Urethritis overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]
Historical Perspective
The urithritis was first described by Albert Neisser, a german doctor in 1879.[1]
Classification
Based on etiology of urethritis, it is classified in to two main group, infectious and non-infectious. The non-infectious causes further divided to gonococcal and non-gonococcal.
Pathophysiology
Urethritis is a genital tract inflammation mostly due to infectious causes. Its pathogenesis depends on underlying pathogen.
- N. gonorrhoeae is usually transmitted via the genital tract to the human host
- Following attachment to host cell which is mediated by pili, gonococci become engulfed in a process known as parasite-directed endocytosis. This organism will survive inside the vacuoles and replicate.[2]
- Chlamydia trachomatis is the most common pathogen among non gonorrheal causes.
- Infectious process starts by cell surface attachment and phagocytosis by host cell. This pathogen survives inside the cell by debilitating the cellular lysosomes and replicate as elementary bodies (the infective form of pathogen).[3][4]
Causes
Urethritis may be caused by either infectious or non infectious causes. Infectious causes are divided to gonorrheal and non-gonorrheal.[5] Non-gonorrheal pathogens are the most common cause of urethritis, Chlamydia trachomatis on top of them.[6][5][7]
Differential Diagnosis of urethritis
Urethritis must be differentiated from other causes of dysuria and urethral discharge which include acute cystitis[8][9][10], epididymitis[11], prostatitis[12], cervicitis[13] and vulvovaginitis.[14]
Epidemiology
Chlamydia and gonorrhea are the most common reportable disease to the US Centers for Disease Control and Prevention (CDC). Worldwide, there are an estimated 78 million cases of gonorrheal and 131 million of chlamydia yearly.[15][16]
Incidence
- Chlamydia trachomatis is the most common reportable disease in the US; 1,441,789 chlamydial infections were reported to the CDC in 2014 which corresponds to a rate of 456.1 cases per 100,000 population.
- Gonorrhea: In 2014, a total of 350,062 gonorrhea cases were reported, and the national gonorrhea rate increased to 110.7 cases per 100,000 population in the US.[17]
Gender
- Chlamydia trachomatis: In 2014, the overall rate of chlamydial infection in the United States among women (627.2 cases per 100,000 females) based on reported cases was over two times the rate among men (278.4 cases per 100,000 males).[17]
- Gonorrhea: In 2014, in the United States incidence of gonorrhea was reported 120 cases per 100,000 males, while it was reported 100 cases per 100,000 female.
Age
- Chlamydia trachomatis: Almost two-thirds of chlamydia infections occur among youth aged 15-24 years.[18]
- Gonorrhea: The highest prevalence rates were found in ages 20 to 24 years both in men and women.
Race
- Chlamydia trachomatis: In 2014, the chlamydia rate in african-americans was 6 times the rate in caucasians, and the rate among American Indians/Alaska Natives was almost 4 times the rate among caucasians[19].
- Gonorrhea: In 2014, the rate of reported gonorrhea cases remained highest among african-americans (405.4 cases per 100,000 population). The rate among african-americanswas 10.6 times the rate among caucasians(38.3 cases per 100,000 population). The gonorrhea rate among American Indians/Alaska Natives (159.4 cases per 100,000 population) was 4.2 times that of caucasians.[19]
Risk Factors
The most important risk factor in developing urethritis is, unprotected sex especially among men who have sex with men. Other risk factors include:[20]
- 1- low socioeconomic status,
- 2- Prior or current STD,
- 3- New or multiple sex partners,
- 4- Circumcision[21].
Screening
According to the U.S. Preventive Service Task Force (USPSTF), all sexually active women aged under 25 and over 25 with increased risk should undergo screening. increased risk include[22]
- Prior history of sexually transmitted infection
- A new sex partner
- More than one sex partner
- A sex partner with concurrent partners
- A sex partner who has a sexually transmitted infection
Natural History
If left untreated it resolve within 3 months in 95% of people with gonococcal urethritis. The symptoms of nongonococcal urethritis generally abate within 3 months in 30% to 70% of untreated people.[23] Prolonged asymptomatic urethral carriage of gonococci occurs in 2% to 3% of newly infected men if left untreated.[24]
Complications
Common complications of urethritis include:
- 1- Acute epididymitis
- 2- Prostatitis
- It occurs In 20% to 30% of men with non-gonorrheal urethritis (NGU); however, it is usually asymptomatic and responds to standard treatments.[25]
- 3- Urethral stricture
- Gonorrhea may cause urethral stricture.
