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Mycoplasma genitalium (MG) is an emerging sexually transmitted infection, which appears to be a cause of urethritis and cervicitis and has been associated with pelvic inflammatory disease (PID), epididymitis, proctitis, infertility, complications during pregnancy, and human immunodeficiency virus (HIV) transmission. Three Food and Drug Administration (FDA) approved tests are available. Testing should be focused to avoid inappropriate antibiotic use. The Center of Disease Control and Prevention (CDC) guidelines recommend testing for persistent male urethritis, cervicitis, and proctitis and state that testing should be considered in cases of PID. Testing is also recommended for sexual contacts of patients with MG. Testing is not recommended in asymptomatic patients, including pregnant patients, who do not have a history of MG exposure. Although resistance-guided therapy is recommended, there are currently no FDA approved tests for MG macrolide resistance, and tests are not widely available in the United States. The CDC recommends 2-step treatment with doxycycline followed by azithromycin or moxifloxacin. Moxifloxacin is recommended if resistance testing is unavailable or testing demonstrates macrolide resistance.., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Gonococcal urethritis (GU) is the second most common sexually transmitted infection (STI). Epidemiologic studies of the situation of GU reinfection and its related risk factors among patients with a history of GU in Thailand remain somewhat limited. A hospital-based retrospective cohort study was conducted between January 1, 2010 and December 31, 2020 to determine the incidence and risk factors of GU reinfection among male patients visiting in Royal Thai Army (RTA) Hospitals. A total of 2,465 male patients presenting a history of GU was included in this study. In all, 147 (6.0%; 95% CI 5.1-6.9) male patients presented GU reinfection, representing an incidence rate of 1.3 (95% CI 1.1-1.5) per 100 person-years. The independent risk factors for GU reinfection were age < 30 years (AHR 1.7; 95% CI 1.0-2.8), number of sexual partners equal to 2 (AHR 3.4; 95% CI 1.0-11.2), ≥ 3 (AHR 5.6; 95% CI 2.7-11.6), and participants residing in the north (AHR 4.1; 95% CI 2.3-7.5) and northeast regions (AHR 2.1; 95% CI 1.1-3.9). Incidence of GU reinfection among male patients visiting RTA Hospitals was significantly high among younger aged patients, especially in the north and northeast regions. Multiple sex partners played a major role in GU reinfection. Effective STI prevention programs should be provided to alleviate reinfection and its complications., (© 2021. The Author(s).)

Objectives: International guidelines recommend Mycoplasma genitalium testing, preferably using an assay to detect macrolide resistance-associated mutations, for men presenting with non-gonococcal urethritis, but there is no specific guidance on such testing for men with gonococcal urethritis., Methods: This study aimed to estimate the proportion of men with gonococcal urethritis who have coinfection with M. genitalium through a retrospective analysis of cases of symptomatic urethral gonorrhoea at Western Sydney Sexual Health Centre in 2017 and 2018., Results: Fourteen of 184 (7.6%, 95% CI 3.7 to 11.5) men with gonococcal urethritis had M. genitalium detected in the urine at the time of presentation. No demographic or behavioural factors predicted M. genitalium coinfection. Coinfection with urethral Chlamydia trachomatis was detected in 29 of 184 (15.8%, 95% CI 10.5 to 21.1). All five men with macrolide-resistant M. genitalium detected returned for treatment with moxifloxacin at a median of 8 days (range 5-16 days) after presentation and treatment of gonorrhoea; three of five were documented to remain symptomatic at this visit., Conclusion: Although M. genitalium coinfection is less common than chlamydia among men with symptomatic gonococcal urethritis, M. genitalium testing, using an assay to detect macrolide resistance, will potentially reduce symptom duration particularly for men with macrolide-resistant infections, but may not be justifiable on cost-benefit analysis., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Male urethritis is an inflammation of the urethra and the periurethral glands; it is widely classified as gonococcal or non-gonococcal. The most frequent microorganisms responsible are Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, Mycoplasma hominis, Ureaplasma urealyticum, and Ureaplasma parvum. In the last three decades, the diagnosis of sexually transmitted diseases depended almost exclusively on traditional methods, such as culture, enzyme immunoassay, fluorescent antibody staining, and hybridization, until the appearance of molecular techniques. Clinical syndromes such as urethritis are rarely specific for a single microorganism, so screening strategies should allow multiple agents to be considered. Multiplex PCR is the fastest and most sensitive technique for the diagnosis of gonococcal and non-gonococcal urethritis. Male urethritis without treatment is one of the main health problems related to reproductive and sexual function, constituting one of the main causes of infertility. The objective of this mini-review was to analyze the epidemiology, causes, diagnosis, and complications of male urethritis., (Copyright © 2020 AEU. Publicado por Elsevier España, S.L.U. All rights reserved.)

