Symptoms Of Urethritis Research Articles

A survey of primary care physician practices in antibiotic prescribing for the treatment of uncomplicated male gonoccocal urethritis

BackgroundThe development of resistance to antimicrobial therapy by Neisseria gonorrhoeae causes on-going problems for individual case management of gonorrhoea. Surveillance data about N. gonorrhoeae have indicated an increase in the incidence of gonorrhoea in France in 2006. As a consequence of the development of antibiotic resistance in N. gonorrhoeae, French guidelines excluded fluoroquinolones as a standard treatment for N. gonorrhoeae. Ceftriaxone became the recommended treatment, associated with azithromycin for Clamydia trachomatis infection. Our aim was to describe the practice patterns of general practitioners (GPs) in managing the antibiotic treatment of patients with symptoms suggestive of uncomplicated male urethritis.MethodsWe developed a clinical vignette describing a man with typical gonococcal urethritis symptoms to elicit questions about antibiotic treatment. We mailed the electronic questionnaire to a random sample of 1000 French GPs belonging to the Sentinelles Network.ResultsBy the end of the survey period, 350 vignettes were received, yielding a response rate of 35%. Sixty-six GPs (20.2%) prescribed the recommended antibiotics for the simultaneous treatment of N. gonorrhoeae and C. trachomatis infections, while 132 GPs (40.4%) prescribed only non-recommended antibiotics, including ciprofloxacin in 69 cases (21.1%). General practitioners with less than 10 years in practice showed better compliance to guidelines than those with more years in practice (p < 0.05).ConclusionsThe results suggest a mismatch between the guidelines and the antibiotic treatment of male uncomplicated urethritis by French GPs, mostly among the subgroup of physicians who have been in practice longer. Educational approaches based on practice feedback need to be developed to improve these deficits in the quality of care.

Real time PCR 法を用いた淋菌，クラミジア診断の有用性の検討

We evaluated performance of Abbott RealTime CT/NG assay (real-time PCR, Abbott Japan) for detect Chlamydia trachomatis and Neisseria gonorrhoeae by real-time PCR in 88 female patients with cervicitis symptoms seen at gynecological clinics and 100 male patients with urethritis symptoms seen at urological or dermatology clinics in Kitakyushu, Japan. Endocervical swab and first-voided urine (FVU) specimens were then collected from women and FVU specimens from men. Detection rates of C. trachomatis and N. gonorrhoeae by real-time PCR in the 3 types of specimens were compared to those by ProbeTec ET assay (ProbeTec, BD Diagnostic System). The overall positive concordance between real-time PCR and ProbTec were 97.1% (66/68) for C. trachomatis and 100% (33/33) for N. gonorrhoeae, C. trachomatis detection yielded 3 discordant results in endocervical specimens and 1 discordant result in male FVU by real-time PCR and ProbTec. Three of 4 reexamined using Aptime Combo 2 Assay (Fuji Rebio Inc.) were positive for C. trachomatis. Endocervical swab and FVU specimen results for C. trachomatis were discordant in 3 cases in real-time PCR and 4 in ProbeTec. Subjects with 2 or more positive endocervical awab results in female or male FVU specimens were assumed to be "true positive" for C. trachomatis. The sensitivities of real-time PCR for detecting C. trachomatis was 94.4% in endocervical swabs, 77.8% in female FVU and 97.4% in the male FVU. The sensitivities for real-time PCR for detecting N. gonorrhoeae was 100% in all 3 specimentypes. Abbott RealTime CT/NG assay was useful for detecting C. trachomatis using endocervical swabs or male FVU specimens and for detecting N. gonorrhoeae using endocervical swabs and all FVU specimens.

Role of Mycoplasma and Ureaplasma Species in Female Lower Genital Tract Infections

Genital mycoplasmas are commonly found in the female genital tract. Despite ongoing debate, the evidence that they cause lower genital tract disease in women remains sparse. The data that Mycoplasma genitalium is primarily transmitted sexually are accumulating, but its role as a cause of symptomatic urethritis or cervicitis is open to debate. Although Mycoplasma hominis may be a co-factor in bacterial vaginosis, it has otherwise not been implicated as a cause of lower tract disease. Now that Ureaplasma urealyticum has been divided into U. urealyticum and Ureaplasma parvum, their role in causing urethritis and cervicitis remains even more unclear. To date, no convincing evidence exists that antimicrobial therapy should be directed solely at these organisms when treating women with urethritis, bacterial vaginosis, trichomoniasis, or cervicitis.

