List of Abbreviations
HIV – human immunodeficiency virus
DNA – deoxyribonucleic acid
STI – sexually transmitted infections
EIA – enzyme immunoassay
NAAT – nucleic acid amplification tests (synonym: molecular biological studies)
ICD – International Classification of Diseases
MSM – men who have sex with men
NGU — nongonococcal urethritis
PCR – polymerase chain reaction
RCT – randomized controlled trial
RNA – ribonucleic acid
NASBA – nucleic acid sequence-based amplification.
FSU — first-stream urine
** - drug is included in the VED list
#- off-label (prescription of a drug outside of registered indications)
Terms and Definitions
Urethritis – an inflammatory disease of the urethra, in most cases of infectious origin.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Nongonococcal urethritis (NGU) is an infectious and inflammatory disease of the male urethra that is not associated with Neisseria gonorrhoeae. The main causative agents of NGU among STIs are Chlamydia trachomatis, Mycoplasma genitalium, and less frequently Trichomonas vaginalis, Herpes Simplex virus (HSV) types 1 and 2. A significant proportion of NGU cases are caused by microorganisms and viruses of the urogenital tract microbiota that are not classified as STIs. Another term used, "nonspecific urethritis," refers to a disease in which no established etiological agents are present. Although the term "nonspecific urethritis" is included in the International Classification of Diseases 10th Revision nomenclature, the term "Nongonococcal urethritis - NGU" is used by the majority of experts.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
C. trachomatis is the most frequent microorganism, causing 11–50% of NGU cases [1–4].
Urogenital chlamydial infection is the most common bacterial sexually transmitted infection (STI), detected predominantly in individuals aged 15–25 years. Infection with C. trachomatis occurs as a result of sexual contact (vaginal, oral, or anal). The risk of sexual transmission of the infection after a single vaginal contact is about 10%, and with regular contacts between two partners over 6 months, it is 55%. Partners of individuals with a chlamydial infection are very likely to be infected, making partner notification, subsequent screening, and treatment critically important [5].
A characteristic feature of chlamydial infection is the predominantly subjectively asymptomatic course of the disease in both men and women, which necessitates annual screening of individuals under 25 years of age for C. trachomatis for effective disease control.
Mycoplasma genitalium is a pathogenic microorganism relatively recently recognized as an STI pathogen capable of causing urethritis in individuals of both sexes, as well as cervicitis and pelvic inflammatory disease (PID) in women. M. genitalium was first isolated in 1981 from patients with urethritis of unclear etiology. They are pear-shaped, motile microorganisms possessing a terminal organelle used for adhesion to eukaryotic cells. Of all currently known bacteria, Mycoplasma genitalium has the smallest size, measuring 150–200 nm, and the smallest genome—580 kb, encoding 470 genes [13].
The proportion of M. genitalium in NGU ranges from 10% to 50%, depending on the geographic region and patient group [1, 3, 4, 6–8].
A multicenter study established that the prevalence of M. genitalium in NGU in the Russian Federation was 28.3% of cases [9, 10].
The proportion of M. genitalium in NGU is highest in acute urethritis. Conversely, in subjectively asymptomatic urethritis, this microorganism is detected less frequently and in lower concentrations [11, 12].
In 30–80% of NGU cases, neither C. trachomatis nor M. genitalium is detected, indicating the etiological role of other infectious agents [1, 2].
Ureaplasma spp. – representatives of the genus Mollicutes, were first isolated in 1954 from a patient with NSU [14]. In 1995, the genus Ureaplasma urealyticum was divided into two separate species: Ureaplasma urealyticum i Ureaplasma parvum. It should be emphasized that cultivation methods do not differentiate U.urealyticum from U.parvum. Despite the fact that when the bacteriological culture result is positive, the laboratory report indicates U.urealyticum. This is because cultivation methods were developed when the genus Ureaplasma included only a single species – Ureaplasma urealyticum. Therefore, the correct interpretation of a positive result for any culture-based study is Ureaplasma spp. (i.e., detection of both Ureaplasma urealyticum i Ureaplasma parvum).