Purpose: Histopathology can provide insights into disease mechanisms but to date it has been poorly described for urethral stricture. The purpose of this study was to comprehensively describe histopathological findings of stricture specimens obtained at the time of anterior urethroplasty., Materials and Methods: All pathological specimens of men who underwent anterior urethroplasty of urethral stricture disease from 2010 to 2017 at a single institution were rereviewed by a single blinded pathologist directed to rule out lichen sclerosus and then describe inflammatory cell type and severity when present. Cohorts comprising strictures with no inflammation, minimal to mild inflammation or moderate to severe inflammation were developed and stricture, patient and surgical outcome characteristics were compared., Results: Histopathology slides from 100 anterior urethroplasty cases were reviewed. Two or more lichen sclerosus characteristics were present in 21% of specimens and 44% of specimens showed chronic inflammation, which was minimal in 20%, mild in 39%, moderate in 39% and severe in 2%. Lymphocytes in 86% of specimens and plasma cells in 12% were the predominant cell types. Patients with inflammatory stricture reported worse overall health. Inflammation was largely absent from isolated bulbomembranous strictures (9%) and more common in lichen sclerosus strictures (100%). The 11% overall failure rate was not affected by the presence (7%) or absence (14%) of inflammation., Conclusions: Chronic inflammation is prevalent in a significant percent of urethral stricture disease specimens. Associations with worse overall health suggest systemic mediators. Absent inflammation in bulbomembranous strictures suggests a unique pathophysiology in this region. The presence of inflammation did not affect surgical outcomes at mid-term followup.

This case report presents a patient who, while undergoing oral isotretinoin therapy for acne vulgaris, developed onychocryptosis and asymptomatic external urethritis. These uncommon adverse events are not well-documented in medical literature. While his urethritis spontaneously resolved, his onychocryptosis symptoms necessitated surgical intervention. This report illustrates both cosmetic and functional adverse effects of isotretinoin and provides insight into the progression of these reactions over time., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Ureaplasma spp. are a genus of bacteria for which two human-associated species exist: Ureaplasma urealyticum and Ureaplasma parvum Their definition as a pathogen in the context of nongonococcal urethritis (NGU) and infertility among males remains highly controversial, largely due to historically high rates of isolation of these bacteria from the urethra of seemingly healthy men. This review summarizes the emerging evidence suggesting a true pathogenic role of these bacteria under specific conditions, which we term risk factors. We examine the historical, clinical, and experimental studies which support a causal role for Ureaplasma spp. in the development of NGU as well as some of the proposed mechanisms behind the association of Ureaplasma spp. and the development of infertility. Finally, we discuss the potential for developing a case-by-case risk-based approach toward the management of men who present with seemingly idiopathic NGU but who are positive for Ureaplasma spp., (Copyright © 2019 American Society for Microbiology.)

Purpose: Evaluate the main etiologies and clinical characteristics of male urethral stricture disease (USD) in Brazil., Methods: This multicentric study was performed using retrospective data collected from six Brazilian referral centers of urethral reconstruction. The database comprised data from 899 patients with USD who had undergone surgical treatment from 2008 to 2018. Age, stricture site and primary stricture etiology were identified for each patient., Results: The mean age was 52.13 ± 16.9 years. The most common etiology was iatrogenic (43.4%), followed by idiopathic (21.7%), trauma (21.5%) and inflammatory (13.7%). Of the iatrogenic causes, 59% were secondary to urethral instrumentation (60% by urethral catheterization and 40% by transurethral procedures), 24.8% by other procedures (prostatectomy, radiotherapy, postectomy) and 16.2% by failed hypospadia repairs. Pelvic fracture urethral distraction injuries were responsible for most of the trauma-related strictures (62.7%). When stratified by age, the most common stricture etiology was trauma in the 0-39 years old group (42.8%), idiopathic in the 40-59 years old group (32.4%) and iatrogenic in patients over 60 years old (68%). In regard to the stricture site, 80% presented with an anterior urethral stricture and 20% with a posterior stenosis. In the anterior stenosis group, the most common stricture site was bulbar (39.5%)., Conclusion: In Brazil, as in many developed countries, the most common cause of urethral stricture diseases is iatrogenic, especially urethral catheterization. These findings emphasize the need of a careful urethral manipulation and a better training of healthcare professionals. Trauma is still responsible for a great proportion of strictures and inflammatory etiologies are now less frequently observed.

Objective: To assess the cost-effectiveness of three testing strategies with or without light microscopic Gram-stained smear (GSS) evaluation for the detection of anogenital gonorrhoea among men who have sex with men (MSM) at the Amsterdam STI clinic using a healthcare payer perspective., Methods: Three testing strategies for MSM were compared: (1) GSS in symptomatic MSM only (currently practised strategy), (2) no GSS and (3) GSS in symptomatic and asymptomatic MSM. The three testing protocols include testing with nucleic acid amplification test to verify the GSS results in (1) and (3), or as the only test in (2). A transmission model was employed to calculate the influence of the testing strategies on the prevalence of anogenital gonorrhoea over 10 years. An economic model combined cost data on medical consultations, tests and treatment and utility data to estimate the number of epididymitis cases and quality-adjusted life years (QALY) associated with gonorrhoea. Incremental cost-effectiveness ratios (ICERs) for the testing scenarios were estimated. Uncertainty and sensitivity analyses were performed., Results: No GSS testing compared with GSS in symptomatic MSM only (current strategy) resulted in nine extra epididymitis cases (95% uncertainty interval (UI): 2-22), 72 QALYs lost (95% UI: 59-187) and €7300 additional costs (95% UI: -€185 000 (i.e.cost-saving) to €407 000) over 10 years. GSS testing in both symptomatic and asymptomatic MSM compared with GSS in symptomatic MSM only resulted in one prevented epididymitis case (95% UI: 0-2), 1.1 QALY gained (95% UI: 0.1-3.3), €148 000 additional costs (95% UI: €86 000 to-€217 000) and an ICER of €177 000 (95% UI: €67 000-to €705 000) per QALY gained over 10 years. The results were robust in sensitivity analyses., Conclusions: GSS for symptomatic MSM only is cost-effective compared with no GSS for MSM and with GSS for both symptomatic and asymptomatic MSM., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Gonorrhea is a major sexually transmitted infection (STI) globally with increasing trends. Despite limited data, gonorrhea remains an important public health problem in Bhutan., Methods: A descriptive study was carried out in two Bhutanese hospitals; Jigme Dorji Wangchuck National Referral Hospital and Phuentsholing General Hospital in 2015. Patients suspected of gonococcal urethritis were sampled, treated and followed up at two weeks. Gonococcal isolates were identified and tested for antibiotic susceptibility by the Calibrated Dichotomous Sensitivity Test (CDS) method., Results: Of the 524 patients, 2.3% (12) were females. Most (46.6%) patients belonged to the 26-35 years age group. About 58% were lost to follow up; 62% (277) of males and all (12) females. N. gonorrhoea was positive in 76% (398) of microscopy and 73.1% (383) by culture. Resistance against ciprofloxacin, penicillin, tetracycline and nalidixic acid were 85.1%, 99.2%, 84.8% and 99.7% respectively. Nearly all the isolates were sensitive to cefpodoxime, ceftriaxone and azithromycin. Sixty-seven percent (350) were treated with injection ceftriaxone alone, 32% (169) with ceftriaxone and oral doxycycline and 1% (5) with ceftriaxone, doxycycline and metronidazole. Probable treatment failure was seen only in one patient (0.5%)., Conclusions: Gonococcal resistance to currently used antibiotics was low and there was a high clinical cure rate. Compliance to treatment guidelines need reinforcement addressing antibiotic regimen, tracing sexual partners and addressing the social stigma. National STI programs should be more women-friendly for effective management, prevention and control of STIs. Laboratories must adopt more reliable susceptibility testing methods, the Minimum Inhibition Concentration method., Competing Interests: The authors have declared that no competing interests exist.