Antimicrobial susceptibility patterns of gonococcal isolates in Pretoria, South Africa, over a 20-year period (1984-2004)

This paper reviews the susceptibility profles of Neisseria gonorrhoeae over a 20-year period in the Pretoria region. Endourethral specimens were collected from adult men with symptoms of urethritis attending primary health care clinics and private medical practitioners. These swabs were plated on enriched media for isolation of N. gonorrhoeae. Antimicrobial susceptibility of the organisms was performed using the disc diffusion and agar dilution methods. Plasmid analyses were performed on beta-lactamase-producing isolates. Penicillase-producing N. gonorrhoeae strains increased from 4% to 16%, whilst chromosomally mediated penicillin-resistant strains increased dramatically from 0% to 16% from 1984 to 2004. There was an equal distribution of the 3.2 MDa African and 4.4 MDa Asian plasmids. High-level tetracycline-resistant strains (36%) were detected for the frst time in 2004. Ciprofoxacin resistance emerged at 7% in the same year. Gonococcal isolates remained susceptible to cefoxitin, ceftriaxone, cefpodoxime, and spectinomycin. However, the minimum inhibitory concentration values for spectinomycin were very close to the breakpoint. We have shown a continuing increase in resistance to penicillin (plasmid and chromosomal), the emergence of high-level tetracycline resistance and an emergence of resistance to ciprofoxacin. Susceptibility testing is essential for successful therapeutic outcomes and needs to be performed in an ongoing basis.

A case-control study of men with non-gonococcal urethritis at Auckland Sexual Health Service: rates of detection of Mycoplasma genitalium

Previous studies have identified Mycoplasma genitalium as a cause of urethritis in men. As there is no New Zealand data, a case-control study was conducted to determine whether this organism is a significant cause of urethritis in men presenting to Auckland Sexual Health Service. Enrollment for the study commenced in March 2006 and finished in February 2008. Inclusion criteria for cases of non-gonococcal urethritis were onset of urethritis symptoms within one month confirmed by urethral Gram staining showing >or=10 polymorphonuclear leucocytes per high-powered field. Controls were men presenting during the same time period for asymptomatic sexual health screening. All participants were tested for Neisseria gonorrhoeae, M. genitalium, and Chlamydia trachomatis. Information regarding symptoms, sexual behaviour and treatment was collected using a standard questionnaire. We recruited 209 cases and 199 controls with a participation rate of 96%. The prevalence of C. trachomatis and M. genitalium in non-gonococcal urethritis cases was 33.5% and 10% respectively. Co-infection with these organisms was uncommon (1.9%). C. trachomatis and M. genitalium were diagnosed in 4% and 2% of controls, respectively, and both infections were detected significantly less often than in the cases (P < 0.0001, P < 0.005). Cases were more likely to report inconsistent condom use, multiple sexual contacts and not having sexual intercourse in the last week (P = 0.03, P = 0.02, P = 0.03). A past history of non-gonococcal urethritis was a significant predictor of current symptoms (P < 0.0001). This is the first study to investigate M. genitalium infection in New Zealand men. Our results confirm that M. genitalium is a cause of non-gonococcal urethritis in men presenting to our service.

Idiopathic urethritis in young men in the United States: prevalence and comparison to infections with known sexually transmitted pathogens.

