714
Management of Chronic Urethral Symptoms in Men Michael H. Augenbraun, Marinella Cummings, and William M. McCormack
From the Department ofMedicine and the Department of Obstetrics and Gynecology. State University ofNew York. Health Science Center at Brooklyn, Brooklyn, New York
Urethral symptoms in men include dysuria, discharge, urethral discomfort, and urethral itching. Demonstration of an abnormal urethral discharge on examination or the detection of an abnormal number of inflammatory cells on a stained urethral smear or in the sediment of a first-voided sample of urine is considered diagnostic of urethritis [I]. The etiologic agents associated with urethritis include Neisseria gonorrhoeae. Chlamydia trachomatis. Ureaplasma urealyticum. and Trichomonas vaginalis. Treatment with appropriate antimicrobial agents is associated with eradication of urethral pathogens and resolution of urethral symptoms in most cases. This report describes a group of patients who had persistent symptoms of urethritis, in most cases following treatment for gonococcal or nongonococcal urethritis. Endourethral samples, obtained with calcium alginate swabs (Inolex, Glenwood, IL), were placed on glass slides, gram stained, and examined for gram-negative cocci and leukocytes with use of the oil-immersion objective of a microscope. Urethral specimens were examined for N. gonorrhoeae, C. trachomatis, U. urealyticum [2], and T. vaginalis with use of the routine methods of our laboratory. First-voided urine (VB 1) samples were obtained from all the patients in the manner described by Meares and Stamey [3]. Midstream urine (VB2) samples were obtained from 11 men. Expressed prostatic secretions (EPS) and a postprostatic massage urine (VB3) sample were obtained from nine and seven patients, respectively. Urine specimens and EPS were
Received 4 May 1992. Reprints or correspondence: Dr. Michael H. Augenbraun, Box 56, SUNY Health Science Center at Brooklyn, 450 Clarkson Avenue, Brooklyn, New York 11203.
Clinical Infectious Diseases 1992;15:714-5 © 1992 by The University of Chicago. All rights reserved.
1058-4838/92/1504-0026$02.00
examined microscopically; these specimens were inoculated onto blood and MacConkey agar plates and examined for bacteria. Twenty men were examined. None had received any antimicrobial agents in the 2 weeks preceding the examination. Eleven (55%) of the patients were heterosexual, six (30%) were homosexual, and three (15%) were bisexual. Fifteen men reported an episode of infectious urethritis; for 14 this episode occurred from 3 to 96 months (mean, 33.1 months) before presentation. Twelve of the fifteen men dated the onset of their chronic urethral symptoms by the episode ofurethritis. Four men had had gonococcal urethritis, nine had had nongonococcal urethritis, and two had had both gonococcal urethritis and nongonococcal urethritis. The patients had been seen by an average of 1.8 physicians (range, 0-6 physicians) and had been treated with an average of 2.4 courses of antimicrobial agents (range, 0-5 courses). The most frequently reported symptom was urethral discomfort (itching or burning), which was noted by 14 (70%) of the patients. Eight (40%) of the 20 men noted dysuria, and five (25%) complained of testicular pain. None of the patients reported an abnormal urethral discharge. Physical examination demonstrated no abnormal findings in any of the 20 patients. None of the urethral smears contained more than five polymorphonuclear leukocytes per high-power field. None of the urine sediments contained more than eight polymorphonuclear leukocytes per highpower field. Cultures of VB 1 samples from 16 patients yielded < 1,000 cfu/mL. Four patients were found to have between 3,000 and 10,000 cfu/mL in VB 1 specimens. In the absence of pyuria, this was not interpreted as evidence of infection. All 1I VB2 specimens contained < 1,000 cfu/mL. Of the patients for whom EPS (nine patients) and VB3 specimens (seven patients) were examined, none had findings consistent with prostatitis. Cultures of urethral specimens
Downloaded from http://cid.oxfordjournals.org/ at The University of British Colombia Library on July 28, 2015
We describe 20 men who were referred because of chronic urogenital symptoms. They had been previously seen by zero to six physicians (mean, 1.8 physicians) and had been treated with zero to five courses of antimicrobial agents (mean, 2.4 courses) without relief of their symptoms. Results of physical examinations of all patients were normal. An extensive evaluation failed to reveal any objective evidence of urethral inflammation. Cultures for Neisseria gonorrhoeae, Chlamydia trachomatis, Ureaplasma urealyticum, and Trichomonas vaginalis were uniformly negative. No additional antimicrobial agents were prescribed. Data from follow-up questionnaires filled out by 10 ofthese men 5-28 months later (mean, 11.8 months) disclosed the disappearance of symptoms in three and the reduction of symptoms in four. Chronic urethral symptoms may occur in the absence of objective evidence of inflammation and infection with known urethral pathogens. Observation without antimicrobial therapy is the treatment of choice for such patients.
