NON-GONOCOCCAL URETHRITIS

URETHRITIS

It is a condition in which the urethra, or the tube that carries urine from the bladder to outside the
body, becomes inflamed and irritated. Semen also passes through the male urethra. Typically causes
pain while urinating and an increased urge to urinate. The primary cause of urethritis is usually
infection by bacteria.

Urethritis is not the same as a urinary tract infection (UTI). Urethritis is an inflammation of the urethra,
while a UTI is an infection of the urinary tract. They may have similar symptoms, but require different
methods of treatment depending on the underlying cause of the urethritis.

Urethritis affects people of all ages. Both males and females can develop the condition. However,
females have a greater chance of developing the condition than males. This is partly because mens
urethras, which are the length of the penis, are much longer than womens. A womans urethra is
typically one and a half inches long. That makes it easier for bacteria to enter the urethra.

TYPES OF URETHRITIS

There are different types of urethritis, classified by the cause of the inflammation. They are gonococcal
urethritis and nongonococcal urethritis.

Gonococcal urethritis is caused by the same bacterium that causes the STI gonorrhea. It accounts
for 20 percent of cases of urethritis. Nongonococcal urethritis is urethritis caused by other infections
that are not gonorrhea. Chlamydia is a common cause of nongonococcal urethritis, with other STIs also
being a probable culprit.

It is possible, however, for irritation unrelated to STIs to occur. These causes can include injury, such
as from a catheter, or other kinds of genital trauma. While plenty of patients have either one type of
urethritis or the other, its possible to have different causes of urethritis at once. This is especially true
in women.

What is NGU or non-gonococcal urethritis?

It is an infection of the urethra (the tube running from the bladder through the penis in men or the
labia in women through which urine passes) caused by some agent other than gonorrhea. This
infection can be caused by any of several different organisms, although the most frequent cause of
NGU is a bacteria called Chlamydia, and is a sexually transmitted disease (STD).

CAUSATIVE AGENTS OF NON-GONOCOCCAL URETHRITIS

Chlamydia trachomatis

Trichomonas vaginalis an STI caused by a tiny parasite

Mycoplasma genitalium tests for this condition have only recently been developed and are not
available in all clinics yet; if you can't be tested, you will be treated as though you might have it

a urinary tract infection

the herpes simplex virus this can also cause cold sores and genital herpes

an adenovirus usually causes a sore throat or an eye infection

NON-INFECTIOUS CAUSES

It's possible for NGU to have a non-infectious cause. This is when something else leads to the urethra
becoming inflamed.

Non-infectious causes of NGU include:

irritation from a product used in the genital area such as soap, deodorant or spermicide

damage to the urethra caused by vigorous sex or masturbation, or by frequently squeezing the
urethra some men may do this if they're worried they have an infection

damage to the urethra caused by inserting an object into it, such as a catheter this can be
done during an operation in hospital
WHO GETS NGU?

NGU is most often found in men since the organisms causing this infection are sexually transmitted
and the female urethra is seldom infected during intercourse. Men between the ages of 15 and 30
having multiple sex partners are most at risk for this infection. Also those who are sexually active,
have had unprotected sex, and have recently a new sexual partner.

TRANSMISSION OF THE DISEASE

Sexual

Most germs that cause NGU can be passed during sex (vaginal, anal or oral) that involves direct
mucous membrane contact with an infected person.
These germs can be passed even if the penis or tongue does not go all the way into the vagina,
mouth or rectum, and even if body fluids are not exchanged.

Nonsexual

Urinary tract infections.

An inflamed prostate gland due to bacteria (bacterial prostatitis).
A narrowing or closing of the tube in the penis (urethral stricture).
A tightening of the foreskin so that it cannot be pulled back from the head of the penis
(phimosa).
The result of a process such as inserting a tube into the penis (catheterization).

Perinatal

During birth, infants maybe exposed to the germs causing NGU in passage through the birth
canal. This may cause the baby to have infections in the: eyes (conjunctivitis) ears, lungs
(pneumonia)

EARLY HISTORY OF NON-GONOCOCCAL URETHRITIS

Gonorrhea simplex was distinguished from Gonorrhea virulenta in the 18th century, an indication that
even at that time there was an appreciation of the existence of two different sorts of disease. However,
it was not until after 1879, the time when Neisser discovered the gonococcus, that the term
urethritis nongonorrhoica was coined.