Urethritis is the most common male reproductive tract disease syndrome; yet 20-50% of diagnosed cases have no defined etiology, and few population-level data exist on the prevalence or etiology of the syndrome. We estimated the prevalence of urethritis among young men in the United States and compared correlates of idiopathic cases to correlates of detected infections with sexually transmitted pathogens. Questionnaire data and urine specimens from 5,447 men aged 18-27 years participating in Wave III of the National Longitudinal Study of Adolescent Health were analyzed. Symptomatic urethritis was defined as self-reported dysuria or urethral discharge in the past 24hours. Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, and Mycoplasma genitalium were identified using nucleic acid amplification tests. Idiopathic urethritis (IU) was defined as urethral symptoms in the absence of these four pathogens. Stratified weighted analyses generated population-based estimates. Urethritis was reported by 1.2% (95% CI=.8-1.6%) of men, of whom 82.4% (61.1-93.3%) had IU. Men with previous STD diagnoses (aOR=9.3 [95% CI=3.0-28.7]), or fewer (1-4) or no lifetime vaginal sex partners (aOR=7.5 [2.9-19.3] and aOR=7.2 [1.9-27.4]), were more likely to have IU compared with men without urethral symptoms or identified pathogens, whereas men of Native American or Asian/Pacific Islander descent (aOR=.04 [.01-.2]) and heavy drinkers (aOR=.08 [.03-.2]) were less likely to have IU. Unlike infection with known pathogens, IU was not associated with black race, Hispanic ethnicity, or age at sexual debut. Urethral symptoms were rarely associated with known pathogens. IU and known pathogens were associated with distinct characteristics.

Azithromycin treatment for nongonococcal urethritis negative for Chlamydia trachomatis, Mycoplasma genitalium, Mycoplasma hominis, Ureaplasma parvum, and Ureaplasma urealyticum

Some patients with nongonococcal urethritis (NGU) are negative for Chlamydia trachomatis, mycoplasmas, and ureaplasmas. The optimal antimicrobial chemotherapy for such NGU has not fully been clarified. We assessed the efficacy of azithromycin for treatment of nonmycoplasmal, nonureaplasmal, nonchlamydial NGU (NMNUNCNGU). Thirty-eight men whose first-pass urine was negative for Chlamydia trachomatis, Mycoplasma genitalium, Mycoplasma hominis, Ureaplasma parvum, and Ureaplasma urealyticum were treated with a single dose of 1 g azithromycin. Urethritis symptoms and polymorphonuclear leukocytes in urethral smears or in first-pass urine were assessed before and after treatment with azithromycin. Thirty-two (84.2%) of the 38 men with NMNUNCNGU showed no signs of urethral inflammation after treatment. The efficacy of this azithromycin regimen was comparable to that of the 7-day regimen of levofloxacin, gatifloxacin, minocycline, or clarithromycin reported previously. A single dose of 1 g azithromycin, which is effective not only for NGU due to specific pathogens but also for NMNUNCNGU, is an appropriate treatment for NGU.

The Significance of Chlamydia trachomatisin Urethritis and Prostatitis – Differences in Therapeutic Approach – Croatian Experience

We examined a total of 1014 patients over 18 years of age; 252 with urethritis and 762 with chronic prostatitis syndrome. The mean age of patients with urethritis was 32.7 and with prostatitis syndrome 37.6 years. Clinical symptoms of urethritis were present from a few days to several months. In patients with chronic prostatitis syndrome, symptoms were present for at least 3 months. Chlamydia trachomatis alone was confirmed in 26 (10%) and in combination with Ureaplasma urealyticum in 6 (2%) patients with urethritis. in 171 (68%) patients with urethritis neither C. trachomatis nor U. urealyticum or Mycoplasma hominis were found. C. trachomatis alone was confirmed in 70 (9%), and in combination with other microorganisms in 7 (1%) patients with chronic prostatitis syndrome. In Croatia, the frequency of chronic chlamydial prostatitis has not significantly changed in the last 10 years, while the frequency of infections among adolescents decreased. the recommended regimen for acute chlamydial urethritis in Croatia is azithromycin 1.0 g as a single dose, and a total dose of 4-4.5 g azithromycin for chronic chlamydial prostatitis.

Mycoplasma genitalium is associated with symptomatic and asymptomatic non-gonococcal urethritis in men

Objectives:To examine the prevalence of Mycoplasma genitalium in a large number of male patients attending a sexually transmitted infections (STI) clinic and to determine if there is an association with...