CIO 1992; 15 (October)
Chronic Urethral Symptoms
mucosal lymphocytic infiltration ofthe urethra characteristic of chronic urethritis [8]. It is interesting that similar findings in the urethral submucosa of chimpanzees experimentally infected with C. trachomatis were noted months after "successful" treatment [9]. Perhaps chronic submucosal inflammation following gonococcal, chlamydial, or ureaplasmal urethritis is responsible for some of the symptoms reported by the patients who are described in this report. Whatever the cause, it is clear from our experience that without objective evidence of urethritis or cultures positive for recognized uropathogens, antimicrobial therapy is of questionable value and may serve to perpetuate whatever psychosomatic elements are involved. These patients should be reassured that they do not have an active infection and should be observed without treatment. References 1. Bowie W. Urethritis in males. In: Holmes K. Mardh P, Sparling P, Wiesner P, eds. Sexually transmitted diseases. 2nd ed. New York: McGraw-Hill,1989:638-50. 2. MinkoffH, Grunebaum A, Schwarz R, et al. Risk factors for prematurity and premature rupture of membranes. Am J Obstet Gynecol 1984; 150:965-72. 3. Meares E, Stamey T. Bacteriologic localization patterns in bacterial prostatitis and urethritis. Invest Urol 1968;5:492-518. 4. Pedder J, Goldberg O. A survey by questionnaire of psychiatric disturbance in patients attending a clinic for sexually transmitted diseases. Br J Yener Dis 1970;46: 58-61. 5. Fitzpatrick R, Frost D, Ikkos G. Survey of psychological disturbance in patients attending a sexually transmitted diseases clinic. Genitourin Med 1986;62: 111-5. 6. Bodner D. The urethral syndrome. U rol Clin North Am 1988; 15:699704. 7. Barbalias G, Meares E. Female urethral syndrome: clinical and urodynamic perspectives. Urology 1984;23:208-12. 8. Tomaszewski J. Urethritis. In: Hill G, ed. Uropathology. New York: Churchill Livingstone, 1989:455-66. 9. Taylor-Robinson D, Purcell R. London W, Sly 0, Thomas B, Evans R. Microbiological. serological and histopathological features of experimental Chlamydia trachomatis urethritis in chimpanzees. Br J Yener Dis 1981;57:36-40.