Background: Increased reports of Neisseria meningitidis urethritis in multiple U.S. cities during 2015 have been attributed to the emergence of a novel clade of nongroupable N. meningitidis within the ST-11 clonal complex, the "U.S. NmNG urethritis clade". Genetic recombination with N. gonorrhoeae has been proposed to enable efficient sexual transmission by this clade. To understand the evolutionary origin and diversification of the U.S. NmNG urethritis clade, whole-genome phylogenetic analysis was performed to identify its members among the N. meningitidis strain collection from the Centers for Disease Control and Prevention, including 209 urogenital and rectal N. meningitidis isolates submitted by U.S. public health departments in eleven states starting in 2015., Results: The earliest representatives of the U.S. NmNG urethritis clade were identified from cases of invasive disease that occurred in 2013. Among 209 urogenital and rectal isolates submitted from January 2015 to September 2016, the clade accounted for 189/198 male urogenital isolates, 3/4 female urogenital isolates, and 1/7 rectal isolates. In total, members of the clade were isolated in thirteen states between 2013 and 2016, which evolved from a common ancestor that likely existed during 2011. The ancestor contained N. gonorrhoeae-like alleles in three regions of its genome, two of which may facilitate nitrite-dependent anaerobic growth during colonization of urogenital sites. Additional gonococcal-like alleles were acquired as the clade diversified. Notably, one isolate contained a sequence associated with azithromycin resistance in N. gonorrhoeae, but no other gonococcal antimicrobial resistance determinants were detected., Conclusions: Interspecies genetic recombination contributed to the early evolution and subsequent diversification of the U.S. NmNG urethritis clade. Ongoing acquisition of N. gonorrhoeae alleles by the U.S. NmNG urethritis clade may facilitate the expansion of its ecological niche while also increasing the frequency with which it causes urethritis.

We assessed whether urethral microscopy was performed as per clinic protocol for male clinic attendees reporting contact with Neisseria gonorrhoeae (GC), urethral symptoms or given a diagnosis of epididymo-orchitis (EO) over a 12-month period (9732 patients). Prevalence of gonorrhoea in the contacts, urethral symptoms and EO groups was 50, 12.7 and 1.6%, respectively. Microscopy was performed reliably for contacts (96%), those with discharge/dysuria with evidence of urethritis on examination (98%), but not those with EO (43%). We explored the clinical utility of microscopy as a point-of-care test for identifying urethral GC in each subgroup, using the APTIMA Combo 2 CT/GC nucleic acid amplification test as the comparator (1710 patients). Sensitivity of microscopy for each subgroup was good; there was no statistical difference between subgroup sensitivity using Fisher's exact test. Microscopy is valuable to ensure prompt diagnosis and contact tracing. All GC contacts were treated 'epidemiologically'; however, half of GC contacts did not have GC. Microscopy identified the majority of GC cases, including amongst contacts (71% of heterosexual contacts, 66% of contacts reporting sex with men). We propose that epidemiological treatment for GC contacts should be reconsidered on the grounds of antibiotic stewardship, favouring use of microscopy to guide treatment decisions.

