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- • Requires objective signs of urethral inflammation.
+++
Nongonococcal Urethritis
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- • Absence of gram-negative intracellular diplococci
on Gram stain.
- • Mucopurulent or purulent discharge, Gram stain
of urethral secretions indicating ≥5 white blood cells (WBCs) per
high-power field (HPF), positive leukocyte esterase test, or ≥10
WBCs per HPF on spun urine sediment.
+++
Persistent Urethritis
++
- • No standard definition; has been defined as
urethritis that fails to resolve or substantially improve within
1 week of initiating therapy.
++
- • No standard definition; has been defined as
the return of urethritis within 6 weeks following an initial response
to therapy.
++
An estimated two million cases of nongonococcal urethritis (NGU)
occur in the United States each year. Approximately 30–50% of
these cases are caused by Chlamydia trachomatis, although
in some studies the proportion caused by chlamydia is lower. Many
etiologies have been proposed for the remaining cases of NGU, but
the most consistent associations have been found with Mycoplasma genitalium, Ureaplasma urealyticum, herpes
simplex virus (HSV), and Trichomonas vaginalis. Even
with extensive evaluations, in 25–30% of cases
of NGU, no microbiologic cause can be identified. The association
between Ureaplasma and NGU has not
been clearly established and remains controversial; however, it
has been suggested that serovars 2, 5, 8, and 9 of U urealyticum are associated with NGU
whereas other serovars are not.
++
Following treatment for chlamydial urethritis, 10–20% of
patients have persistent or recurrent urethritis. However, in nonchlamydial
NGU, failure rates in excess of 50% often are reported. When
a patient returns with symptoms consistent with urethritis following
treatment for NGU, urethritis must be objectively documented. Furthermore,
it is important to confirm adherence with previous therapy and to
assess the possibility the patient has been reinfected by a new
or untreated sex partner.
++
There are no widely accepted definitions for persistent or recurrent
NGU (PRNGU), and none are provided in the 2006 treatment guidelines
for sexually transmitted diseases provided by the Centers for Disease
Control and Prevention. For the purposes of this chapter, we define persistent urethritis as urethritis
that has not substantially improved within 1 week of initiating
therapy for NGU. This definition was chosen because the majority
of cases of NGU respond to therapy within this time. Recurrent urethritis is defined as
urethritis occurring within 6 weeks of a previous episode of NGU.
Some men have persistent or recurrent episodes of nonchlamydial
NGU over a long period of time. However, the longer the duration
between episodes of urethritis in a sexually active man, the greater
is the likelihood that reinfection is the cause.
++
The causes of PRNGU are poorly understood. After reinfection
and poor adherence to treatment have been ruled out, the clinician
should consider other infectious causes. Possible infectious causes
of PRNGU include ...