It is important to emphasize that the role of Ureaplasma spp. in urogenital pathology is controversial due to their detection among clinically healthy individuals. The prevalence of Ureaplasma spp. accounts for 11–26% of cases of acute and chronic NGU [2-4, 15]. At the same time, it has been shown that Ureaplasma urealyticum is associated with NGU, while another species—Ureaplasma parvum—is more frequently detected in urethral biological material of healthy men [16].
Currently, the generally accepted international recommendation is the inexpediency of routine laboratory screening of clinically healthy men and women for the presence of Ureaplasma spp. without determining the species and degree of bacterial load, since in practice their detection generally leads to the prescription of unjustified antibiotic therapy, resulting in the selection of resistant strains of obligate STI pathogens and disruption of the normal host microbiota.
Trichomonas vaginalis was first described by Alfred Donné in 1837, and currently the proportion of these protozoa in the etiological spectrum of NGU in heterosexual men reaches up to 20% according to some reports [17].
Urogenital trichomoniasis in men is often asymptomatic, and individuals over 30 years of age are most frequently affected.
Infection caused by Trichomonas vaginalis is one of the few causes of NGU that is subject to mandatory reporting. Approximately 156 million people are infected worldwide annually [18].
Herpes simplex virus 1 and Herpes simplex virus 2 (Herpes simplex virus types 1 and 2, abbr. HSV-1,2) play an important role in the etiology of NGU. Characteristic herpetic lesions can be found in the area of the external urethral meatus, as well as throughout its length upon urethroscopy. The proportion of HSV-1 and -2 in NGU is estimated at 2–3%, but it can significantly increase in men practicing unprotected orogenital contacts [8, 19–20].
It should be noted that not all cases of herpetic urethritis present with the typical clinical picture of genital herpes [40]. When typing HSV, HSV type 2 is more frequently detected, although there are reports of an equal ratio of HSV types 1 and 2 [21].
Apparently, the ratio of HSV types 1 and 2 depends on how frequently orogenital contacts are practiced.
Although the etiology of a significant proportion of NGU remains undetermined, the role of other microorganisms in the development of NGU is substantially smaller. There is evidence of sporadic cases of urethritis caused by Giardia lamblia and Entamoeba histolytica [22, 23].
During unprotected anogenital sexual contact, contamination of the urethra with intestinal microflora occurs, representatives of which can serve as etiological agents of NGU [24].
Sporadically, the cause of NGU may be Neisseria meningitidis and other nongonococcal neisseriae, as well as Haemophilus spp., Streptococcus spp., Candida spp.
The first case of urethritis caused by N. meningitidis dates back to 1942, and such reports began to appear regularly starting from the 1970s. It has been established that various species of Neisseria are associated with NGU, but N. meningitidis is identified in 85% of cases [25].
To date, a large number of publications have emerged regarding the clinical significance of anaerobic microorganisms associated with bacterial vaginosis (in women—sexual partners) in the development of NGU in men. The results of early studies investigating the role of anaerobic microorganisms, conducted using bacteriological laboratory diagnostic methods, were contradictory [26]. The results of recent studies have demonstrated that bacteria associated with bacterial vaginosis (Gardnerella vaginalis, Atopobium vaginae, Mycoplasma hominis, etc.) can cause NGU [27].
In addition, there is evidence that urinary tract infection is the cause of NGU in 6% of cases [28].
Currently, routine screening of men for NGU in the absence of clinical symptoms of urethral inflammation is not recommended [29, 30].
1.3 Epidemiology of the Disease or Condition
Urethritis is the most frequent infectious and inflammatory disease of the male urogenital system. Generalized data on the prevalence of NGU are lacking because only certain STIs (C. trachomatis, T. vaginalis) are subject to mandatory reporting, while state statistical accounting of such an important etiological agent of NGU as M. genitalium is not yet implemented.
Chlamydial infection is one of the leading STIs alongside urogenital trichomoniasis. The incidence of chlamydial infection in the Russian Federation in 2020 was 19.4 per 100,000 population. A total of 28,413 patients with this infection were registered in the Russian Federation in 2020 [31].
In a number of countries, in particular the USA, Canada, the UK, and Scandinavian countries, a steady increase in the incidence of urogenital chlamydial infection has been noted since the 1990s. Thus, according to the European Centre for Disease Prevention and Control based on data from 26 European Union countries, the prevalence of chlamydial infection in 2017 was 146 per 100,000 population (409,646 cases), while significant variability in the detection rate of C. trachomatis infection was observed: the highest rate was 5,000 times greater than the lowest [32].
