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  • • Requires objective signs of urethral inflammation.

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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.

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Persistent Urethritis

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  • • No standard definition; has been defined as urethritis that fails to resolve or substantially improve within 1 week of initiating therapy.

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Recurrent Urethritis

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  • • No standard definition; has been defined as the return of urethritis within 6 weeks following an initial response to therapy.

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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.

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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.

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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.

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Infectious Causes

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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 genital mycoplasmas (eg, U ...

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