A comparative study of three different PCR assays for detection of Mycoplasma genitalium in urogenital specimens from men and women

The aim of this study was to compare conventional 16S rRNA gene PCR, real-time 16S rRNA gene PCR and real-time Mycoplasma genitalium adhesin protein (MgPa) gene PCR as detection methods for M. genitalium infection. The study also determined the prevalence of M. genitalium in male and female patients attending a sexually transmitted infections clinic in a rural area in the west of Sweden. First void urine (FVU) and/or urethral swabs were collected from 381 men, and FVU and/or cervical swabs and/or urethral swabs were collected from 298 women. A total of 213 specimens were used in the PCR comparative study: 98 consecutively sampled specimens from patients enrolled in the prevalence study, 36 consecutively sampled specimens from patients with symptoms of urethritis and 79 specimens from patients positive for M. genitalium by real-time MgPa gene PCR in the prevalence study. A true-positive M. genitalium DNA specimen was defined as either a specimen positive in any two PCR assays or a specimen whose PCR product was verified by DNA sequencing. The prevalence of M. genitalium infection in men and women was 27/381 (7.1 %) and 23/298 (7.7 %), respectively. In the PCR comparative study, M. genitalium DNA was detected in 61/76 (80.3 %) of true-positive specimens by conventional 16S rRNA gene PCR, in 52/76 (68.4 %) by real-time 16S rRNA gene PCR and in 74/76 (97.4 %) by real-time MgPa gene PCR. Real-time MgPa gene PCR thus had higher sensitivity compared with conventional 16S rRNA gene PCR and had considerably increased sensitivity compared with real-time 16S rRNA gene PCR for detection of M. genitalium DNA. Real-time MgPa gene PCR is well suited for the clinical diagnosis of M. genitalium.

The detection of urethritis pathogens among patients with the male urethritis syndrome, genital ulcer syndrome and HIV voluntary counselling and testing clients: should South Africa’s syndromic management approach be revised?

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...

Clinical efficacy of azithromycin for male nongonococcal urethritis

The aim of this study was to confirm the clinical efficacy of a single-dose azithromycin (AZM) regimen (1000 mg) for patients with nongonococcal urethritis in real-life practice. The study finally evaluated 55 patients, 42 who were symptomatic and 13 who were asymptomatic, after excluding 40 who visited clinics only once. Sixteen of the symptomatic patients were diagnosed as having nongonococcal chlamydial urethritis, 7 as having nongonococcal nonchlamydial urethritis, and 19 as having urethritis without any microbial detection. Chlamydia trachomatis was detected in 11 asymptomatic patients, Mycoplasma genitalium in 1, and Ureaplasma urealyticum in 1. Of the patients who were microbiologically evaluated before and after single-dose AZM, microbiological cure was achieved in 87% (20/23) of those with symptomatic nongonococcal urethritis and in 100% (13/13) of those with asymptomatic nongonococcal urethritis. The clinical cure rate was 86% for the 42 symptomatic patients with detectable and undetectable pathogens. There were adverse events in 5 (9%) patients but they were commonly mild and self-limited. In conclusion, the single-dose AZM regimen was well tolerated and eradicated the estimated and potential pathogens of nongonococcal urethritis.

Gonococcal Keratoconjunctivitis without Genitourinary Infection: An Uncommon Presentation in Adults

Gonococcal keratoconjunctivitis is a well known infection, usually in newborn babies from the developing countries, and it can develop in adults who are latent gonococcal carrier without symptomatic urethritis or endocervicitis. However, the keratoconjunctivitis produced by Neisseria gonorrhoeae is the less frequently reported clinical form of bacterial conjunctivitis. Keratoconjunctivitis of the right eye caused by beta-lactamase-producing Neisseria gonorrhoeae was diagnosed in a 48-year-old woman. Visual acuity of the eye was 6/12 before management. The patient was satisfactorily treated with intravenous ceftriaxone 1000 mg every 12 hours, 5% topical fortified ceftriaxone every 2 hours, and moxifloxacin eye drops every 2 hours to the right eye. At the week 20 follow-up, her right eye showed healing of the peripheral cornea without vascularization and VA of 6/6.