Young age (usually under 25 years) and behavioral risk factors, such as a history of prior STIs, inconsistent use of barrier contraception, and a new partner (or multiple partners) within the past year, are the main risk factors for acquiring the main etiological agents of NGU—C. trachomatis and M. genitalium [7, 33, 34].
1.4 Features of Coding the Disease or Condition
In accordance with the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), the following codes are used:
N 34.1 Nonspecific urethritis
Urethritis:
nongonococcal
non-venereal
A56.0 Chlamydial infections of the lower urogenital tract (used in the clinical guidelines for Chlamydial infection);
A59.0 Urogenital trichomoniasis (used in the clinical guidelines for Urogenital trichomoniasis)
A60 Anogenital herpesviral infection (used in the clinical guidelines for Anogenital herpesviral infection)
A63.8 Other specified sexually transmitted diseases + A 49.3 Mycoplasmal infection, unspecified (used in the clinical guidelines for M. genitalium urogenital diseases)
B37.4 Candidiasis of other urogenital sites (used in the clinical guidelines for Urogenital candidiasis)
B96.8 Other specified bacterial agents
1.5 Classification of the disease or condition
The currently accepted term is "Nongonococcal urethritis" (NGU), which will be used in these Methodological Recommendations (ICD code N 34.1).
Next, the disease code corresponding to the etiological agent of NGU is indicated according to ICD-10.
Clinical classification:
Stages of NGU:
1. Acute NGU
2. Chronic NGU
Course of NGU:
1. Manifest course
2. Asymptomatic course
Complications of NGU:
1. Uncomplicated
2. Complicated (specify)
1.6 Clinical presentation of the disease or condition
Subjective symptoms of NGU (complaints);
Urethral discharge
Discomfort in the urethral area
Pain/burning/stinging during urination, frequent urge to urinate, pollakiuria)
Objective symptoms (upon clinical examination):
Mucous, purulent, or mucopurulent urethral discharge (may be spontaneous or appear upon urethral massage)
Hyperemia and/or edema of the external urethral meatus
Dysuria
Pollakiuria
Indirect signs of NGU:
traces of discharge on underwear (a detailed interview can help exclude a non-inflammatory nature of the discharge, such as recent sexual contact or sexual arousal).
turbid urine with inclusions (threads, flakes)
exudate of various character obtained when collecting urethral biological material using a urogenital swab
Direct (subjective/objective) clinical symptoms and indirect signs of urethritis may be absent. A high concentration of etiological agents such as C. trachomatis and/or M. genitalium (high bacterial load) is positively associated with the presence of clinical symptoms of NGU [35,36].
Complications of NGU
Prostatitis – inflammatory process of the prostate gland (N41)
Vesiculitis – inflammatory process of the seminal vesicles (N49.0)
Epididymitis/epididymo-orchitis – inflammatory process of the epididymis/epididymis and testis (N45)
Balanoposthitis – inflammatory process of the glans penis and prepuce (N48.1)
Sexually acquired reactive arthritis (SARA) – <1% (M02)
Epididymitis can lead to reproductive disorders. Thus, in unilateral epididymitis, the probability of infertility is 20–35%, and in bilateral epididymitis, it is 80–87% [37,38].
Sexually acquired reactive arthritis (SARA)
SARA can occur as a result of C. trachomatis infection (the prevalence of SARA is 30–40 cases per 100,000 cases of chlamydial infection) [39,40].
In typical cases, the disease develops 1–4 weeks after the onset of NGU.
SARA is a multisystem disease that develops predominantly in young men who test positive for human leukocyte antigen (HLA) B27 and typically includes a combination of urethritis, conjunctivitis, and arthritis [41].
Asymmetric lesions of the knee, ankle, and foot joints are detected, and sacroiliitis occurs in 10% of cases. Arthritis is accompanied by morning stiffness and nocturnal pain. Concomitant musculoskeletal disorders are possible (up to 40% of cases): enthesitis, fasciitis, tenosynovitis, and dactylitis. About 10% of patients report general symptoms: malaise, nausea, weight loss, and fever.
One in three patients has eye involvement—conjunctivitis, less frequently uveitis. In the latter case, rapid irreversible vision loss is possible, which requires timely collaboration with an ophthalmologist.
