2009 European Guideline on the Management of Male Non-gonococcal Urethritis

Abstract

Urethritis, or inflammation of the urethra, in men is characterized by discharge and/or urethral symptoms such as dysuria or urethral itching, but may be asymptomatic. Urethritis is mainly due to sexually transmitted pathogens. The diagnosis of urethritis is confirmed by demonstrating an excess number of polymorphonuclear leukocytes (PMNLs) in the anterior urethra. This is usually assessed using a urethral smear, but a first-pass urine (FPU) specimen can also be used. Urethritis is described as either gonococcal, when Neisseria gonorrhoeae is detected, or non-gonococcal urethritis (NGU), when it is not. Mucopurulent cervicitis is the female equivalent of male NGU with approximately 40% of cases being due to infection with Chlamydia trachomatis, although female NGU due to C. trachomatis and Mycoplasma genitalium has been reported. There are a number of uncertainties with NGU. There is significant inter-observer and intra-observer error in performing and reading urethral slides and counting PMNLs, especially in samples with low-grade inflammation. In many men with urethritis, a known pathogen is not isolated. Up to one-third of men infected with either C. trachomatis or M. genitalium will not have an excess of PMNLs, the sensitivity of smear ( 5 PMNLs) being far better in the case of an overt discharge, variations being furthermore dependent on populations and techniques of sampling. Indeed if a discharge is present, the isolation rate of C. trachomatis or M. genitalium reaches 50%. In 3–20% an undiagnosed C. trachomatis or M. genitalium infection is found in the partner of a patient with non-chlamydial, non-M. genitalium urethritis if he or she is tested. AETIOLOGY † N. gonorrhoeae. The isolation rate varies enormously in different social settings and different European countries. N. gonorrhoeae is more common in inner city urban, deprived areas compared with more affluent neighbourhoods. The prevalence of the common organisms associated with NGU in more recent studies are listed in Tables 1 and 2. Reported isolation rates of pathogens is lower in more recent studies despite the use of more sensitive tests. The commonest organisms implicated are C. trachomatis and M. genitalium with the latter perhaps causing more symptoms; † Chlamydia is more likely to be isolated in younger patients than M. genitalium and the two organisms rarely coexist in the same individual; † In 30–80% of the cases with NGU neither C. trachomatis nor M. genitalium is detected; † The isolation of Trichomonas vaginalis is dependent on the prevalence of the organism in the community, being more common in non-white ethnic groups and Eastern Europe, and greatly increases with the use of more sensitive polymerase chain reaction assays. T. vaginalis isolation is greater in men .30 years; † The exact role of ureaplasmas in NGU has been controversial, due to conflicting observations in clinical studies. Ureaplasmas are ubiquitous microorganisms which can be isolated from 30% to 40% of healthy sexually active young men. They have recently been divided into two species: U. parvum (biovar 1) and U. urealyticum (biovar 2) and in some studies U. urealyticum has been associated to 5–10% of cases of acute NGU;