Objective: Previous studies have quantified bacterial loads of Neisseria gonorrhoeae in the pharynx and rectum of men but not the urethra. We quantified the bacterial load of N. gonorrhoeae in men with symptomatic and asymptomatic urethral gonorrhoea infections., Methods: Consecutive men diagnosed with urethral gonorrhoea by Aptima Combo 2 testing of urine at the Melbourne Sexual Health Centre between March and July 2016 were eligible for the study: symptomatic men with purulent urethral discharge and asymptomatic men with no urethral symptoms. The gonococcal bacterial load in both groups was measured by urethral swab using a standardised collection method and real-time quantitative PCR targeting the opa gene., Results: Twenty men were recruited into the study: 16 had purulent urethral discharge and 4 had asymptomatic urethral gonorrhoea. The median gonococcal bacterial load was significantly higher among symptomatic men (3.7×10 6 copies per swab, IQR 2.5×10 6 -4.7×10 6 ) compared with asymptomatic men (2.0×10 5 copies per swab, IQR 2.7×10 4 -4.5×10 5 ) (p=0.002)., Conclusions: Gonococcal loads in men with urethral discharge were higher than loads seen with asymptomatic urethral gonorrhoea and loads seen in asymptomatic pharyngeal and rectal gonorrhoea infections in previous studies., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Mycoplasma genitalium is increasingly appreciated as a common cause of sexually transmitted disease syndromes, including urethritis in men and cervicitis, endometritis, pelvic inflammatory disease, and possibly preterm birth, tubal factor infertility, and ectopic pregnancy in women. Despite these disease associations, which parallel those of Chlamydia trachomatis and Neisseria gonorrhoeae, the mechanisms by which this pathogen elicits inflammation, causes cellular damage, and persists in its only natural host (humans) are unique and are not fully understood. The purpose of this review is to briefly provide a historical background on the discovery, microbiology, and recognition of M. genitalium as a pathogen, and then summarize the recent advances in our understanding of the molecular biology and pathogenesis of this unique urogenital organism. Collectively, the basic scientific discussions herein should provide a framework for understanding the clinical and epidemiological outcomes described in the accompanying articles in this supplemental issue., (© The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background: Mycoplasma genitalium is very difficult to grow in culture but has been more able to be studied for disease associations since the advent of research molecular amplification assays. Polymerase chain reaction (PCR) and other molecular assays have demonstrated an association with adverse disease outcomes, such as urethritis or nongonococcal urethritis in men and adverse reproductive sequelae in women-for example, cervicitis, endometritis, and pelvic inflammatory disease (PID), including an association with risk for human immunodeficiency virus. The lack of commercially available diagnostic assays has limited widespread routine testing. Increasing reports of high rates of resistance to azithromycin detected in research studies have heightened the need available commercial diagnostic assays as well as standardized methods for detecting resistance markers. This review covers available molecular methods for the diagnosis of M. genitalium and assays to predict the antibiotic susceptibility to azithromycin., Methods: A PubMed (US National Library of Medicine and National Institutes of Health) search was conducted for literature published between 2000 and 2016, using the search terms Mycoplasma genitalium, M. genitalium, diagnosis, and detection., Results: Early PCR diagnostic tests focused on the MPa adhesion gene and the 16S ribosomal RNA gene. Subsequently, a transcription-mediated amplification assay targeting ribosomes was developed and widely used to study the epidemiology of M. genitalium. Newer methods have proliferated and include quantitative PCR for organism load, AmpliSens PCR, PCR for the pdhD gene, a PCR-based microarray for multiple sexually transmitted infections, and multiplex PCRs. None yet are cleared by the Food and Drug Administration in the United States, although several assays are CE marked in Europe. As well, many research assays, including PCR, gene sequencing, and melt curve analysis, have been developed to detect the 23S ribosomal RNA gene mutations that confer resistance to azithromycin. One recently developed assay can test for both M. genitalium and azithromycin resistance mutations at the same time., Conclusions: It is recommended that more commercial assays to both diagnose this organism and guide treatment choices should be developed and made available through regulatory approval. Research is needed to establish the cost-effectiveness of routine M. genitalium testing in symptomatic patients and screening in all individuals at high risk of acquiring and transmitting sexually transmitted infections., (© The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Infertility can be attributed to reproductive tract infections (RTI), most commonly nongonococcal urethritis, mainly including Mycoplasma and Chlamydia infections, which may directly or indirectly damage spermatozoa and spermatogenic cells. In addition, a series of immune responses caused by such infections are also associated with male infertility. Methods for the clinical detection of these microbial infections are being constantly improved for more specific and precise control over the impact of Mycoplasma and Chlamydia infections on male fertility.

Background: Three recent prospective studies have suggested that the 1-g dose of azithromycin for Chlamydia trachomatis (Ct) was less effective than expected, reporting a wide range of treatment failure rates (5.8%-22.6%). Reasons for the disparate results could be attributed to geographic or methodological differences. The purpose of this study was to reexamine the studies and attempt to harmonize methodologies to reduce misclassification as a result of false positives from early test-of-cure (TOC) or reinfection as a result of sexual exposure rather than treatment failure., Methods: Men who had sex with women, who received 1-g azithromycin under directly observed therapy for presumptive treatment of nongonococcal urethritis with confirmed Ct were included. Baseline screening was performed on urethral swabs or urine, and TOC screening was performed on urine using nucleic acid amplification tests. Posttreatment vaginal sexual exposure was elicited at TOC. Data from the 3 studies were obtained and reanalyzed. Rates of Ct retest positive were examined for all cases, and a sensitivity analysis was conducted to either reclassify potential false positives/reinfections as negative or remove them from the analysis., Results: The crude treatment failure rate was 12.8% (31/242). The rate when potential false positives/reinfections were reclassified as negative was 6.2% (15/242) or when these were excluded from analysis was 10.9% (15/138)., Conclusions: In these samples of men who have sex with women with Ct-related nongonococcal urethritis, azithromycin treatment failure was between 6.2% and 12.8%. This range of failure is lower than previously published but higher than the desired World Health Organization's target chlamydia treatment failure rate of < 5%.