Study of partner-related and situational risk factors for symptomatic male urethritis

During the last decade, the incidence of male urethritis stopped declining in France. Risk factors associated with unprotected intercourse have been extensively studied in men who have sex with men, but not in men in general. The purpose of the study was to determine major risk factors for urethritis among men and to describe the sociodemographic and medical characteristics of this population in 2005. We conducted a prospective case-crossover study of sexual behaviors among men with acute urethritis attending at general practitioners or sexually transmitted infection (STI) clinics in France. Each patient filled out a selfcompleted questionnaire focusing on sociodemographic characteristics, and on sexual behaviors for the month before urethritis onset and for the preceding 3 months. The doctor reported medical information on a separate questionnaire. Between January and September 2005, 121 cases of male urethritis, defined as recent-onset pain on micturition and/or purulent or mucoid discharge, were included. Median age was 33 years, 22.3% were MSM, 55.1% were single, and 72.0% had at least high school education. Conditional logistic regression analysis showed that intercourse with only casual partners or with both casual and steady partners (OR = 2.6, CI 95%: 0.8-8.7, and OR = 8.7, CI 95%: 2.7-28.0), as well as inconsistent condom use (OR = 5.8, CI 95%: 1.7-19.2) significantly increased the risk of male urethritis. STI prevention campaigns should continue to focus on consistent condom use and should not neglect men over 30 years of age.

Quantitative Detection of Ureaplasma parvum (biovar 1) and Ureaplasma urealyticum (biovar 2) in Urine Specimens from Men With and Without Urethritis by Real-Time Polymerase Chain Reaction

We previously reported a significant association between Ureaplasma urealyticum (biovar 2) and nongonococcal urethritis (NGU). We also found that the presence of Ureaplasma parvum (biovar 1) in the male urethra might be the result of colonization. The objective of this study was to clarify the pathogenic role of human Ureaplasma in NGU by assessing the association of bacterial loads with clinical findings and inflammatory responses in the urethra. The 16S rRNA gene of Ureaplasma was quantified by a TaqMan-based real-time polymerase chain reaction assay in first-pass urine from 37 men with Ureaplasma-positive nonmycoplasmal nonchlamydial NGU (NMNCNGU) and 30 Ureaplasma-positive men without urethritis. U. urealyticum (biovar 2) loads in 23 men with NMNCNGU were significantly higher than those in 14 men without urethritis. However, U. parvum (biovar 1) loads did not differ significantly between 14 men with NMNCNGU and 20 men without urethritis. The association of increased U. urealyticum (biovar 2) loads with symptomatic urethritis suggests that U. urealyticum (biovar 2) may be a pathogen of NGU. Our results also suggest that the presence of U. parvum (biovar 1) may not be significant in the development of NGU.

Treatment of men with urethritis negative for Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, Mycoplasma hominis, Ureaplasma parvum and Ureaplasma urealyticum

Some patients with symptomatic non-gonococcal urethritis (NGU) are negative for Chlamydia trachomatis, mycoplasmas and ureaplasmas. The optimal antimicrobial chemotherapy for such NGU has not fully been elucidated, though many studies of antimicrobial chemotherapies for C. trachomatis-positive NGU have been performed. We assessed the efficacy of antimicrobial agents that are active against C. trachomatis on non-mycoplasmal, non-ureaplasmal and non-chlamydial NGU (NMNUNCNGU). One hundred men whose first-pass urine samples were negative for C. trachomatis, Mycoplasma genitalium, Mycoplasma hominis, Ureaplasma parvum, and Ureaplasma urealyticum were treated with levofloxacin, gatifloxacin, minocycline, or clarithromycin for 7 days. Urethritis symptoms and the presence of polymorphonuclear leukocytes (PMNL) in urethral smears were assessed before and after treatment. Eighty-eight (88.0%) of 100 men with NMNUNCNGU showed no signs of urethral inflammation after treatment, but two men complained of some symptoms of urethritis. Twelve (12.0%) of 100 men had significant numbers of PMNL in urethral smears, but five of these 12 men had no symptoms of urethritis. The efficacy for normalization of urethral smears was 90.7% for clarithromycin, 89.7% for levofloxacin, 87.5% for gatifloxacin, and 75.0% for minocycline. The 12 men who showed signs of urethral inflammation were retreated with levofloxacin, gatifloxacin, minocycline or clarithromycin for an additional 7 days. The 10 men who returned after the second treatment had negative urethral smears. Our present findings suggest that antimicrobial agents active against C. trachomatis are effective against NMNUNCNGU and that a 7-day treatment regimen with an appropriate antimicrobial agent may be sufficient to manage patients with NMNUNCNGU.