Downloaded from http://cid.oxfordjournals.org/ at The University of British Colombia Library on July 28, 2015
from all 20 patients were negative for N. gonorrhoeae, C. trachomatis. U. urealyticum, and T. vaginalis. Patients were told that they had neither objective evidence ofinflammation nor microbiological evidence ofgenital tract infection and that use of additional antimicrobial agents was not indicated. Follow-up data accumulated through the use of a questionnaire were available for 10 patients (50%). Responses were received between 5 and 28 months after evaluation (mean, 11.8 months). Patients were asked to subjectively rate the status of their symptoms. In three men, the symptoms had gone away without treatment; seven had persistent symptoms. Of these seven men, four noted some abatements while three noted no change in their symptoms. Four of the men who had persistent symptoms sought further medical evaluation and received additional antimicrobial therapy. Undoubtedly, some of these symptoms were due to psychological factors regarding sexuality and other health concerns. Given the social and psychological ramifications of sexually transmitted diseases, the mix of organic and functional factors at patient presentation may be complex. Screening with use of health questionnaires in sexually transmitted diseases clinics has suggested that 30%-43% of patients attending such clinics may have significant levels of psychological disturbance. However,
Management of Chronic Urethral Symptoms in Men Michael H. Augenbraun, Marinella Cummings, and William M. McCormack
From the Department ofMedicine and the Department of Obstetrics and Gynecology. State University ofNew York. Health Science Center at Brooklyn, Brooklyn, New York
Urethral symptoms in men include dysuria, discharge, urethral discomfort, and urethral itching. Demonstration of an abnormal urethral discharge on examination or the detection of an abnormal number of inflammatory cells on a stained urethral smear or in the sediment of a first-voided sample of urine is considered diagnostic of urethritis [I]. The etiologic agents associated with urethritis include Neisseria gonorrhoeae. Chlamydia trachomatis. Ureaplasma urealyticum. and Trichomonas vaginalis. Treatment with appropriate antimicrobial agents is associated with eradication of urethral pathogens and resolution of urethral symptoms in most cases. This report describes a group of patients who had persistent symptoms of urethritis, in most cases following treatment for gonococcal or nongonococcal urethritis. Endourethral samples, obtained with calcium alginate swabs (Inolex, Glenwood, IL), were placed on glass slides, gram stained, and examined for gram-negative cocci and leukocytes with use of the oil-immersion objective of a microscope. Urethral specimens were examined for N. gonorrhoeae, C. trachomatis, U. urealyticum [2], and T. vaginalis with use of the routine methods of our laboratory. First-voided urine (VB 1) samples were obtained from all the patients in the manner described by Meares and Stamey [3]. Midstream urine (VB2) samples were obtained from 11 men. Expressed prostatic secretions (EPS) and a postprostatic massage urine (VB3) sample were obtained from nine and seven patients, respectively. Urine specimens and EPS were
Received 4 May 1992. Reprints or correspondence: Dr. Michael H. Augenbraun, Box 56, SUNY Health Science Center at Brooklyn, 450 Clarkson Avenue, Brooklyn, New York 11203.
Clinical Infectious Diseases 1992;15:714-5 © 1992 by The University of Chicago. All rights reserved.
1058-4838/92/1504-0026$02.00
examined microscopically; these specimens were inoculated onto blood and MacConkey agar plates and examined for bacteria. Twenty men were examined. None had received any antimicrobial agents in the 2 weeks preceding the examination. Eleven (55%) of the patients were heterosexual, six (30%) were homosexual, and three (15%) were bisexual. Fifteen men reported an episode of infectious urethritis; for 14 this episode occurred from 3 to 96 months (mean, 33.1 months) before presentation. Twelve of the fifteen men dated the onset of their chronic urethral symptoms by the episode ofurethritis. Four men had had gonococcal urethritis, nine had had nongonococcal urethritis, and two had had both gonococcal urethritis and nongonococcal urethritis. The patients had been seen by an average of 1.8 physicians (range, 0-6 physicians) and had been treated with an average of 2.4 courses of antimicrobial agents (range, 0-5 courses). The most frequently reported symptom was urethral discomfort (itching or burning), which was noted by 14 (70%) of the patients. Eight (40%) of the 20 men noted dysuria, and five (25%) complained of testicular pain. None of the patients reported an abnormal urethral discharge. Physical examination demonstrated no abnormal findings in any of the 20 patients. None of the urethral smears contained more than five polymorphonuclear leukocytes per high-power field. None of the urine sediments contained more than eight polymorphonuclear leukocytes per highpower field. Cultures of VB 1 samples from 16 patients yielded < 1,000 cfu/mL. Four patients were found to have between 3,000 and 10,000 cfu/mL in VB 1 specimens. In the absence of pyuria, this was not interpreted as evidence of infection. All 1I VB2 specimens contained < 1,000 cfu/mL. Of the patients for whom EPS (nine patients) and VB3 specimens (seven patients) were examined, none had findings consistent with prostatitis. Cultures of urethral specimens
Downloaded from http://cid.oxfordjournals.org/ at The University of British Colombia Library on July 28, 2015
We describe 20 men who were referred because of chronic urogenital symptoms. They had been previously seen by zero to six physicians (mean, 1.8 physicians) and had been treated with zero to five courses of antimicrobial agents (mean, 2.4 courses) without relief of their symptoms. Results of physical examinations of all patients were normal. An extensive evaluation failed to reveal any objective evidence of urethral inflammation. Cultures for Neisseria gonorrhoeae, Chlamydia trachomatis, Ureaplasma urealyticum, and Trichomonas vaginalis were uniformly negative. No additional antimicrobial agents were prescribed. Data from follow-up questionnaires filled out by 10 ofthese men 5-28 months later (mean, 11.8 months) disclosed the disappearance of symptoms in three and the reduction of symptoms in four. Chronic urethral symptoms may occur in the absence of objective evidence of inflammation and infection with known urethral pathogens. Observation without antimicrobial therapy is the treatment of choice for such patients.