Nephropathy occurs in half of the cases and is characterized by proteinuria, microhematuria, and aseptic pyuria.
Manifestations on the skin and mucous membranes include psoriasiform rash, erosive circinate balanitis, "geographic" tongue, stomatitis, oral ulcers, and nail dystrophy.
In most cases, symptoms of the disease resolve completely within 4–6 months, half of the patients experience relapses, and in 17% symptoms persist for more than 1 year. A serious complication of SARA is ankylosing spondylitis.
2. Diagnostics, medical indications and contraindications for diagnostic methods
Criteria for diagnosis.
The diagnosis of NGU is based on the medical history, evaluation of clinical and laboratory findings, and identification of an etiological agent other than Neisseria gonorrhoeae.
Indications for laboratory testing.
Presence of subjective symptoms (complaints): urethral discharge and/or discomfort in the urethra, discomfort in the area of the urinary tract.
Clinical symptoms of urethritis in men.
2.1 Complaints and Anamnesis
During the initial consultation, it is necessary to ascertain the patient's reason for seeking medical care, the nature of subjective symptoms (patient complaints), as well as [42,43]:
1) history of present illness: when symptoms appeared, dynamics of the pathological process, use of systemic and/or local medications for symptoms, presence and nature of symptoms in the sexual partner;
2) past medical history: social status, occupational hazards, somatic diseases, allergic history, alcohol use, drug use, smoking;
3) sexual history: sexual orientation, age of sexual debut, marital status, presence/absence of a regular sexual partner, nature of sexual contacts – vaginal, oral, anal, date of last sexual contact;
4) STI history: history of STIs, history of STIs in the sexual partner;
5) urological history: previous urological diseases, sexual dysfunction, infertility;
6) presence of STI risk factors: age under 25 years, multiple sexual partners and/or casual sexual contacts without barrier protection, urogenital infections in sexual partners, sexual assault, commercial sex work, men who have sex with men, drug use, alcohol abuse, homelessness.
2.2 Physical Examination
A thorough physical examination is performed [43,44]:
1) examination of the skin of the head, trunk, upper and lower extremities, skin appendages, visible mucous membranes, palpation of regional lymph nodes, and abdominal palpation;
2) palpation of the scrotal organs and penis, digital rectal examination of the prostate gland and seminal vesicles;
Differential diagnosis of NGU
Symptoms of NGU are differentiated from the following diseases and conditions:
Chronic prostatitis
Vesiculitis
Urinary tract infection
Spermatorrhea
Sexual arousal
Crystalluria
Benign prostatic hyperplasia (lower urinary tract symptoms)
Venerophobia
Genital allergy
Urinary tract infection is a clinical syndrome, one of the manifestations of which may be urethritis.
As a rule, a urinary tract infection is an acute pathological condition accompanied by fever and systemic intoxication: weakness, fatigue, and headache. Urinary tract infections are characterized by frequent urges to urinate and pollakiuria. Occasionally, patients report terminal hematuria: pain and blood at the end of urination, which indicates inflammation of the bladder neck.
In men, urinary tract infections manifest as acute pyelonephritis, prostatitis, or, less commonly, cystitis. The history often indicates recent hypothermia and/or cold-related illnesses. Additionally, urinary tract infections are typically accompanied by urolithiasis and/or diabetes mellitus, and prior urogenital surgeries.
Physical examination reveals tenderness in the lumbar region, lower abdomen, and upon digital rectal examination of the prostate gland.
Instrumental examinations reveal signs of urohydrodynamic disorders and/or the presence of calculi.
If these changes are detected, the patient requires specialized urological medical care.
Spermatorrhea, prostatorrhea – the discharge of semen/prostatic secretion from the urethra during defecation. It is often perceived by patients as a sign of an STI and prompts them to seek medical care. Spermatorrhea and prostatorrhea are based on functional disorders or diseases of the prostate gland: prostatic atony, chronic prostatitis, vesiculitis.
Crystalluria– the appearance of salt crystals in the urine: oxalates, urates, phosphates, mixed salts, accompanied by dysuria symptoms. The passage of small calculi with corresponding symptoms is also possible.