Introduction: Gonorrhea and chlamydia are sexually transmitted infections (STI) that are the most common causes of urethritis in men. The role of specific sexual behaviors and presentation of urethritis is often overlooked., Methods: Data was retrospectively reviewed on all men presenting at the major STI clinic in Providence, Rhode Island. Predictors of gonorrhea and chlamydia infection were modeled using a generalized model assuming a binary distribution., Results: Of the men with urethritis, 27% had chlamydia, 13% gonorrhea, 3% both, and 63% neither (non-gonococcal, non-chlamydial urethritis). MSM were more likely to test positive for gonorrhea than MSW (25% of MSM versus 6% of MSW; p<0.01)., Conclusions: MSM with urethritis were much more likely to test positive for gonorrhea which may be due to increased risk behaviors and spread within concentrated sexual networks. A large number of both MSM and MSW had non-gonococcal, non-chlamydial urethritis, which suggests the need for improved diagnostic testing. [Full article available at http://rimed.org/rimedicaljournal-2016-06.asp, free with no login].

The article shows the high efficacy of the additional local use of the drug Miramistin in combination therapy of chronic urethritis, associated with sexually transmitted infections (STIs). In accordance with the principles of evidence-based medicine, patients were assigned to the study group (n=110) treated with conventional therapy and Miramistin, and the comparison group (n=40) treated with conventional therapy only. The between-group comparison of treatment effectiveness was carried out by matching results of the etiological healing, the changes of the endoscopic picture of the urethra, and basic clinical manifestations of STI: the degree of inflammatory reaction of urethral mucous membrane, dysuria, pain and sexual syndrome.

We present eight cases and review the literature of concurrent urethritis and conjunctivitis where adenovirus was identified as the causative pathogen. The focus of this review concerns the identification of specific sexual practices, symptoms, signs and any serotypes that seem more commonly associated with such adenovirus infections. We discuss the seasonality of adenovirus infection and provide practical advice for clinicians to give to the patient., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

There are problems in attributing causality in inflammatory arthritis. So far as C. trachomatis and sexually acquired reactive arthritis are concerned, there is much in favour of a causal relationship, although there are important caveats which need to be explored before it is possible to say unreservedly that C. trachomatis plays a causative role in reactive arthritis. For example, micro-organisms have never been cultured from synovial effusions in early disease, and only once has substantial benefit of antimicrobial treatment been reported. The claim that ocular strains of C. trachomatis are of over-riding importance in pathogenesis needs confirmation before it can be accepted. No conclusion can be made about the possibility of other small intracellular bacteria in joints having a role in causing disease. However, if it can be shown that eradication of the micro-organism, which may be difficult to prove, coincides with clinical recovery, it would go some way to recognising causality. In spite of the recognised difficulties, antibiotic studies have an important role in identifying aetiology. They need to focus on very early disease and on eradication of intra-articular bacteria. Treatment of established disease is likely to be less informative. Although a combination of antibiotics might have a future in treating established disease, diagnosing and treating non-gonococcal urethritis as soon as possible should be the aim in order to prevent the development of reactive arthritis., (© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

This article provides an overview of infectious and inflammatory conditions associated with male infertility. These conditions may affect several components of the male reproductive tract and therefore have the ability to potentially alter sperm function. The effect of these conditions on male fertility is poorly understood and often underestimated., (Copyright © 2014 Elsevier Inc. All rights reserved.)

In this article we present the causes of urethral stenosis in the adult male and review data about incidence. Regarding disease physiopathology we emphasize the inflammatory causes and, more specifically lichen sclerosus, as the clinical scenario that presents the greater difficulty for the management of urethral stenosis since we do not know its natural evolution. Regarding treatment of urethral stenosis we discuss the various options from excision and terminal-terminal anastomosis to oral mucosal graft augmentation urethroplasty, passing by two-step operations in more severe cases. Looking forward to the future a real gate opens with the application of tissue engineering to obtain oral mucosa.

Objective: To estimate the prevalence of and risk factors for cutaneous lesions of the scrotum and intrascrotal lesions/anomalies among men included in a prostatic cancer screening program in a Brazilian metropolitan city., Design and Setting: Cross-sectional study, private outpatient healthcare service., Methods: 1731 men aged 40 years or over, participating in a prostate cancer screening program conducted by the municipal public employees' healthcare system, underwent systematic urological assessment by a single examiner., Results: The prevalence of scrotal diseases in our sample was 44.7% (773/1731). Tinea cruris occurred in 203 (11.7%) of the participants, with higher risk among diabetics and lower prevalence among nonwhite individuals; scrotal tinea in eight (0.5%), with higher risk among hypertensive men; subcutaneous nodules in 12 (0.7%), especially in individuals with low schooling level; hydrocele in 283 (16.4%), with higher frequency among participants over the age of 60 years, diabetics or individuals with previous histories of nonspecific urethritis; spermatoceles in 174 (10.1%), with greater prevalence among individuals over the age of 60 years or diabetics, and lower frequency among individuals who underwent vasectomy; unilateral testicular hypotrophy/atrophy in 167 (9.7%) and bilateral hypotrophy/atrophy in 93 (5.4%), both occurring more frequently in individuals over the age of 60 years; absence of palpable testicles due to cryptorchidism in 7 (0.4%); and epididymitis/orchitis in 5 (0.3%), with higher prevalence among diabetics. No cases of cancer were identified in this sample., Conclusions: Scrotal diseases were highly prevalent in this population of Brazilian men.

Mycoplasma genitalium is an important cause of sexually transmitted infections that is gaining recognition and is an independent cause of acute and chronic nongonococcal urethritis in men. M. genitalium has been implicated as a possible causative factor in reactive arthritis. We report a case of reactive arthritis complicating M. genitalium urethritis in an HLA-B27-positive patient., (© 2013.)

