Nongonococcal Urethritis - An Overview

Introduction

The urethra is a tube through which urine leaves the body. Inflammation of the urethra is called urethritis. When the cause of urethritis is a sexually transmitted infection other than gonorrhea, it is termed nongonococcal urethritis. Nongonococcal urethritis is also called non-specific urethritis when the cause is not known. Nongonococcal urethritis is more common in men than women.

What Is Nongonococcal Urethritis?

Inflammation of the tube urethra that carries urine outside the body is called the urethra. When sexually transmitted infections other than gonorrhea cause urethritis, it is called nongonococcal urethritis. The infection is transmitted through unprotected sexual intercourse.

What Are the Causes of Nongonococcal Urethritis?

The causes are divided into two categories:

• Sexual Causes: Sexually transmitted infections are the leading cause of nongonococcal urethritis. The bacteria called Chlamydia trachomatis is one of the causative agents. Around 15 % to 40 % of nongonococcal urethritis cases are caused by Chlamydia trachomatis. Mycoplasma genitalium is the second most common, accounting for 15 % to 20 % of the nongonococcal urethritis cases. Lesser common causes include Herpes simplex virus, Epstein Barr virus, Trichomonas vaginalis, and Adenovirus. Enteric bacteria rarely cause nongonococcal urethritis in individuals who practice insertive anal intercourse. In 50 % of the nongonococcal urethritis cases, the etiology is unknown.

• Nonsexual Causes: The nonsexual causes are:

Phimosis is a condition that affects both adults and children who have not undergone circumcision. It involves the foreskin on the head or glans of the penis and can not be retracted or pulled back. The penis appears to have rings on its tip. Phimosis is usually asymptomatic and only presents symptoms in severe cases with an opening the size of a pinhole. Phimosis can be divided into two groups:

Physiologic: This type is associated with children and resolves with age.

Pathologic Type: This is associated with the condition balanitis xerotica obliterans (scarred and inflamed head of the penis).

Catheterization is one of the non-sexual causes. In this procedure, a tube is inserted into the penis.

Who Are the Population at Risk for Nongonococcal Urethritis?

Men are more prone to acquiring nongonococcal urethritis than women because of the anatomical consideration of the male urethra. The centers for disease control and prevention have stated that rates of chlamydia infection are two times higher in females than males. Adolescents and young adults from fifteen to thirty years of age are commonly affected. Having multiple sexual partners is also prone to acquiring nongonococcal urethritis.

What Are the Symptoms of Nongonococcal Urethritis?

The symptoms involve:

• Pruritus (uncomfortable, irritating sensation causing an urge to itch).

• Dysuria (difficult or painful urination).

• Penile burning (burning sensation in the penis).

• Urethral Discharge: Discharges may be noted in scant or stains in the undergarment.

Around 40 % of the cases of nongonococcal urethritis are asymptomatic. Symptoms caused by herpes simplex virus nongonococcal urethritis are:

• Regional lymphadenopathy.

• Constitutional symptoms (headache, fever, anorexia, and myalgia).

• Vesicles having urethritis.

Penile discharges of nongonococcal urethritis appear clear or mucoid, whereas gonococcal urethritis has purulent discharge. Symptoms of severe cases include:

• Testicular pain.

• Testicular swelling.

• Infertility.

• Sore throat.

• Rectal pain.

• Rectal discharge.

What Are the Complications of Nongonococcal Urethritis?

Complications involve:

• Epiphydimitis (inflammation of the rope-like structure near the testicles).

• Abscess formation.

• Prostatitis (inflammation of the prostate gland).

• Reactive arthritis (swelling and joint pain caused by infections in other parts of the body).

• Skin lesions.

• Lymphogranuloma venerum.

Complications are more common in women than men. Complications in women involve:

• Vaginitis caused due to yeast infection.

• Mucopurulent cervicitis (cervix infection) causes unusual bleeding during periods, vaginal discharge, and pain during sexual intercourse.

If left untreated, nongonococcal urethritis will cause infertility and pelvic inflammatory disease.

Children born to mothers infected with chlamydia urethritis have the following symptoms:

• Iritis.

• Pneumonia.

• Conjunctivitis.

How to Evaluate Nongonococcal Urethritis?

Nongonococcal urethritis is diagnosed based on its discharges:

• Mucopurulent, purulent, or mucoid discharges.

• Urethral secretions in gram staining depict equally to two white blood cells per oil immersion field.

• Urine analysis that shows a positive leukocyte esterase test or ten white blood cells per high power field examined from the sediments of spun first void urine.

To diagnose nongonococcal urethritis, gonococcal urethritis should be first ruled out. This can be done by negative gonorrhea tests such as culture and nucleic acid testing. It can also be ruled out by gram stain, which lacks gram-negative diplococci. A nucleic acid amplification test (NAAT) can be performed for gonorrhea, chlamydia, and trichomoniasis. The nucleic acid amplification test has a high rate of specificity and sensitivity and hence should be recommended over culture tests.

What Is the Treatment for Nongonococcal Urethritis?

Empiric treatment for nongonococcal urethritis is started at diagnosis.

Regimen for Presumptive Treatment for Nongonococcal Urethritis:

1. Single-dose oral Azithromycin 1 gram.

2. Oral Doxycyclin 100 mg two times a day for seven days.

Azithromycin and Doxycycline are used for the treatment of chlamydial urethritis.

Regimen for Nongonococcal Urethritis Without a Microscope:

1. Ceftriaxone 250 mg IM.

2. Single-dose oral Azithromycin 1 gram.

3. Oral Doxycyclin 100 mg two times a day for seven days.

Persistent nongonococcal urethritis, even after following a treatment regimen, is quite common. The individual with recurring nongonococcal urethritis may show symptoms such as discharge on examination, leukocyte esterase in urine analysis, and an elevated white blood cell on microscopic examination. The common cause of recurrence is M.genitalium, and treatment should focus on it.

The regimen involves:

1. Single-dose oral Azithromycin 1 gram, if it was not used priorly.

2. Moxifloxacin 400 mg orally for seven days if Azithromycin was used priorly.

3. For T. vaginalis cases, Metronidazole 2 g orally is used.

The Differential Diagnosis for Nongonococcal Urethritis:

The differential diagnosis involves:

• Vaginitis.

• Prostatitis.

• Epididymitis.

• Cystitis.

Patient Education:

Patient education involves the following:

• During the therapy and completion, the individual should abstain from sexual activity for seven days.

• Doxycyclin causes photosensitivity to sun exposure. Hence individuals on Doxycycline should be careful.

• Individuals on Metronidazole should abstain from alcohol consumption.

How to Prevent Nongonococcal Urethritis?

Prevention of nongonococcal urethritis can be done by practicing safe sex. Usage of protection such as condoms during sexual intercourse. Getting tested for nongonococcal urethritis or sexually transmitted diseases. Individuals with multiple sexual partners should have regular tests conducted.

Conclusion

Nongonococcal urethritis is the inflammation of the urethra caused by unprotected sexual intercourse. Nongonococcal urethritis has nonsexual causes as well. It is advised that individuals having unprotected sex or having multiple sexual partners should get themselves tested, as nongonococcal urethritis can be symptomatic to avoid further complications.