In 1904, Ludwig Waelsch described mild nongonococcal urethritis and said it was difficult to cure, a
clinical comment well appreciated to this day. The first event in understanding the microbial etiology of
NGU may be traced back to 1903 when Neisser, who was interested in doing experimental work on
syphilis in monkeys, made an expedition to Java. He took with him Ludwig Halberstaedter and
Stanislaus von Prowazek who, not much to Neisser's liking, inoculated the eyes of orangutans with
trachoma material and found that they developed conjunctival inclusions.

Later, similar inclusions recognized as being caused by an infectious agent, which was at first
named Chlamydozoa, were found in what is now a familiar triad, namely the conjunctiva of infants,
the cervix of mothers, and the urethral scrapings from male partners with NGU, or in what was called,
at that time, Waelsch urethritis.

In the 1930s and later, Philip Thygeson and others in the United States confirmed the babymother
NGU relationship. In the United Kingdom in the 1940s, Arthur Harkness, a venereologist working at a
urological center in London and a contemporary of Thomas Parran, undertook a comprehensive
reappraisal of NGU which, embodied in a monograph published in 1950, reawakened interest in the
condition. His observations confirmed that chlamydial organisms had an important role although, of
course, they had not yet been isolated and Harkness did not have the techniques that became
available later to look at this relationship.

Chlamydia trachomatis
Is a Gram-negative bacterium and is an obligate intracellular parasite. It exists in two forms an
infectious form and an intracellular form. The infectious form is the elementary body and the
intracellular form is the reticulate body. The reticulate body uses the host cells to replicate and
multiply. Approximately two hours after the elementary body enters the cell it transforms into the
reticulate body, and they grow and divide over the next several hours. The reticulate bodies then
transform into elementary bodies and once the host cell bursts (48 to 72 hours after infection) the
elementary bodies are released to infect new host cells.

VIRULENCE MECHANISMS:

Chlamydia trachomatis has several virulence factors. These include the polymorphic outer membrane
autotransporter family of proteins, the putative large cyotoxin, type three secretion effectors, stress
response proteins, and proteins or other regulatory factors produced by the plasmid. The polymorphic
outer membrane autotransporter family of proteins helps with adherence to host cells and modulating
inflammation. The type three secretion effectors promote delivery of the effector proteins after making
contact with the host cell. The chlamydial toxin causes actin reorganization in a manner similar to
clostridium toxin B. The plasmid contributes to the virulence as studies have shown that plasmidless
strains exhibit a loss of virulence in mice. Chlamydia trachomatis has the ability to sequester iron,
which appears to make it an important virulence factor in genital tract infections.

HOW IS IT CONTRACTED?

Chlamydia is transmitted primarily through sexual activity. The following are the most common ways:
unprotected intercourse (vaginal, anal) with an infected partner oral sex, although a less common
cause of infection as bacteria Chlamydia trachomatis targets the genital area rather than the throat.
Although it is possible theoretically, the cases of infestation from mouth-to-penis and penis-to-mouth
contact are rare vagina, cervix, anus, penis or mouth contacting infected secretions or fluids which
means that contraction can occur even if the penis or tongue does not enter the vagina or anus
bacteria can travel from the vaginal area to the anus or rectum of women while wiping with toilet
paper sharing sex toys from mother to the newborn during vaginal childbirth through the infected birth
channel infection can be transferred on fingers from the genitals to other parts of the body (for
example, chlamydia can occur in the eyes)

EPIDEMIOLOGY
Urethritis is a common condition, accounting for several million clinic visits annually in the US. Non-
gonococcal urethritis (NGU) from chlamydia is four times as common as gonococcal urethritis (GU).
Chlamydia and gonorrhoea are the first and second most common reportable diseases to the US
Centers for Disease Control and Prevention (CDC). Worldwide, there are an estimated 62 million cases
of GU and 89 million of NGU yearly. An increased incidence of chlamydia in developed countries may
be a result of improved screening and/or more sensitive tests.