Sexual arousal is accompanied by the appearance of clear urethral discharge. This is a manifestation of the physiological function of the accessory glands, moistening the urethral mucosa and preparing it for ejaculation. A detailed history helps establish the nature of the discharge and rule out a diagnosis of NGU.
Benign prostatic hyperplasia (BPH) is often accompanied by dysuria and can mimic urethritis. It typically affects patients over 50 years of age. The disease is based on an increase in prostate volume and spasm of the muscles of the prostatic urethra and bladder neck. In some cases, dysuria significantly predominates over symptoms of urethral obstruction. However, detecting a prostate volume greater than 22 cm3 and adenomatous nodes in the periurethral zone helps verify the diagnosis of BPH.
Venerophobia develops in impressionable patients with elevated anxiety regarding STIs. Such patients tend to check for infection by repeatedly expressing discharge from the urethra. Following persistent efforts, the urethra becomes traumatized, and scant mucous discharge may indeed appear.
Genital allergy may develop in response to urethral instillations of various chemical substances. In such cases, allergic urethritis occurs, accompanied by clear discharge and urethral symptoms. Allergic reactions to latex and spermicidal agents are also possible.
2.3 Laboratory Diagnostics
Biological, chemical, and alimentary provocations are not performed to increase the diagnostic yield of STIs [43].
It is recommended that all patients with subjective and/or objective symptoms of urethritis undergo microscopic examination of urethral discharge (methylene blue and Gram stain) and/or microscopic examination of urine sediment to assess the severity of the inflammatory process (number of polymorphonuclear leukocytes - PMNLs), and as an incidental finding - the detection of Gram-negative diplococci inside PMNLs, Trichomonas vaginalis, and fungi of the genus Candida [45-48].
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments: The diagnosis of "urethritis" is confirmed by:
1. Detection of more than 4 PMNLs in five fields of view with the highest concentration of leukocytes at 1000x microscope magnification during microscopic examination
And/or
2. Detection of 10 or more leukocytes upon microscopic examination of the centrifuged sediment of the first 10–20 ml of urine, at 1000x microscope magnification in 5 fields of view with the highest concentration of leukocytes. The test is performed if threads are present in the first urine sample.
The quality of microscopy depends on the correct technique for obtaining biological material. The urogenital swab should be inserted 1 cm into the urethra. If urethral discharge is present, it can be used as the biological material, in which case inserting the urogenital swab into the urethra is not recommended [49].
The accuracy of the microscopic diagnosis of "urethritis" may decrease with a low degree of inflammatory reaction and leukocyte count in the specimen.
When using microscopy (Gram stain), Gram-negative diplococci may be detected; to determine whether they belong to Neisseria gonorrhoeae, additional microbiological (culture) or molecular biological testing must be performed. Microscopy of native urethral discharge is a highly specific, although poorly sensitive, method for detecting T. vaginalis. The absence of trichomonads upon microscopic examination of biological material from the urethra does not rule out the diagnosis of trichomonal urethritis [43, 50-52].
The sensitivity of microscopy for diagnosing urethritis depends on the time since the last urination. The optimal urine retention time for diagnosing urethritis in symptomatic men is 2–4 hours (IV, C).
Negative microscopy results do not imply the absence of urogenital infections, and the absence of urethritis symptoms does not rule out the presence of STI pathogens in the patient. In patients without subjective and objective clinical symptoms of urethritis, microscopic examination of urethral biological material is impractical [29]. In patients with symptoms of urethritis whose microscopic findings do not allow for the verification of the diagnosis of "urethritis", a repeat test is performed after overnight urine retention. To avoid morning bladder overfilling, patients should be advised to urinate late in the evening prior to the repeat visit and refrain from fluid intake for 3 hours before sleep [43].
It is recommended that all patients with subjective and/or objective symptoms of urethritis undergo molecular biological testing of urethral discharge for sexually transmitted infection pathogens (Neisseria gonorrhoeae, Trichomonas vaginalis, Chlamydia trachomatis, Mycoplasma genitalium) to identify the infectious agent [53,54,56-60, 65-67].
LoE AGoE 2Level of Evidence A (Grade of Recommendation 2)
Comments: Molecular biological methods for detecting N. gonorrhoeae, C. trachomatis, M. genitalium, and T. vaginalis have the highest sensitivity and specificity compared to other laboratory methods. Both urethral biological material and first-catch urine samples are used as biological material for testing [55, 61-64].
