Non-Gonococcal Urethritis Flashcards
What are the two top causes of NGU?
Chlamydia trachomatis
Mycoplasma genitalium
Name 4 other causes of NGU other than Chlamydia and Mycoplasma genitalium and its prevalence
Ureaplasmas
Trichomonas vaginalis
Adenoviruses
Herpes simplex virus
What is the prevalence of Chlamydia among patients with NGU?
11-50%
What is the prevalence of Mycoplasma genitalium among people with NGU?
6-50%
In what percentage of cases of NGU is Chlamydia and Mycoplasma genitalium NOT detected?
30-80%
What factors increase the likelihood of pathogen-negative NGU
Increased age
Absence of urethral discharge
Absence of symptoms
Which species of Ureaplasma is pathogenic in men?
Ureaplasma urealyticum
What are the symptoms of NGU?
Urethral discharge Dysuria Penile irritation Urethral discomfort None (asymptomatic)
What signs would you expect in a patient presenting with NGU?
Urethral discharge
Balano-posthitis
None (normal examination)
Name two complications of NGU
Epididymo-orchitis
Sexually-acquire reactive arthritis (SARA)
How do you confirm the diagnosis of urethritis?
≥ 5 PMNLs per HPF (averaged over 5 fields with the greatest concentration of PMNLs) on anterior urethral smear
Which patients should be assessed for the presence of urethritis?
Symptomatic patients
Visible discharge
Presence of balano-posthitis
How do you collect a urethral smear?
Use either:
- A 5mm plastic loop
- Cotton tipped swab
Introduced 1cm into urethra
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
- 5mm plastic loop
- Dacron swab
- Rayon swab
Name two alternative ways urethritis can be diagnosed other than taking a urethral smear
- Gram-stain preparation from 10-20mL of a centrifuged sample of FPU specimen - contains ≥ 10 PMNLs per HPF
- Examine FPU for threads - if present, Gram-stain and interpret as for a spun deposit ( ≥10 PMNLs per HPF
How can a diagnosis of NGU be made in the context of a negative urethral smear?
FPU dipstick with ≥ 1 leukocytes
What is the first line management of patients diagnosed with NGU? (assuming no allergies)
Doxycycline 100mg BD, PO for 7 days
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?
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
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?
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.
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?
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
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?
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
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?
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
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?
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
what is the definition of recurrent NGU and how should it be managed if the patient was initially treated with doxycycline for NGU
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