Chlamydia trachomatis is the most common reportable disease in the US; 1,401,906
chlamydial infections were reported to the CDC in 2013. The corresponding prevalence is 446.6
cases per 100,000 population, an increase from the previous year. In the US for 2013, reported
chlamydial infections in women were over 2 times more than the rate among men. This is most
likely to be a reflection of the fact that more women are screened for chlamydial infection. In
men, the highest prevalence rates were found in ages 20 to 24 years. In women, the highest
prevalence rates were in the 15 to 24 years age groups. Higher rates were found among people
who identify as black, Native American/Alaskan Native, or Hispanic.

Mycoplasma species and Ureaplasma species have been implicated in NGU but are also
frequent commensals in the urogenital tract. Consequently, their prevalence as disease-causing
agents is much more difficult to measure and there are no approved nucleic acid amplification
tests for these organisms. One study showed that the presence of Mycoplasma genitalium was
associated with a 6.5-fold increased risk of urethritis. Primary HSV, Trichomonas , and
adenovirus are generally considered rare causes of urethritis in the US. In other countries,
adenovirus (Australia) and Trichomonas vaginalis (Russia, India, Africa, and South America) are
more significant causes of urethritis.

SIGNS AND SYMPTOMS

Much of the time there are no symptoms, especially in females. When women do exhibit symptoms
they can be cystitis, a change in vaginal secretions, lower abdominal pain, and irregular bleeding. In
men the symptoms can include a discharge from the penis and mild irritation at the tip of the penis. In
both males and females as well as infants it can cause conjunctivitis. If left untreated it can cause
complications both in females as well as males. In women it can cause pelvic inflammatory disease
that can damage the Fallopian tubes. It can also cause salpingitis, a painful inflammation of the
Fallopian tubes. In men it can trigger joint inflammation as well and can affect sperm function and
fertility. In men under 35 it is the most common cause of epididymo-orchitis (inflammation of the
epididymis and testicles.

TREATMENT

Antibiotics such as Azithromycin and Doxycycline

Azithromycin found to be more effective than Doxycyline on M. genitalium and U. urealyticum

infections. Doxycycline is more effective than Azithromycin on Chlamydia. Azithromycin appears to be
an effective and safe alternative to doxycycline for the treatment of chlamydial and nonchlamydial
urethritis, and its single-dose administration is an advantage in terms of patient compliance.

For recurrent or persistent NGU Metronidazole with Erythromycin is recommended.

GOVERNMENT HEALTH PROGRAM

HIV and STD Prevention Program (2011)- DOH

Objective: Reduce the transmission of HIV and STI among the Most At Risk Population and General
Population and mitigate its impact at the individual, family, and community level.

Adolescent and Youth Health Program (AYHP)

Objective: The threat of HIV and other sexually related diseases

Reported cases increased substantially increased over the past year.Among the 15-24 year olds,
reported HIV infections nearly tripled between 2007 and 2008 from 41 cases to 110 per year, which is
substantial cause for alarm. In 2009, 15-24 year olds make 29% of all new infections; in 2009, the
number of new infections among 20-24 equals the number of new infections among 25-29; with
10 cases see July DoH AIDS Registry Report. The substantial increase from the past year can
be traced from the adolescents early engagement in health risk behaviour, due to serious
gaps of the knowledge on the dangers of drugs, as well as the cause as well as
causes on the transmission of STD and HIV AIDS , dangers of indiscriminate tattooing and body-
piercing and inadequate population education. Under this threat, young males are prone to
engaging in health risk behaviour and more young fermales are also doing the
same without protection and are prone to aggressive or coercive behaviours of others in the
community such that it often results to significant number of unwanted pregrancies,septic abortion
and poor self-care practices.

PREVENTION AND RISK REDUCTION

Abstinence from sex is the best form of prevention.

Using latex condoms from start to finish every time you have oral, vaginal or anal sex.
Having sex with only one uninfected partner whom only has sex with you (mutual monogamy).
Water-based spermicides can be used along with latex condoms for additional protection during
vaginal intercourse.
Use of spermicide is not recommended nor found to be effective for oral or anal intercourse.
Have regular check-ups if you are sexually active.
If you have an STD, dont have sex (oral, vaginal, anal) until all partners have been treated.
Prompt, qualified and appropriate medical intervention, treatment and follow-up are important
steps in breaking the disease cycle.
Know your partner(s). Careful consideration and open communication between partners may
protect all partners involved from infection.