Bacteriological finding in the urethra in men with and without non-gonococcal urethritis

Non-gonococcal urethritis (NGU) is a very common sexually transmitted disease. The etiology of the disease is complex and not completely solved. The aim of this study was to determine the bacteriological finding in the urethra in men with and without non-gonococcal urethritis. The study group comprised 200 men with symptoms of urethritis. The control group consisted of 60 men without symptoms of urethritis. The diagnosis of nongonococcal infection was made by finding of an increased number of polymorphonuclear leukocytes (> or = 5) under the microscope in a sample of Gram-stain of urethral smear (x 1 000) and without evidence of Neisseria. gonorrhoeae in specimens (negative direct microscopy and cell culture). Bacteriological examination included: direct microscopy with the Gram-stained and methylblue-stained smears of urethral discharges, and cultivation of specimens under the aerobic/unaerobic conditions. In addition to standard bacterial examination and performinig direct imunofluorescence test to detect Chlamydia trachomatis (bioMerieux, France), urethral smears were also examined for the presence of Ureaplasma urealyticum and Mycoplasma hominis by commercially available Mycofast Evolution 2 test (International Microbio, France). The finding of mycoplasmas > or = 10(4) CCU/ml was positive. The data were statistically analyzed using Pearson chi2 and Student t test. C. trachomatis was predominant bacterial species found in urethra in men with nongonococcal urethritis. It was isolated alone and/or mixed with mycoplasmas and/or other bacteria in 86 (43.0%) of examinees. There was statistically significant difference in finding of C. trachomatis between the study group and the control group (p < 0.001). U. urealyticum was found in men with NGU: 30.2% were with C. trachomatis and 36.0% were without C. trachomatis (p > 0.05). In 16 (8.0%) men with NGU, C. trachomatis was isolated alone, while in 13.0% examinees it occurred with U. urealyticum. Staphylococcus saprophyticus was isolated in one subject with NGU, alone. Streptococcus agalactiae was found in 1.5% of men with urethritis. Anaerobic bacteria were found in 38 (19.0%) subjects with NGU and in 7 (11.7%) subjects from the control group. C. trachomatis was predominant bacterial species found in urethra in men with nongonococcal urthretitis. Mixed infections were frequent.

Failure to detect urethral Trichomonas vaginalis in Japanese men with or without urethritis

Trichomonas vaginalis may cause symptomatic or asymptomatic urethritis in men. There are few recent studies on the prevalence of T. vaginalis infection in Japanese men, and quantification of the number of cases of urethritis attributable to this pathogen has not been performed in Japan. The aim of this study was to determine the prevalence and morbidity of T. vaginalis infection in Japanese men. One hundred subjects with or without urethritis were examined for the presence of urethral T. vaginalis using culture swabs. Urethral swabs from all subjects were negative for T. vaginalis. These results indicate Japanese men, including those with urethritis, have a low incidence of urethral T. vaginalis infection or colonization. T. vaginalis appears to be an uncommon pathogen for male urethritis in Japan.

MP-14.01: Brachytherapy for prostate cancer: is pre-treatment prostate volume important?

Brachytherapy for prostate cancer is associated with temporary urethritis and lower urinary tract symptoms. There is concern that patients with large prostates may develop more troublesome symptoms. The aim of this study was to assess the influence of prostate volume upon post-operative lower urinary tract symptoms.

Mycoplasma genitalium is associated with symptomatic urethritis

In order to further investigate the epidemiology of Mycoplasma genitalium, 680 men attending departments of genitourinary medicine in Bristol, Bath and Truro were studied. M. genitalium was detected in 36 men (5.3%) and was present at all three clinics. Clinically, both urethritis and the presence of a urethral discharge and/or dysuria, but not penile irritation were independently associated with the detection of M. genitalium, the former being with the strongest association (odds ratio [OR] 10.76, 95% confidence interval [CI] [3.10-37.29], P < 0.0001; OR 3.01, 95% CI [1.28-7.05], P = 0.011 and OR 1.28, 95% CI [0.61-2.69], P = 0.51, respectively). In men with urethritis, those with a discharge and/or dysuria were more likely to have M. genitalium detected (OR 2.61, 95% CI [1.09-6.25], P = 0.032). We found no association with younger age or a recent change of sexual partner. In conclusion, M. genitalium is associated with symptomatic urethritis.