Corynebacterium propinquum is usually considered part of the normal human oropharyngeal flora and is rarely responsible for clinical infection. We report here what seems to be the first case of acute purulent urethral discharge in a young Iranian man with urethritis acquired after orogenital contact. Attention should be devoted to less common nondiphtheriae Corynebacterium species for differential diagnosis.

Pharyngeal chlamydial and gonococcal infections can occur as a consequence of oral sex, and they also can be transmitted from the pharynx to the genital tract of sex partners. There have been many reports on the prevalence of pharyngeal Chlamydia trachomatis and Neisseria gonorrhoeae in men who have sex with men; however, there have been few reports on the prevalence of these pathogens in the pharynges of heterosexual men. In this study, we determined the prevalence of pharyngeal C. trachomatis and N. gonorrhoeae in 42 heterosexual men diagnosed with urethritis. Pharyngeal swabs and first-voided urine specimens were tested using the Gen-Probe APTIMA Combo 2 transcription-mediated amplification assay. The prevalence of pharyngeal C. trachomatis and N. gonorrhoeae in patients with urethritis was 2.4 % (1/42) and 11.9 % (5/42), respectively. Among patients with either chlamydial or gonococcal urethritis, 9.1 % (1/11) and 25.0 % (5/20) had pharyngeal C. trachomatis or N. gonorrhoeae, respectively. Our results suggest that screening for pharyngeal colonization by N. gonorrhoeae and C. trachomatis using validated nucleic acid amplification tests should be performed in heterosexual men diagnosed with urethritis.

Objectives: To conduct a case-control study of abnormalities in the semen of genitourinary (GU) medicine clinic attendees compared with general practice (GP) controls and in patients with asymptomatic and symptomatic non-specific urethritis (NSU) before and after the urethritis resolves., Methods: Rates of semen abnormalities were compared between the different groups (19 with symptomatic and 27 with asymptomatic NSU, seven with symptomatic non-NSU and 64 clinic controls) and between clinic attendees and 417 patients attending GP for the first investigation of possible infertility. Those with symptomatic or asymptomatic NSU gave repeat semen samples on resolution of the NSU., Results: The study included 117 clinic volunteers. They were shown to have statistically significantly worse total sperm counts (p=0.002), volume of semen (p<0.001) and percentage of abnormal forms (p<0.04) compared with 417 GP controls. Compared with the rest of the clinic volunteers, asymptomatic NSU patients had statistically significantly lower total sperm counts (p<0.02). Asymptomatic NSU patients had statistically significantly lower total sperm counts compared with symptomatic NSU patients (p<0.02). Compared with GP controls, clinic controls had statistically significantly inferior total sperm counts (p=0.009) and semen volume (p<0.001)., Conclusions: GU clinic attendees are more likely to have abnormalities of semen than patients attending GP for the first check for possible infertility. A high rate of abnormal semen findings are found in patients with and without NSU but the highest rate occurred in those with asymptomatic NSU. Is asymptomatic NSU therefore pathogenic and does it require treatment like symptomatic NSU?

Objectives: Chlamydia trachomatis and Ureaplasma urealyticum are common pathogens of sexually transmitted diseases. The majority of human ureaplasma isolates belong to the new species U. parvum. Clinically, C. trachomatis and U. parvum usually double infect in the nongonococcal urethritis patients. A novel method for simultaneous detection of C. trachomatis and U. parvum was set up in the present work., Design and Methods: Multiple real-time quantitative PCR was developed to allow for rapid, sensitive, specific and quantitative detection of C. trachomatis and U. parvum, simultaneously. To evaluate the applicability of the multiplex real-time quantitative PCR assay to clinical specimens, 64 samples of cervical swabs collected were studied., Results: Compared to the results obtained from single real-time quantitative PCR of C. trachomatis and U. parvum, the specificity, sensitivity and quantitative detection results of multiple real-time quantitative PCR are approximately identical with those of the former., Conclusions: This assay will be of great value in the simultaneous and rapid diagnosis of C. trachomatis and U. parvum in the future., (Copyright © 2012 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.)

Objective: To identify the etiology and current clinical characteristics of male urethral stricture disease (USD) in Senegal., Patients and Methods: A retrospective and mono-centric study over a 10-year period (between January 1999 and December 2008) was carried out and included all male patients with USD admitted to the Urology Department of Aristide Le-Dantec Hospital (Dakar)., Results: We recorded 414 USD cases. The maximum annual incidence was observed in 2004, and from then, the incidence tended to decrease gradually. The mean age of patients was 43.7 ± 19.6 years (1-89 years), and 43% of patients were younger than 40 years old. The mean time from symptoms onset to the consultation was 20.1 ± 24.9 months (1-120 months). Most patients (42.2%) were admitted because they suffered dysuria. In 57.8% of patients, USD was diagnosed with complications. The most common site of stricture was at the bulbar urethra (72.7%). The length of the urethral stricture was smaller than 1 cm in 59.6% of patients, between 1 and 3 cm in 28.5% and between 3 and 5 cm in 7.7%. The stricture was longer than 5 cm in eight patients and was staged (multifocal) in nine patients. The etiology of urethral stricture was infectious in 63% of patients, traumatic in 13.7% and iatrogenic in 8.2%. The etiology was not identified in 14.9% of cases. The infectious etiology was urethritis in 259 cases and urogenital schistosomiasis in 12 cases. A study of the etiology according to stricture site showed that bulbar USD was infectious in 77.7% of cases and that all membranous USD cases were traumatic., Conclusion: Male urethral stricture in Senegal is often a sequela of gonococcal urethritis and is frequently detected because of infectious complications such as gangrene of the genitalia or urinary tract infections. Its prevention in this geographical region thus requires fighting against sexually transmitted infections and treating appropriately and effectively all urethritis.