Reagent kits based on NAATs must be registered in accordance with the applicable legislation of the Russian Federation.
Detection of M. genitalium is entirely based on molecular biological assays—nucleic acid amplification tests (NAATs). When detecting M. genitalium, testing for macrolide and fluoroquinolone resistance mutations in the microorganism should be performed simultaneously whenever possible.
Detection of Trichomonas vaginalis in men is associated with age 30 and older, while clinical symptoms of urethritis are often absent [68-70].
It is recommended that all patients with subjective and/or objective symptoms of urethritis undergo the following examinations to identify the infectious agent when molecular biological tests are unavailable: microbiological (culture) examination of urethral discharge for gonococcus (Neisseria gonorrhoeae) and microbiological (culture) examination of urethral discharge for trichomonas (Trichomonas vaginalis) [43,53].
GrR ALE 2Level of Recommendations Assurance A (Level of Evidence - 2)
Comments: while possessing high specificity, microbiological examination for Neisseria gonorrhoeae and Trichomonas vaginalis is inferior in sensitivity to molecular biological methods [43].
It is recommended that patients undergo the following examinations as indicated for the purpose of diagnosing NGU [27,43]:
1) in the presence of erosive or vesicular rashes on the genitalia: molecular biological examination of urethral discharge for herpes simplex virus types 1 and 2 (Herpes simplex virus types 1, 2); molecular biological examination of biopsy and puncture specimens from organ and tissue lesions for Epstein-Barr virus (Epstein-Barr virus);
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
2) in the presence of a clinical picture of urogenital candidiasis, diabetes mellitus and/or metabolic syndrome, use of glucocorticoids, cytostatic drugs (antineoplastic agents and immunomodulators), or HIV-positive status, for the detection of fungi of the genus Candida spp. microbiological (culture) examination of urethral discharge for yeast fungi (genus Candida with species identification) or molecular biological examination of urethral discharge for fungi of the genus Candida with species identification is used.
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
3) In the presence of clinical symptoms of urethritis and negative laboratory test results for the aforementioned NGU pathogens, bacterial vaginosis-associated bacteria (in female sexual partners) may be considered as etiologic agents of the inflammatory process in the urethra. Considering that the development of bacterial vaginosis involves, in addition to G. vaginalis and A. vaginae, predominantly anaerobic bacteria—Sneathia, Leptotrichia, Megasphaera spp., Prevotella, BVAB2, etc.—such NGU can be conventionally designated as "anaerobic urethritis".
GGR BLEL 3Grade of Recommendation B (Level of Evidence 3)
Since most anaerobic bacteria are difficult to culture or unculturable, for routine laboratory diagnosis of "anaerobic urethritis", a molecular biological examination of urethral biological material is recommended for: the presence of Gardnerella spp., Atopobium vaginae, Sneathia spp., Leptotrichia spp., as well as a molecular biological examination of urethral discharge for opportunistic genital mycoplasmas (Ureaplasma parvum, Ureaplasma urealyticum, Mycoplasma hominis), which, although not classified as anaerobic bacteria, are also associated with bacterial vaginosis and are capable of causing urethritis in men [26,27].
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
It is recommended that all NGU patients be screened for syphilis, HIV, and viral hepatitis B and C to diagnose comorbid conditions [43,71,72]:
1) Determination of antibodies to Treponema pallidum in blood by enzyme immunoassay (EIA) and/or determination of antibodies to Treponema pallidum using nontreponemal tests (RPR, VDRL) (qualitative and semiquantitative assay) in blood serum.
1) Determination of classes M and G antibodies (IgM, IgG) to human immunodeficiency virus HIV-1 (Human immunodeficiency virus HIV 1) in blood; determination of classes M and G antibodies (IgM, IgG) to human immunodeficiency virus HIV-2 (Human immunodeficiency virus HIV 2) in blood.
2) Determination of hepatitis B virus surface antigen (HBsAg) (Hepatitis B virus) in blood and determination of hepatitis C virus antigen (Hepatitis C virus) in blood.
Level of reliability of recommendations CLevel of evidence validity 5Level of reliability of recommendations C (level of evidence validity 5)
Comments: tests are carried out in accordance with the incubation period for syphilis, viral hepatitis B, C, and HIV infection, or all sexual partners of the patient over the past 6 months are screened for these infections.
