Non-gonococcal urethritis (NGU)

Commonly referred to as NSU: non-specific urethritis.

Organism: This is not usually identified, but up to 30% of cases may be due to Chlamydia trachomatis (see below). Mycoplasma genitalis and Ureaplasma urealyticum may be implicated in some of the Chlamydia negative patients. Trichomonas vaginalis may also be rarely implicated and consideration may need to be given to intraurethral herpes simplex and syphilis. However, no infective agent is found in the majority of cases.

Indications: Urethral discharge or dysuria may also be asymptomatic.

Laboratory tests: A urethral smear is taken and examined microscopically in the Genito-urinary Medicine clinic to identify the presence of pus cells. Swabs are sent to the laboratory for culture for gonorrhoea and chlamydia. The urine may be examined for evidence of infection such as threads of pus.

It is important that male patients attending Genito-urinary Medicine clinics do not pass urine for 4 hours prior to the examination, or the exudate may be washed away, making diagnosis difficult.

Treatment: Broad-spectrum tetracycline or macrolide based antibiotics are usually prescribed for non-gonococcal urethritis, but if a specific infection is diagnosed on culture further treatment may be required. The patient is advised not to have sexual intercourse.

Notijy partner. People with non-gonococcal urethritis should consult a health adviser or nurse specialist for information about safer sex practices. Sexual contacts are treated, if results of swabs indicate this is necessary.

Complications: Occasionally men develop a chronic and persistent urethritis or prostatitis.

Chlamydia

Organism: Chlamydia trachomatis, intracellular bacteria.

Indications: Up to 70% of women and 30% of men have no signs and symptoms. If present, symptoms appear 7-21 days after infection and may be vague, e.g. slight vaginal discharge or discomfort in women and dysuria and urethral discharge in men. Women with untreated infections may develop pelvic inflammatory disease and experience lower abdominal pain with uterine tenderness, dysuria, dyspareunia, bleeding between periods and after sexual intercourse, heavy or irregular periods, mucopurulent cervicitis, vaginal discharge. Infections affecting the rectum or throat are usually symp-tomless.

Laboratory tests: Women require endocervical and urethral swabs; a high vaginal swab is not appropriate. Care should be taken not to contaminate the swab on the vaginal wall. The local laboratory should be consulted regarding the use of transport media as this may vary. A first voided urine test may be used. Men should provide a first voided urine specimen at the clinic after holding urine for 4 hours. A urethral swab from 5 — 6cms into the distal urethra may be required. People who receive anal sex will need to provide a rectal swab.

Treatment: Broad-spectrum tetracycline or macrolide based antibiotic. In pregnancy and in lactation, erythromycin. There are now single-dose treatments available. The patient is advised not to have sexual intercourse.

Notijy partner: This is undertaken because of the possible severe sequelae of untreated infection in women, and the likelihood of reinfection if the partner is not notified and treated.

Complications: In women, chronic abdominal pain, pelvic inflammatory disease with increased risk of ectopic pregnancy and infertility. There may be transmission to the neonate if infection is present at time of delivery, causing eye and chest infections. Reiter’s syndrome (rare in women).

In men, complications include epididymitis, Reiter’s syndrome (reactive arthritis and conjunctivitis with urethral discharge). Chlamydia trachomatis can infect the rectum, conjunctiva and throat.

Gonorrhoea

Organism: Neisseria gonorrhoea, which infects the site of columnar epithelium especially in genital tract.

Indications: In men, these appear 2 — 14 days after infection. 90% of infected men have symptoms of dysuria, yellow or green urethral discharge. The rectum or throat may also be infected, when there may be few indications.

In women the infection affects the cervix and urethra, producing a profuse watery discharge, low abdominal pain and dysuria. Many women are asymptomatic. Women may develop gonorrhoea of the throat or rectum, but this is less common.

Laboratory tests: In men and women the infection may be diagnosed in the Genito-urinary Medicine clinic by microscopic examination of a Gram-stained smear of the discharge. In women, an endocervical, urethral smear is taken and examined as above. Microscopic examination alone is not sufficient to exclude gonorrhoea. Swabs required are: endocervical, urethral, throat and rectal for women and urethral and throat, plus rectal swab if recieving anal sex for men.

Treatment: Penicillin is the drug of choice, but care must be used in history-taking as penicillin-resistant strains are common in some parts of the world and would require alternative treatments (guidance on current treatment is available from microbiologists). Treatment is given as a stat dose in the clinic and the patient is followed up for two consecutive weeks to ensure treatment has been effective. The patient is advised not to have sexual intercourse.