- 4- Oculogenital syndrome
- Consisting of conjunctivitis and non-gonorrheal urethritis (NGU) may be seen in approximately %4 of patients with urethritis.[26]
History
- A detailed history especially, about sexual activity must be taken. Specific areas of focus when obtaining a history from the patient include:[27]
- 1- Recent sexual activities
- 2- Number of sex partners or any new partner
- 3- Using condom
- 4- History of prior STDs
- 5- History of recent urethral instrumentation e.g. urethral catheters.
Symptoms
- Symptoms suggestive for urethritis include: dysuria and urethral discharge.
Physical Examination
- The most common physical finding in urethritis is, urethral discahrge. The entire genital area must be examined to rule out other possibilities.[28]
- Patients should be examined for inguinal lymphadenopathy, ulcers, or urethral discharge.
Laboratory Findings
- 1- Mucoid, mucopurulent, or purulent discharge on examination.
- 2- Gram stain of urethral secretions demonstrating ≥2 WBC per field
- 3- Positive leukocyte esterase test on first-void urine or microscopic examination of sediment from a spun first-void urine demonstrating ≥10 WBC per high power field.[32][33]
References
- ↑ Oriel JD (1996). "The history of non-gonococcal urethritis". Genitourin Med. 72 (5): 374–9. PMC 1195709. PMID 8976858.
- ↑ Scheuerpflug I, Rudel T, Ryll R, Pandit J, Meyer TF (1999). "Roles of PilC and PilE proteins in pilus-mediated adherence of Neisseria gonorrhoeae and Neisseria meningitidis to human erythrocytes and endothelial and epithelial cells". Infect. Immun. 67 (2): 834–43. PMC 96394. PMID 9916098.
- ↑ Beatty, Wandy L., Richard P. Morrison, and Gerald I. Byrne. "Persistent chlamydiae: from cell culture to a paradigm for chlamydial pathogenesis." Microbiological reviews 58.4 (1994): 686-699.
- ↑ Baron, Samuel. Medical microbiology. Galveston, Tex: University of Texas Medical Branch at Galveston, 1996. Print.
- ↑ 5.0 5.1 Al-Sweih NA, Khan S, Rotimi VO (2011). "The prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae infections among men with urethritis in Kuwait". J Infect Public Health. 4 (4): 175–9. doi:10.1016/j.jiph.2011.07.003. PMID 22000844.
- ↑ Kimberly A. Workowski & Gail A. Bolan (2015). "Sexually transmitted diseases treatment guidelines, 2015". MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 64 (RR-03): 1–137. PMID 26042815. Unknown parameter
|month=ignored (help) - ↑ Le Roux MC, Ramoncha MR, Adam A, Hoosen AA (2010). "Aetiological agents of urethritis in symptomatic South African men attending a family practice". Int J STD AIDS. 21 (7): 477–81. doi:10.1258/ijsa.2010.010066. PMID 20852197.
- ↑ Stephen Bent, Brahmajee K. Nallamothu, David L. Simel, Stephan D. Fihn & Sanjay Saint (2002). "Does this woman have an acute uncomplicated urinary tract infection?". JAMA. 287 (20): 2701–2710. PMID 12020306. Unknown parameter
|month=ignored (help) - ↑ W. E. Stamm (1981). "Etiology and management of the acute urethral syndrome". Sexually transmitted diseases. 8 (3): 235–238. PMID 7292216. Unknown parameter
|month=ignored (help) - ↑ W. E. Stamm, K. F. Wagner, R. Amsel, E. R. Alexander, M. Turck, G. W. Counts & K. K. Holmes (1980). "Causes of the acute urethral syndrome in women". The New England journal of medicine. 303 (8): 409–415. doi:10.1056/NEJM198008213030801. PMID 6993946. Unknown parameter
|month=ignored (help) - ↑ A. Stewart, S. S. Ubee & H. Davies (2011). "Epididymo-orchitis". BMJ (Clinical research ed.). 342: d1543. PMID 21490048.