A 27-year-old man who has sex with men presented with a painful lesion at the urethral meatus. A diagnosis of genital herpes was suspected, and initial tests for sexually transmitted infections (STIs), including syphilis serology, were negative. However, a polymerase chain reaction (PCR) swab for Treponema pallidum from the lesion was positive, and a diagnosis of chancre of primary syphilis at the meatus was made. Subsequently, the patient required urological surgery due to the formation of a urethral stricture. Chancre at the meatus and development of stricture are unusual complications of syphilis that may become more common in the future with increasing case numbers. We also discuss the development of PCR as a useful test for early primary syphilis.

Penile injury is common as an emergency and should be accurately diagnosed and treated. We analysed 22 patients with penile injury admitted to the emergency unit of Dubrava University Hospital during a 4-year period. According to the American Association for the Surgery of Trauma five-grade classification of penile injuries, there were 14 grade I, 6 grade II and 2 grade III cases. Diagnosis was mainly based on clinical and ultrasonography findings, and in some cases on cavernosography. Nineteen patients underwent immediate surgery and three patients received conservative therapy. On outpatient follow up, sexual function was assessed by use of the 5-item International Index of Erectile Function (IIEF-5) test at 3 and 12 months of injury. At 3-month follow up, moderate, mild and no erectile dysfunction was recorded in 5, 6 and 11 patients respectively (mean IIEF-5: 19.62). At 12-month follow up, mild erectile dysfunction was found in only one patient (IIEF-5: 20), whereas all other patients were free from erectile dysfunction (mean IIEF-5: 23.75). The 12-month follow up yielded a higher statistical difference (P < 0.001) when compared with 3-month follow up. Study results indicated that appropriate treatment of penile injuries resulted in complete recovery of sexual function within 12 months., (© 2011 Blackwell Verlag GmbH.)

Introduction: Urethral strictures remain a reconstructive dilemma, due to high incidence of recurrence and less than satisfactory outcomes. Even experienced surgeons following strict surgical principles have not achieved optimal results, leading us to think whether the etiology of strictures dictate the outcome . We evaluated this "cause-effect" relationship highlighting the significance of the etiology on the overall prognosis of urethral strictures., Materials and Methods: A total of 302 males with urethral strictures were assessed (both retrospectively and prospectively) over a period of ten years. The preoperative evaluation was performed by retrograde urethrogram, urethrosonogram, and uroflowmetry and categorized, based on etiology: a) as post traumatic, b) post infective, c) iatrogenic or d) unknown. Traumatic strictures were subjected to pelvic X-ray and sub-categorized into grades A, B and C, following the TILE classification. Patients were operated; with tunica albuginea urethroplasty for anterior strictures and U shape prostato-bulbar anastomosis for posterior strictures., Results: Traumatic strictures accounted for 54% of cases. 127 of the 302 patients were treated using Tunica Albuginea Urethroplasty, while U shaped Prostatobulbar Anastomosis was performed on others. Post traumatic strictures had best outcome whereas post infective strictures had the worse outcome. Among strictures following pelvic fractures, TILE grades A and B had a better post operative course as compared to TILE C. Overall complication rate was 13.24%., Conclusion: Our study demonstrated that etiology of urethral strictures may play a vital role for the overall prognosis of urethral strictures.

The study is aimed at investigation of efficacy and safety of a combined effect of laser therapy and vibromagnetotherapy in complex treatment of patients with chronic urethroprostatitis in the presence of sexually transmitted infection (STI). A total of 35 males aged 20 to 51 years entered the study. They were divided into 3 groups. Group 1 received standard basic therapy, group 2 received basic and laser therapy, group 3 - basic treatment and laser plus vibromagnetotherapy. Effectiveness of the treatment was assessed by the evidence obtained from clinical, bacteriological, device and functional examinations. The results of the treatments were evaluated after 2 weeks of the follow-up. It is shown that patients of groups 2 and 3 achieved more pronounced improvement of clinical and laboratory indices, parameters of basal blood flow. Thus, physiotherapy, added to antibacterial treatment, is safe and effective in the treatment of chronic urethroprostatitis and STI.

Background: Approximately 25% of carcinoid tumors develop in the respiratory system. Neuroendocrine carcinoids represent ~5% of all mediastinal tumors and 1-5% of all intrathoracic neoplasms. They contain numerous neurosecretory granules that synthesize, store and release neurohumoral substances that can induce the carcinoid syndrome., Clinical Case: A 21-year-old male presented with a rapidly progressive paraneoplastic syndrome unleashed by an acute urethritis. Two left mediastinal masses were identified and resected. Postoperative evolution has been uneventful during the first year., Conclusions: We emphasize the importance of early detection of primary and satellite lesions of these tumors including neurohumoral markers and PET/CT scans as in this case, as well as the participation of a multidisciplinary team.

A multidisciplinary approach is mandatory in defining the cause and directing the treatment of childhood urinary incontinence. Both pediatricians and pediatric urologists should carefully evaluate a child with incontinence for possible overlapping etiologies, before labeling him or her as a refractory case. We report an epileptic boy with dysfunctional elimination syndrome (DES) with associated rare complications of giggle incontinence and idiopathic urethritis, proving the need for a good voiding diary, patient history and structured symptom scores.