2.4 Instrumental Diagnostics
It is recommended that male patients undergo urethroscopy based on strict clinical indications (concomitant symptoms of infravesical obstruction) to rule out urethral stricture, foreign body, or urethral tumor; however, this invasive procedure should not be performed routinely. Urethroscopy is contraindicated during the acute phase of the inflammatory process [73].
GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4)
2.5 Other Procedures
It is recommended that patients consult a urologist when indicated to verify complications and determine further management strategies [43].
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments: consultation with a urologist is necessary in the presence of symptoms of prostatitis, epididymitis, urinary tract infection, infravesical obstruction, etc., to clarify the diagnosis.
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
Indications for NGU therapy
Presence of clinical and/or laboratory signs of urethritis
Identification of C. trachomatis and/or M. genitalium and/or T. vaginalis and/or other etiologic agents of NGU in urethral biological material (ruling out N. gonorrhoeae)
3.1 Conservative Treatment
Prior to treatment, the patient must be informed about the causes of their disease and its consequences for the health of the patient and their sexual partner(s) (see the "Patient Information" appendix). Additionally, the following should be discussed:
Potential adverse drug reactions
The necessity of disciplined adherence to medical recommendations regarding medication intake and follow-up care
The need to abstain from sexual contact, or, if impossible, to consistently use barrier methods of contraception (condoms) during all forms of sexual practice.
The most optimal management strategy for patients is verification of NGU during the patient visit based on clinical data and the results of microscopic examination, and prescribing treatment immediately upon receiving the results of molecular biological tests for STIs (N. gonorrhoeae, C. trachomatis, M. genitalium, and T. vaginalis). When these microorganisms are detected, patient management is carried out in accordance with the relevant clinical guidelines.
In situations where a longer wait for molecular biological test results is required, empirical treatment is recommended.
When choosing medications, one should keep in mind the complex susceptibility profile of one of the most significant etiologic agents of NGU—M. genitalium. According to foreign data, the rate of M. genitalium resistance to macrolides reaches 41.4%, and to moxifloxacin**—6.6% [74-77]
Furthermore, in the Moscow region, the detection rate of M. genitalium strains with resistance mutations to macrolides and fluoroquinolones for the period 2014–2018 was 7.4% and 9.8%, respectively; meanwhile, over the specified observation period, a 2.6-fold increase in M. genitalium mutations associated with macrolide resistance and a 1.9-fold increase in those associated with fluoroquinolone resistance were noted [78].
In addition, there is ample evidence that the treatment efficacy of M. genitalium infection with tetracyclines does not exceed 30–40% [79-80].
Treatment of NGU, caused by HSV-1,2 or Epstein-Barr virus, is carried out according to the relevant clinical guidelines.
It is recommended that patients receive empirical NGU treatment when test results for N. gonorrhoeae, C. trachomatis, M. genitalium, T. vaginalis, HSV-1,2, and Epstein-Barr virus are negative [81-86]:
First-line therapy: Doxycycline** 100 mg orally 2 times a day for 7 days
Alternative therapy: Macrolides
LoE AGoE 2Level of Evidence A (Grade of Recommendation 2)
Comments: first-line or alternative treatment regimens in the presence of clinical symptoms and laboratory signs of urethritis can be used for microorganisms sensitive to the drug (see package insert), including when urogenital mycoplasmas such as M. hominis or Ureaplasma spp. are detected in a clinically significant diagnostic quantity (104 CFU/mL or more, or 105 genome equivalents/mL or more).
It is recommended that male patients with NGU undergo treatment upon detection of Gardnerella spp. and/or other anaerobic microorganisms (Atopobium spp., Bacteroides spp., etc.) in the urethral biological material only: 1) in the presence of clinical and/or laboratory signs of an inflammatory process in the urethra; 2) upon exclusion of STIs (N. gonorrhoeae, C. trachomatis, M. genitalium, T. vaginalis, HSV-1,2) and other causes of NGU, and 3) upon establishing a diagnosis of bacterial vaginosis in the female sex partner [26,27,97]:
Lincosamides
or
Imidazole derivatives
or
other antimicrobials and antiseptics (ATC G01AX)
GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4)
Comments: medicinal products may be used to eliminate microorganisms sensitive to these medicinal products (see package insert). When choosing a treatment regimen for anaerobic urethritis, the presence of resistance of Atopobium vaginae to metronidazole should be taken into account**.
