Welcome to I-TECH HIV/AIDS Clinical Seminar Series

May 20, 2010

Sexually Transmitted Diseases: Genital Syndromes in Men

Julie Dombrowski, MD, MPHWith photos and selected slides from H. Hunter Handsfield, MD

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

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)

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

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”

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

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)

Treatment of Uncomplicated GonorrheaTreatment 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-infectionIs common. Include if chlamydia has not been ruled out.

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.

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

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

Differential Diagnosis of Urethritis

Non-Gonococcal*

Chlamydial infectionOther sexually

acquired pathogens

Non-sexually acquired

Gonococcal

*Also called non-specific urethritis

Gonorrhea versus NGU

GC NGU

Incubation period

2-5 d 7-14 d

Dysuria Prominent Mild or absent

Discharge amount

Copious Scant to moderate

Discharge type

Purulent Mucoid, mucopurulent

Comparison of Typical Discharge*

• Gonococcal • Non-gonococcal

*Cannot reliably distinguish on visual exam alone

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

Etiologies of NGU

Chlamydia trachomatis 15-40% (median 30%)*

Mycoplasma genitalium 15-25% (median 19%)*

Trichomonas vaginalis 5-15%

Ureaplasma urealyticum? Doubtful role

HSV (in absence of lesion)

2-3% (HSV-1 > HSV-2 in one study**)

Adenovirus 2-4%

No identified pathogen ~30-70%

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

Role of oral sex?

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

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

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

Male Genital InfectionsCase 3

PRESENTATION

• 24 year-old man

• History– ““Incredibly painful” urination for 2 days Incredibly painful” urination for 2 days – 2 lifetime female sex partners2 lifetime female sex partners– 1 new partner in the past 2 mo1 new partner in the past 2 mo– Last sex 4 days agoLast sex 4 days ago– Always used condoms with vaginal sex Always used condoms with vaginal sex – Oral sex (penile-oral & oral-vaginal)Oral sex (penile-oral & oral-vaginal)

Male Genital InfectionsCase 3

EXAM• Several small ulcers on

tongue• No groin lymphadenopathy• Meatal inflammation• Urethral discharge

moderate & clear

MICROSCOPY• >10 PMNs per high-

powered field

Picture source: O’Mahony, C. International Journal of STD & AIDS 2006; 17: 203-4.

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

Bacterial versus Viral NGU

CT MG Adeno HSV

Mod/severe dysuria

28% 20% 69% 78%

Meatal erythema 33% 26% 92% 89%

Bradshaw C et al. JID 2006;193:336-45

Consider acyclovir in patients with prominent dysuria and meatal inflammation

Male Genital InfectionsCase (#4)

• 34 year old HIV-infected man

• Intermittent ART• CD4 100• Weight loss, cough • Painful, swollen R testicle

7 days

Male Genital Infections Case #4 – Testicular Enlargement

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

“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

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

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

Thank you!Next session: June 3, 2010

R. Scott McClelland, MD: Contraception and HIV in Women

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