Chapter 124. Sexually Transmitted Infections: Overview and Clinical Approach (Part 5) pot

Mycoplasma genitalium Ureaplasma urealyticum Trichomonas vaginalis Herpes simplex virus complications Urethral Gram's stain to confirm urethritis, detect gram-negative diplococci Test

Chapter 124 Sexually Transmitted Infections:

Overview and Clinical Approach

(Part 5)

1 Treat urethritis promptly, while test results are pending

Table 124-4 summarizes the steps in management of sexually active men with urethral discharge and/or dysuria

Table 124-4 Management of Urethral Discharge in Men

Usual causes

Chlamydia trachomatis

Neisseria gonorrhoeae

Usual initial evaluation

Demonstration of urethral discharge or pyuria

Exclusion of local or systemic

Mycoplasma genitalium

Ureaplasma

urealyticum

Trichomonas vaginalis

Herpes simplex virus

complications

Urethral Gram's stain to confirm urethritis, detect gram-negative diplococci

Test for N gonorrhoeae, C trachomatis

Initial Treatment for Patient and Partners

Treat gonorrhea

(unless excluded):

plus Treat chlamydial infection:

Ceftriaxone, 125 mg

IM; or

Azithromycin, 1 g PO; or

Cefpodoxime, 400 mg

PO; or

Doxycycline, 100 mg bid for

7 days

POa

Management of Recurrence

Confirm objective evidence of urethritis If patient was reexposed to untreated or new partner, repeat treatment of patient and partner

If patient was not reexposed, consider infection with T vaginalis b or

doxycycline-resistant M genitalium or Ureaplasma, and consider treatment with

metronidazole, azithromycin, or both

a

Updates on the availability of cefixime can be obtained from the Centers for Disease Control and Prevention or state health departments

b

In men, the diagnosis of T vaginalis infection requires culture (or nucleic

acid amplification test, where available) of early-morning first-voided urine sediment or of a urethral swab specimen obtained before voiding

Urethritis in Men: Treatment

In practice, if Gram's stain does not reveal gonococci, urethritis is treated with a regimen effective for NGU, such as azithromycin (1.0 g PO in a single dose) or doxycycline (100 mg PO bid for 7 days) Both are effective, although

azithromycin may give better results in M genitalium infection If gonococci are

demonstrated by Gram's stain or if no diagnostic tests are performed to exclude gonorrhea definitively, treatment should include a single-dose regimen for

gonorrhea (Chap 137) plus azithromycin or doxycycline treatment for C trachomatis, which frequently occurs as a urethral co-infection in men with

gonococcal urethritis Sexual partners should be tested for gonorrhea and chlamydial infection and should receive the same regimen given to the male index case Patients with confirmed persistence or recurrence of urethritis after treatment should be re-treated with the initial regimen if they did not comply with the original treatment or were reexposed to an untreated partner Otherwise, an

intraurethral swab specimen and a first-voided urine sample should be tested for T vaginalis (currently best done by culture, although NAATs appear to be more

sensitive and are likely to become commercially available in the future) If compliance with initial treatment is confirmed and reexposure excluded, the recommended treatment is with metronidazole or tinidazole (2 g PO in a single dose) plus azithromycin (1 g PO in a single dose); the azithromycin component is especially important if this drug has not been given during initial therapy