagnosis for non-specific genital infection (NSGI) in clinics in England and Wales are described. In most clinics (92%) microscopical findings were used by consultants to establish the diagnosis of non-specific urethritis (NSU) in male patients. However, the microscopical criteria that they used in reaching a diagnosis varied between clinics. The most commonly applied criterion was that of less than five leucocytes per high power field. NSGI in female patients and non-specific proctitis in passive homosexuals were recognised as distincy in 60% of clinics and the latter in 57%. Among those who recognised these conditions the diagnostic criteria varied. The establishment of acceptable and uniform criteria for diagnosis are discussed.