- ↑ Felix Millan-Rodriguez, J. Palou, Anna Bujons-Tur, Mireia Musquera-Felip, Carlota Sevilla-Cecilia, Marc Serrallach-Orejas, Carlos Baez-Angles & Humberto Villavicencio-Mavrich (2006). "Acute bacterial prostatitis: two different sub-categories according to a previous manipulation of the lower urinary tract". World journal of urology. 24 (1): 45–50. doi:10.1007/s00345-005-0040-4. PMID 16437219. Unknown parameter
|month=ignored (help) - ↑ Kimberly A. Workowski & Gail A. Bolan (2015). "Sexually transmitted diseases treatment guidelines, 2015". MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 64 (RR-03): 1–137. PMID 26042815. Unknown parameter
|month=ignored (help) - ↑ Daniel V. Landers, Harold C. Wiesenfeld, R. Phillip Heine, Marijane A. Krohn & Sharon L. Hillier (2004). "Predictive value of the clinical diagnosis of lower genital tract infection in women". American journal of obstetrics and gynecology. 190 (4): 1004–1010. doi:10.1016/j.ajog.2004.02.015. PMID 15118630. Unknown parameter
|month=ignored (help) - ↑ WHO epidemiology http://www.who.int/mediacentre/factsheets/fs110/en/ (2016) Accessed on September 26, 2016
- ↑ Torrone E, Papp J, Weinstock H (2014). "Prevalence of Chlamydia trachomatis genital infection among persons aged 14-39 years--United States, 2007-2012". MMWR Morb. Mortal. Wkly. Rep. 63 (38): 834–8. PMID 25254560.
- ↑ 17.0 17.1 "National Overview - 2014 STD Surveillance".
- ↑ Chlamydia CDC Fact Sheet. CDC.http://www.cdc.gov/std/chlamydia/stdfact-chlamydia-detailed.htm#_ENREF_3. Accessed on September 28,2016
- ↑ 19.0 19.1 "Chlamydia - 2014 STD Surveillance".
- ↑ Chacko MR, Lovchik JC (1984). "Chlamydia trachomatis infection in sexually active adolescents: prevalence and risk factors". Pediatrics. 73 (6): 836–40. PMID 6547226.
- ↑ Van Howe RS (2007). "Genital ulcerative disease and sexually transmitted urethritis and circumcision: a meta-analysis". Int J STD AIDS. 18 (12): 799–809. doi:10.1258/095646207782717045. PMID 18073009.
- ↑ US preventive services task forces. Gonorrhea and chlamydia screening (2014) https://www.uspreventiveservicestaskforce.org/Page/Document/ClinicalSummaryFinal/chlamydia-and-gonorrhea-screening Accessed on September 28, 2016
- ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 9781455748013.
- ↑ Detels R, Green AM, Klausner JD, Katzenstein D, Gaydos C, Handsfield H, Pequegnat W, Mayer K, Hartwell TD, Quinn TC (2011). "The incidence and correlates of symptomatic and asymptomatic Chlamydia trachomatis and Neisseria gonorrhoeae infections in selected populations in five countries". Sex Transm Dis. 38 (6): 503–9. PMC 3408314. PMID 22256336.
- ↑ Holmes KK, Handsfield HH, Wang SP, Wentworth BB, Turck M, Anderson JB, Alexander ER (1975). "Etiology of nongonococcal urethritis". N. Engl. J. Med. 292 (23): 1199–205. doi:10.1056/NEJM197506052922301. PMID 165407.
- ↑ Rönnerstam R, Persson K (1982). "Chlamydial eye infection in adults". Scand J Infect Dis Suppl. 32: 111–5. PMID 6958007.
- ↑ "Information from your family doctor. Urethritis in men". Am Fam Physician. 81 (7): 879. 2010. PMID 20358658.
- ↑ Brill JR (2010). "Diagnosis and treatment of urethritis in men". Am Fam Physician. 81 (7): 873–8. PMID 20353145.
- ↑ Jacobs NF, Kraus SJ (1975). "Gonococcal and nongonococcal urethritis in men. Clinical and laboratory differentiation". Ann. Intern. Med. 82 (1): 7–12. PMID 67816.
- ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 9781455748013.
- ↑ Workowski KA, Bolan GA (2015). "Sexually transmitted diseases treatment guidelines, 2015". MMWR Recomm Rep. 64 (RR-03): 1–137. PMID 26042815.
- ↑ Horner PJ, Taylor-Robinson D (2007). "Is there a role for leucocyte esterase testing in non-invasive screening using nucleic acid amplification tests of asymptomatic men?". Int J STD AIDS. 18 (2): 73–4. doi:10.1258/095646207779949718. PMID 17331273.
- ↑ Chernesky M, Jang D, Chong S, Sellors J, Mahony J (2003). "Impact of urine collection order on the ability of assays to identify Chlamydia trachomatis infections in men". Sex Transm Dis. 30 (4): 345–7. PMID 12671557.