Notify partner: This is undertaken under the NHS VD Regulations (1974). Because many people with gonorrhea have symptoms, the government has been able to use the reports of numbers of cases as an indicator of unsafe sexual activities.

Complications: In men, epididymo-orchitis and in women salpingitis, damage to fallopian tubes. Two rare complications are perihepatitis, and disseminated gonococcal infection. If present at delivery the eyes of the neonate may be infected.

Syphilis

Organism: Treponema pattidum.

Indications:

Primary stage

Appears 9-90 days after infection. A painless, usually single, ulcer at site of inoculation develops, called a primary chancre, which may exude serous fluid. In men, chancre is usually on the shaft of the penis or glans penis, in women it appears on the vulva, cervix or vaginal walls. It may also appear on the anus, rectum or anywhere on body where inoculation occurred. Chancre can heal spontaneously within 2 — 3 weeks if untreated or may last into the secondary stage of disease and may even be unnoticed if not present on the genitals.

Secondary stage

This occurs 3 — 20 weeks after infection and the primary chancre may occasionally still be present. It is a generalized illness, consisting of headaches, malaise, sore throat, maculo-papular rash and mucosal ulceration, which will clear without treatment.

Latent stage

This occurs when the secondary systemic signs and symptoms have healed. Syphilis can then only be detected by serological tests.

Laboratory tests: If the affected person presents at a Genito-urinary Medicine clinic during the primary stage exudate from the chancre can be examined by darkground microscopy, to visualize the spirochaetes characteristic of syphilis. In the early stages this may be the only way to establish diagnosis because serological tests may be negative. Serological tests undertaken are VDRL (venereal diseases research laboratory test), TPHA (Treponema pallidum haemagglutination test). If any of the initial screening tests offered to pregnant women and people attending GU clinics prove positive, further tests, e.g. FTA (fluorescent treponemal antibody test) and ELISA test is undertaken. Other infections may give false positive results and guidance should be sought from a GU medicine consultant and microbiologist. Serological tests undertaken will be decided by local laboratory in conjunction with the Genito-urinary Medicine clinic and may vary in different parts of U.K.

Treatment: Penicillin is the drug of choice, given intra-muscularly Tetracyclines or erythromycin may be used if the patient is sensitive to penicillin. Syphilis can be treated at any stage. Some of the serology tests always remain positive after treatment.

Notify partner: Syphilis is covered by NHS VD Regulations (1974), so contact tracing of all partners is undertaken by the health adviser working with the patient. In women this may include children, because syphilis can cross the placental barrier in pregnancy and a mother may also infect a child after the disease has ceased to be sexually transmissible. The disease is no longer sexually transmissible approximately 2 years after the initial infection.

Complications: There may an allergic reaction to penicillin.

At the secondary stage there may be involvement of the liver, kidneys or meninges (all rare). If untreated, syphilis may progress to a tertiary stage with neurological symptoms such as dementia, or GPI (generalized paralysis of the insane). These are extremely rare, however. There may also be cardiovascular involvement such as aortitis, or aortic aneurism. Damage to the cardiovascular and neurological systems will not be reversed by treatment. Many people with untreated syphilis develop no related health problems.

Chancroid

Organism: Haemophilus ducreyi.

Indications: Appear within 3-7 days. An inflamed papule develops at the site of entry of the organism, which erupts within 2 — 4 days forming a well-defined ulcer. Ulcers are often multiple and painless. The formation of abscess in inguinal lymph glands may occur. A Genito-urinary Medicine clinic referral is recommended for everyone with genital ulceration.

Laboratory tests: Swab from the ulcer is sent for culture.

Treatment. Antibiotic therapy is given after sensitivity has been determined by the laboratory as drug-resistant strains may be a problem.

Notify partner: This should be undertaken under NHS VD Regulations (1974). However, chancroid is extremely rare in the U.K.

Trichomoniasis: A protozoal infection

Organism: Trichomonas vaginalis.

Indications: In women there will be a vaginal discharge which may smell offensive, soreness around vulva, dysuria, dyspareunia. In men, occasionally urethritis or dysuria. This infection may be asymptomatic, especially in men.

Laboratory tests: The live organism can usually be seen by microscopy in the Genito-urinary Medicine clinic, but may be difficult to isolate in males. Tests for other sexually transmissible conditions should be undertaken.

Treatment: Metronidazole, which in pregnancy should be used with caution.

Notify partner: Regular sexual partners are offered examination and treatment.

Complications: If present in pregnancy the infection may be associated with premature labour, and neonatal infections.

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