CIO 1992; 15 (October)
Chronic Urethral Symptoms
mucosal lymphocytic infiltration ofthe urethra characteristic of chronic urethritis [8]. It is interesting that similar findings in the urethral submucosa of chimpanzees experimentally infected with C. trachomatis were noted months after "successful" treatment [9]. Perhaps chronic submucosal inflammation following gonococcal, chlamydial, or ureaplasmal urethritis is responsible for some of the symptoms reported by the patients who are described in this report. Whatever the cause, it is clear from our experience that without objective evidence of urethritis or cultures positive for recognized uropathogens, antimicrobial therapy is of questionable value and may serve to perpetuate whatever psychosomatic elements are involved. These patients should be reassured that they do not have an active infection and should be observed without treatment. References 1. Bowie W. Urethritis in males. In: Holmes K. Mardh P, Sparling P, Wiesner P, eds. Sexually transmitted diseases. 2nd ed. New York: McGraw-Hill,1989:638-50. 2. MinkoffH, Grunebaum A, Schwarz R, et al. Risk factors for prematurity and premature rupture of membranes. Am J Obstet Gynecol 1984; 150:965-72. 3. Meares E, Stamey T. Bacteriologic localization patterns in bacterial prostatitis and urethritis. Invest Urol 1968;5:492-518. 4. Pedder J, Goldberg O. A survey by questionnaire of psychiatric disturbance in patients attending a clinic for sexually transmitted diseases. Br J Yener Dis 1970;46: 58-61. 5. Fitzpatrick R, Frost D, Ikkos G. Survey of psychological disturbance in patients attending a sexually transmitted diseases clinic. Genitourin Med 1986;62: 111-5. 6. Bodner D. The urethral syndrome. U rol Clin North Am 1988; 15:699704. 7. Barbalias G, Meares E. Female urethral syndrome: clinical and urodynamic perspectives. Urology 1984;23:208-12. 8. Tomaszewski J. Urethritis. In: Hill G, ed. Uropathology. New York: Churchill Livingstone, 1989:455-66. 9. Taylor-Robinson D, Purcell R. London W, Sly 0, Thomas B, Evans R. Microbiological. serological and histopathological features of experimental Chlamydia trachomatis urethritis in chimpanzees. Br J Yener Dis 1981;57:36-40.
Downloaded from http://cid.oxfordjournals.org/ at The University of British Colombia Library on July 28, 2015
from all 20 patients were negative for N. gonorrhoeae, C. trachomatis. U. urealyticum, and T. vaginalis. Patients were told that they had neither objective evidence ofinflammation nor microbiological evidence ofgenital tract infection and that use of additional antimicrobial agents was not indicated. Follow-up data accumulated through the use of a questionnaire were available for 10 patients (50%). Responses were received between 5 and 28 months after evaluation (mean, 11.8 months). Patients were asked to subjectively rate the status of their symptoms. In three men, the symptoms had gone away without treatment; seven had persistent symptoms. Of these seven men, four noted some abatements while three noted no change in their symptoms. Four of the men who had persistent symptoms sought further medical evaluation and received additional antimicrobial therapy. Undoubtedly, some of these symptoms were due to psychological factors regarding sexuality and other health concerns. Given the social and psychological ramifications of sexually transmitted diseases, the mix of organic and functional factors at patient presentation may be complex. Screening with use of health questionnaires in sexually transmitted diseases clinics has suggested that 30%-43% of patients attending such clinics may have significant levels of psychological disturbance. However,
