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May 20, 2010 Sexually Transmitted Diseases: Genital Syndromes in Men Julie Dombrowski, MD, MPH

May 20, 2010 Sexually Transmitted Diseases: Genital Syndromes in Men Julie Dombrowski, MD, MPH With photos and selected slides from H. Hunter Handsfield, MD. I-TECH STD Update Series. Genital syndromes in men: Urethritis and related conditions

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May 20, 2010 Sexually Transmitted Diseases: Genital Syndromes in Men Julie Dombrowski, MD, MPH

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  1. May 20, 2010 Sexually Transmitted Diseases: Genital Syndromes in Men Julie Dombrowski, MD, MPH With photos and selected slides from H. Hunter Handsfield, MD

  2. I-TECH STD Update Series Genital syndromes in men: Urethritis and related conditions Genital syndromes in women I: Cervicitis, vaginal infections Genital syndromes in women II: PID, STD and pregnancy, HPV and cervical cancer Genital ulcer disease: Herpes, syphilis, and miscellaneous STDs

  3. Introduction STDs increase HIV transmission and acquisition Important implications for female partners Two clinical approaches Etiologic diagnosis Target treatment to an identified pathogen Syndromic management Identify syndrome and treat possible causes Guided by algorithm (WHO)

  4. The STD-Focused Male Exam Palpate inguinal nodes Palpate scrotal contents Testes, spermatic cord, epididymis Exam penis visually, retracting foreskin Rashes, ulcers, inflammation of meatus, urethral discharge If no discharge apparent, milk urethra

  5. Male Genital InfectionsCase 1 PRESENTATION 44 year-old man History 3 days of burning with urination Has noticed stains on underwear for 2 days 3 new vaginal sex partners during travel last week Last sex 7 days ago Used condoms most of the time “except when I drank too much”

  6. Diagnosis of Urethritis Symptoms: dysuria, urethral itching/tingling Confirmation requires one of the following: Abnormal urethral discharge Purulent or mucopurulent Preferably examine >4 hr since last urination Documented urethral inflammation Gram stain of discharge with ≥5 WBC per oil immersion field (preferred) Gram stain of urine sediment with ≥10 WBC per oil immersion field +Leukocyte esterase in first-void urine

  7. Gonorrhea (Neisseria gonorrhoeae) Males Urethritis (usually symptomatic) Complications Epididymitis Urethral stricture Gonococcal abscess Disseminated gonococcal infection Reactive arthritis (formerly Reiter’s syndrome) Female partners Cervicitis (often asymptomatic) Can lead to PID, ectopic pregnancy, infertility Urethritis Also pharyngitis, proctitis if exposed (males & females)

  8. Treatment of Uncomplicated Gonorrhea RECOMMENDED Ceftriaxone 125-250 mg IM Cefixime 400 mg PO x 1 Ciprofloxacin 500 mg PO Ofloxacin 400 mg PO Levofloxacin 250 mg PO PLUS Azithromycin or Doxycycline No longer recommended Chlamydia co-infection Is common. Include if chlamydia has not been ruled out.

  9. Gonococcal Isolate Surveillance Project (CDC) Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2007 Supplement, Gonococcal Isolate Surveillance Project (GISP) Annual Report 2007. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, March 2009.

  10. The Next Problem: Cephalosporin Resistance • Resistance to 3rd generation cephalosporins • Emerged and spread in Asia, Australia • Sporadic cases elsewhere • Limited data from Africa, Latin America, Caribbean • Mechanisms not fully elucidated • Reported treatment failures with oral cephalosporins

  11. Male Genital InfectionsCase 2 PRESENTATION 40 year-old man with AIDS on antiretroviral therapy CD4 count 107, HIV RNA undetectable History 2 days of urethral itching and discharge 1 male sex partner in past 2 months, 6 in past 12 months Insertive anal and oral sex, never used condoms

  12. Differential Diagnosis of Urethritis Gonococcal *Also called non-specific urethritis

  13. Gonorrhea versus NGU

  14. Comparison of Typical Discharge* • Gonococcal • Non-gonococcal *Cannot reliably distinguish on visual exam alone

  15. Examination of gram stained smear for gram-negative intracellular diplococci • Sensitivity 90-95% • Specificity 90-95% • If positive -> Treat for gonorrhea and chlamydia • If negative -> Treat for NGU

