Abstract
Persistent or recurrent non-gonococcal urethritis has been reported to affect up to 10–20% of men attending sexual health clinics. An audit was undertaken to review the management of persistent or recurrent non-gonococcal urethritis in men presenting at Whittall Street Clinic, Birmingham, UK. Detection of Trichomonas vaginalis infection was with the newly-introduced nucleic acid amplification test. A total of 43 (8%) of 533 men treated for urethritis re-attended within three months with persistent or recurrent symptoms. Chlamydia trachomatis infection was identified in 13/40 (33%), T. vaginalis in 1/27 (4%) and Mycoplasma genitalium in 6/12 (50%). These findings suggest that the prevalence of T. vaginalis infection remains low in our clinic population and may not contribute significantly to persistent or recurrent non-gonococcal urethritis.
Introduction
Urethritis is characterised by discharge and/or dysuria, but may be asymptomatic. The diagnosis is confirmed by the presence of polymorphonuclear leucocytes (PMNLs) on urethral smear, and Chlamydia trachomatis (CT), Mycoplasma genitalium (MG) and Trichomonas vaginalis (TV) are the most commonly recognised pathogens contributing to non-gonococcal urethritis (NGU).
Empirical treatment for NGU is currently directed primarily at Chlamydia. Studies on the prevalence of TV infection have been hampered by the relatively poor sensitivity of wet mount microscopy or culture. Nucleic acid amplification tests (NAAT) may provide more accurate data on the significance of TV infection in recurrent or persistent urethritis.
An audit was undertaken in patients with persistent or recurrent symptoms of urethritis attending the Whittall Street Clinic, Birmingham, UK. Standards for the audit were identified from the local departmental protocol and the British Association of Sexual Health and HIV Medicine national guidelines on the management of NGU. 1 These were: assessing patients for risk of reinfection, screening for TV infection and prescribing treatment with azithromycin and metronidazole.
Method
Symptomatic men presenting between January and May 2013 with evidence of PMNLs on microscopy of a stained smear from the urethra and receiving treatment with either azithromycin or doxycycline were identified as having had a diagnosis of urethritis. From this group, men presenting with symptoms of urethritis between 30 and 90 days following treatment of acute NGU, were identified using case note review.
Detection of CT, TV and MG was performed using Gen-Probe APTIMA assays and MG by MgPa (in-house PCR at Public Health England, Colindale). Clinical and demographic information were gathered from the electronic patient record.
Results
From January to May 2013, a total of 533 symptomatic men were screened and treated for urethritis; 43 (8%) of those treated for acute NGU reattended with persistent or recurrent symptoms and did not have evidence of gonorrhoea infection.
Characteristics of patients with persistent or recurrent NGU.
NGU, non-gonococcal urethritis; PMNLs, polymorphonuclear leucocytes;
Persistent symptoms – no resolution of symptoms following treatment for acute NGU.
Recurrent symptoms – symptomatic following resolution of symptoms after treatment for acute NGU.
Regular partner did not receive concurrent treatment or sexual contact with new partner.
A total of 33 (77%) men had urethral discharge visible on examination; 27 (60%) were screened for TV, 12 (27%) for MG, 40 (93%) for gonorrhoea and CT. A total of 37 men had a urethral smear taken for microscopy, of whom 23 (62%) had > 5 PMNLs/high power field. CT infection was identified in 13/40 (33%), TV in 1/27 (4%) and MG in 6/12 (50%).
Twelve (28%) men were treated with a prolonged course of azithromycin and metronidazole as recommended by the BASHH national guidelines as empirical treatment for both MG and TV; 16 (37%) were treated with azithromycin, 7 (16%) doxycycline and eight (18%) did not receive any treatment.
Discussion
Recurrent or persistent urethritis has been reported in 10–20% of patients treated for NGU. 1 Our audit shows similar results, with 8% of men treated for acute NGU re-attending with symptoms of urethritis.
CT was the commonest causative pathogen and was isolated in 13/40 (33%) men. Twelve of these men had CT infection on their initial visit and had been treated with azithromycin; 2/13 gave a history of possible reinfection.
TV infection has been identified in up to 20% of men presenting with NGU attending sexual health clinics in America, where it has been reported to have a similar prevalence rate to Chlamydia,3,4 but in our audit, TV infection was detected in only one individual with recurrent or persistent urethritis. Although the number of cases reviewed in this audit is relatively small and only two-thirds of individuals were screened for TV infection, it is likely that the prevalence of TV infection in men with recurrent or persistent symptoms of urethritis is low in our clinic population, despite recommendations in the UK National guideline to give empirical antibiotic treatment to cover both MG and TV in this group of patients. 1
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.