Non-Gonococcal Urethritis

Question 1

What are the two top causes of NGU?

Answer 1

Chlamydia trachomatis

Mycoplasma genitalium

Question 2

Name 4 other causes of NGU other than Chlamydia and Mycoplasma genitalium and its prevalence

Answer 2

Ureaplasmas
Trichomonas vaginalis
Adenoviruses
Herpes simplex virus

Question 3

What is the prevalence of Chlamydia among patients with NGU?

Answer 3

11-50%

Question 4

What is the prevalence of Mycoplasma genitalium among people with NGU?

Answer 4

6-50%

Question 5

In what percentage of cases of NGU is Chlamydia and Mycoplasma genitalium NOT detected?

Answer 5

30-80%

Question 6

What factors increase the likelihood of pathogen-negative NGU

Answer 6

Increased age
Absence of urethral discharge
Absence of symptoms

Question 7

Which species of Ureaplasma is pathogenic in men?

Answer 7

Ureaplasma urealyticum

Question 8

What are the symptoms of NGU?

Answer 8

Urethral discharge
Dysuria
Penile irritation
Urethral discomfort
None (asymptomatic)

Question 9

What signs would you expect in a patient presenting with NGU?

Answer 9

Urethral discharge
Balano-posthitis
None (normal examination)

Question 10

Name two complications of NGU

Answer 10

Epididymo-orchitis

Sexually-acquire reactive arthritis (SARA)

Question 11

How do you confirm the diagnosis of urethritis?

Answer 11

≥ 5 PMNLs per HPF (averaged over 5 fields with the greatest concentration of PMNLs) on anterior urethral smear

Question 12

Which patients should be assessed for the presence of urethritis?

Answer 12

Symptomatic patients
Visible discharge
Presence of balano-posthitis

Question 13

How do you collect a urethral smear?

Answer 13

Use either:

• A 5mm plastic loop
• Cotton tipped swab

Introduced 1cm into urethra

Question 14

Rank the following swabs from least painful (1) to most painful (3) in terms of sample collection for urethral smear:

Dacron swab
5mm plastic loop
Rayon swab

Answer 14

1. 5mm plastic loop
2. Dacron swab
3. Rayon swab

Question 15

Name two alternative ways urethritis can be diagnosed other than taking a urethral smear

Answer 15

1. Gram-stain preparation from 10-20mL of a centrifuged sample of FPU specimen - contains ≥ 10 PMNLs per HPF
2. Examine FPU for threads - if present, Gram-stain and interpret as for a spun deposit ( ≥10 PMNLs per HPF

Question 16

How can a diagnosis of NGU be made in the context of a negative urethral smear?

Answer 16

FPU dipstick with ≥ 1 leukocytes

Question 17

What is the first line management of patients diagnosed with NGU? (assuming no allergies)

Answer 17

Doxycycline 100mg BD, PO for 7 days

Question 18

James comes to your clinic with symptoms of urethral discharge and dysuria. Urethral smear shows > 5 PMNL per high powered field. He tells you when he was treated for chlamydia two years ago he kept being sick and was unable to complete the course.

What are two treatment options?
Which option would you choose for James?

Answer 18

options are

a) azithromycin 1g stat, followed by 500mg OD for 2 days
b) ofloxacin 200mg BD or 400mg OD for 7 days

I would choose option a initially and advise to avoid sex for 14 days from start of Rx

Question 19

James was treated for NGU with a 3 day course of azithromycin (1g stat, 500mg OD for 2 days as per BASHH guidance). How long would you advice him to abstain from sex? And what advice would you give re PN?

Answer 19

when treating with azithromycin advice them to abstain for 14 days (compared to if Rx with doxycycline advice just 7 days), always advice to abstain until symptoms resolved.

current regular partners should be offered routine STI screen and treated empirically with doxycycline 100mg BD for 7 days.

Question 20

What is the rationale for patients treated with azithromycin abstaining from sex for 14 days compared to patients treated with doxycycline abstaining for 7 days?

Answer 20

This is likely to reduce the risk of selecting/inducing macrolide resistance if exposed to Mgen or Neisseria gonorrhoeae which would make these infections more difficult to treat

Question 21

James was treated for NGU with a three day course of azithromycin as he informed us that doxycycline made him feel very sick and previously struggled to take it. His results have come back positive for MGen how would you treat?

Answer 21

OPTIONS:

a) counsel about doxycycline enquire if he took it with food and risks of gastritis - could see if he is willing to take it - then it would be doxycycline 100mg BD 7 days + azithromycin 1g stat, 500mg OD for 2 days
b) Moxifloaxcin 400mg OD for 7 days

Question 22

Michael was treated for NGU 1 month ago with doxycycline 100mg BD for 7 days. He has not had sex since the treatment and returned to clinic as he feels his symptoms of urethral discharge and discomfort have not really improved. RFP was treated empirically.

He is heterosexual, cis gender male. He has held his urine for > 2 hours.
his previous tests came back negative for CT/GC and MGen.

Urethral smear today confirms of the diagnosis of NGU.

How would you treat today? and are there any other tests you should consider offering at this stage?

Answer 22

Azithromycin 1g stat, 500mg OD for 2 days followed by metronidazole 400mg BD for 5 days

Consider testing for TV

Advise no sex for 14 days and until symptoms have resolved

Question 23

If azithromycin has been used first line in treatment of NGU and a patient comes back with persistence symptoms confirmed by urethral smear (assuming MGen was also negative) what are the treatment options for persistent/ recurrent NGU?

Answer 23

1) preferred regime: Moxifloaxcin 400mg OD for 10 days followed by metronidazole 400mg BD for 5 days

or alternative

2) Doxycycline 100mg BD for 7 days followed by metronidazole 400mg BD for 5 days

Question 24

what is the definition of recurrent NGU and how should it be managed if the patient was initially treated with doxycycline for NGU

Answer 24

Recurrent NGU is defined as re-occuring symptoms of NGU within 30-90 days following original treatment
if initially treated with doxycycline 100mg bd 7 days then the preferred regime now would be:

moxifloxacin 400mg OD 10 days with metronidazole 400mg BD for 5 days

ensuring treatment covers for TV, mgen and bv