  16. Etiologies of NGU Role of oral sex? *Median of 16 studies since 1992 (Sexually Transmitted Diseases, 4th Ed, Holmes KK et al) **Bradshaw C et al. JID 2006;193:336-45

  17. Urethritis - Laboratory Testing Gram stained smear of urethral secretions Gram negative intracellular diplococci If available and cost effective N. gonorrhoeae Culture or nucleic acid amplification testing (NAAT) C. trachomatis NAAT Not recommended generally, but may be appropriate in selected cases and settings M. genitalium (not widely available) T. vaginalis HSV

  18. Treatment of NGU Azithromycin 1.0 g, single dose Chlamydia efficacy ~95% Clinical efficacy ~90% Usually effective against M. genitalium, but risk of inducible resistance Doxycycline 100 mg po BID x 7 days Chlamydia efficacy >98% Clinical efficacy ~90% Alternatives: erythromycin, fluoroquinolones Notification and treatment of partners (<60 days) No systematic studies of clinical outcomes in partners

  19. Recurrent and Persistent NGU • Symptoms may take 10-14 days to resolve • 10-15%: persistent/recurrent symptoms at 4-6wk • Documented urethritis? • If no  don’t retreat • If yes  retreat with different medication • Partner re-treatment not recommended

  20. Male Genital InfectionsCase 3 PRESENTATION 24 year-old man History “Incredibly painful” urination for 2 days 2 lifetime female sex partners 1 new partner in the past 2 mo Last sex 4 days ago Always used condoms with vaginal sex Oral sex (penile-oral & oral-vaginal)

  21. EXAM Several small ulcers on tongue No groin lymphadenopathy Meatal inflammation Urethral discharge moderate & clear MICROSCOPY >10 PMNs per high-powered field Male Genital InfectionsCase 3 Picture source: O’Mahony, C. International Journal of STD & AIDS 2006; 17: 203-4.

  22. Male Genital InfectionsCase 3 TREATMENT (prior to lab results) • Azithromycin • Acyclovir LAB RESULTS • NAAT negative for N. gonorrhoeae and C. trachomatis • Culture + for HSV-1 and adenovirus • Serology negative for HSV-1 & HSV-2

  23. Bacterial versus Viral NGU Consider acyclovir in patients with prominent dysuria and meatal inflammation Bradshaw C et al. JID 2006;193:336-45

  24. 34 year old HIV-infected man Intermittent ART CD4 100 Weight loss, cough Painful, swollen R testicle 7 days Male Genital InfectionsCase (#4)

  25. Epididymitis Age <35 Chlamydia, gonorrhea Ceftriaxone x1 and Doxycycline x 10 days Age >35 (Also insertive anal sex, recent urethral instrumentation) Enteric pathogens (E. coli) Levofloxacin x 10 days Male Genital Infections Case #4 – Testicular Enlargement

  26. “The 4 T’s” Trauma Torsion Age <20 Sudden onset, often during sleep Surgical emergency Tuberculosis Local epidemiology Higher risk in HIV Gradual onset Tumor Usually non tender Male Genital Infections Case #4 – Testicular Enlargement

  27. Prostatitis (National Institutes of Health Classification) • Acute bacterial • Fever, chills, dysuria, pelvic pain • Age <35: GNR > GC, CT • Age ≥35: GNR and other UTI pathogens • More frequent in HIV infection • Chronic bacterial* • Dysuria without other acute signs • Four week duration of antibiotics • Chronic prostatitis/pelvic pain syndrome* • Inflammatory • Non-inflammatory • MOST cases of “prostatitis” • May not involve prostate, not infectious, antibiotics ineffective • Asymptomatic inflammatory* *Not clearly shown to be caused by sexually transmitted pathogens

  28. Take Home Points Urethritis in men is classified as gonococcal vs. non-gonococcal C. trachomatis is most common identifiable pathogen in NGU Treat for gonorrhea + chlamydia or chlamydia alone based on gram stain Partners within 60 days should be treated Epididymitis treatment based on age, risk factors Think through the “4 T’s” also, especially TB

  29. Next session: June 3, 2010 R. Scott McClelland, MD: Contraception and HIV in Women Listserv: itechdistlearning@u.washington.edu Email: DLinfo@u.washington.edu

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