Reactive arthritis (ReA) was first described 100 years ago. It is defined as a sterile joint inflammation following a primary, extra-articular infection often in the form of urethritis or enteritis and less frequently respiratory infection and is characterized by the presence of bacterial antigens or non-culturable bacteria in the joint,. The prevalence is estimated to be 40/100,000 adults, while the incidence is 4-5/100,000. The classic HLA-B27-associated form with asymmetric involvement of the lower extremities and/or the spine is part of the spondyloarthritis concept. The phenomenon of persistence, which will be discussed in detail herein, plays an important role in the pathogenesis of ReA. Up to 30% of patients develop chronic symptoms posing a therapeutic challenge. Combination antibiotic treatment showing a response in up to 63% of patients has recently been proposed. Biologics could represent an alternative therapeutic option for patients showing a severe and highly active disease course.

Symptoms of urethritis in men typically include urethral discharge, penile itching or tingling, and dysuria. A diagnosis can be made if at least one of the following is present: discharge, a positive result on a leukocyte esterase test in first-void urine, or at least 10 white blood cells per high-power field in urine sediment. The primary pathogens associated with urethritis are Chlamydia trachomatis and Neisseria gonorrhoeae. Racial disparities in the prevalence of sexually transmitted infections persist in the United States, with rates of gonorrhea 40 times higher in black adolescent males than in white adolescent males. Recent studies have focused on identifying causes of nongonococcal urethritis and developing testing for atypical organisms, such as Mycoplasma genitalium and Ureaplasma species. Less common pathogens identified in patients with urethritis include Trichomonas species, adenovirus, and herpes simplex virus. History and examination findings can help distinguish urethritis from other urogenital syndromes, such as epididymitis, orchitis, and prostatitis. The goals of treatment include alleviating symptoms; preventing complications in the patient and his sexual partners; reducing the transmission of coinfections (particularly human immunodeficiency virus); identifying and treating the patient's contacts; and encouraging behavioral changes that will reduce the risk of recurrence. The combination of azithromycin or doxycycline plus ceftriaxone or cefixime is considered first-line empiric therapy in patients with urethritis. Expedited partner treatment, which involves giving patients prescriptions for partners who have not been examined by the physician, is advocated by the Centers for Disease Control and Prevention and has been approved in many states. There is an association between urethritis and an increased human immunodeficiency virus concentration in semen.

We report a case of reactive arthritis in a 21-year-old man who was successfully treated with methotrexate. In July 2008, the patient experienced arthritis in the left knee 3 days after being diagnosed as having urethritis by the urology clinic. The patient was treated with loxoprofen sodium and fosfomycin calcium at an orthopedic clinic. Antibiotics induced clinical improvement of urethritis, although arthritis became worse. Even after sulphasalazine and corticosteroid were started, polyarthritis remained persistent. Finally, methtrexate was added ; thereafter, polyarthritis and elevated CRP were resolved. HLA-B270502 was positive. Methotrexate could be one of the choices for sulphasalazine-resistant reactive arthritis.

We report a case of Chlamydia-associated arthritis in a 40-year-old man. The patient experienced four episodes of Chlamydia trachomatis urtethritis within a few years. During the present episode, polyarthritis developed a few days after Chlamydia trachomatis urethritis was noted. The patient was diagnosed as having Chlamydia-associated arthritis. Loxoprofen sodium and azithromycin were started. Antibiotics induced clinical improvement of urethritis, although arthritis persisted for 3 months. HLA-B27 was negative, but both HLA-B35 and B40 were positive. Thus, we speculate that positivity for both HLA-B35 and HLA-B40 contributed to the persistence of arthritis in this case. During the course, the levels of Th1, Th17 and regulatory T cells in the peripheral blood were increased on flowcytometry. Thus, we speculate that Th17 may play, at least in part, an important role of the pathogenesis in this case.

Objectives: To investigate prevalence of Mycoplasma genitalium, Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis in men, frequency of co-infections, and association of organisms with urethritis in men., Methods: This was a cross-sectional study of 290 men (age range 19-34 years) attending Baltimore City STD clinics. M genitalium, C trachomatis, N gonorrhoeae and T vaginalis, during 2004 were detected using nucleic acid amplification tests (NAATs) (153 with urethritis and 137 without urethritis). Demographic characteristics and risk factors were ascertained., Results: The overall prevalences of infection with C trachomatis, N gonorrhoeae, T vaginalis and M genitalium were 20.3%, 12.8%, 3.4% and 15.2%, respectively. Prevalences in men with urethritis were 32.7%, 24.2%, 5.2% and 22.2% for C trachomatis, N gonorrhoeae, T vaginalis and M genitalium, respectively. Percentages of co-infections were high. All men with N gonorrhoeae had urethritis. C trachomatis and M genitalium were found to be significantly associated with urethritis in univariate analysis and in multiple logistic regression analysis., Conclusion: The association of M genitalium with urethritis in this study provides confirmation of the importance of screening men for M genitalium as a cause of non-gonococcal urethritis and supports treatment considerations for urethritis for agents other than gonococci and chlamydia.

Idiopathic urethritis is a disorder that typically occurs in male children between the ages of 5 and 15 years. The commonest symptoms are blood stained urethral discharge, urethral bleeding between episodes of micturition and dysuria. As the aetiology is poorly understood, there is no reliable means of treating this condition. In this case report we describe the use of intravesical steroid instillation in such patients to alleviate symptoms.