Patient management during treatment
In some patients, symptoms of urethritis often persist despite adequately administered treatment. Depending on the clinical features, persistent and recurrent urethritis are distinguished.
Persistent urethritis is defined as urethritis in which symptoms persist during and after drug administration, which may be due to treatment failure and/or reinfection and is detected in 15-25% of patients with acute NGU. Recurrent urethritis is defined as urethritis in which symptoms that resolved as a result of treatment reappear within 30-90 days after the end of therapy, which may be observed in 10-20% of patients [87-88].
In some patients with persistent and/or recurrent urethritis, infectious agents are re-detected due to reinfection: M. genitalium, C. trachomatis, T. vaginalis [89-91].
Patients with persistent/recurrent urethritis should undergo a follow-up clinical and laboratory examination 3-4 weeks after completing therapy [43,53]. Control laboratory testing is not indicated for patients who have received adequate NGU treatment in the absence of subjective and objective clinical symptoms of the disease. The completeness of the received NGU treatment should be assessed (low patient adherence to the treatment regimen: missed doses, vomiting, diarrhea).
It is necessary to rule out the possibility of reinfection, which will be indicated by unprotected sexual contacts that have occurred (including orogenital and anogenital ones).
If symptoms of urinary tract infection are present, a urological examination is required to rule out urethral stricture, chronic prostatitis, vesiculitis, chronic pelvic pain syndrome, and other pathological conditions.
The etiology of persistent or recurrent urethritis is multifactorial, while the etiological agent can be detected in less than half of the cases [92-94]. Retreatment is performed only if the diagnosis of "Urethritis" is confirmed based on the results of clinical and laboratory examination.
At the same time, the effectiveness of treatment should not be evaluated straightforwardly, since the persistence of urethritis symptoms does not always signify the continuation of the infectious process [95].
The patient should be informed that urethral discharge may persist for a long period of time despite the fact that the etiological agent will be eradicated as a result of treatment [96].
Treatment of patients with persistent/recurrent urethritis should be aimed at the eradication of C. trachomatis, M. genitalium, T. vaginalis, and other etiological agents.
As a rule, sex partners of patients with persistent/recurrent NGU who have received adequate treatment do not require a repeated prescription of antimicrobial therapy, although the possibility of treatment failure for M. genitalium infection in case of infection with a mutant strain should be considered.
TREATMENT REGIMENS FOR PERSISTENT/RECURRENT URETHRITIS
It is recommended to prescribe to patients with persistent/recurrent NGU who were prescribed doxycycline** during the initial NGU treatment [45, 92]:
macrolides + imidazole derivatives.
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments. The use of a single dose of azithromycin** for the treatment of NGU can no longer be recommended, as it has been established that such a low-dose regimen is a growth factor for M. genitalium resistance to macrolides. In studies by Moi H. et al. (2015), azithromycin** was used simultaneously with metronidazole** in standard therapeutic dosages for the treatment of persistent/recurrent urethritis.
It is recommended to prescribe to patients with persistent/recurrent NGU who were prescribed azithromycin** during the initial NGU treatment [45, 92]:
fluoroquinolones + imidazole derivatives
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments. In studies by Moi H. et al. (2015), fluoroquinolones and imidazole derivatives in standard therapeutic dosages were used in this case for the treatment of persistent/recurrent urethritis. Fluoroquinolones should be used with caution due to infrequent but serious adverse reactions. The growing level of resistance of M. genitalium strains to fluoroquinolones and macrolides should also be taken into account.
3.2 Surgical Treatment
Not applicable
3.3 Other Treatment
Pain management and dietary therapy are not used.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
Not applicable
5. Prevention and Dispensary Observation
It is recommended to implement primary prevention, which consists in the use of barrier contraceptive methods (condoms) for all types of sexual contact and reducing the number of sexual partners [43].
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments: Sexual partners of men with NGU are considered a high-risk group for STIs. There is evidence of STI detection in sexual partners of individuals with NGU [101].
Patients with NGU are recommended to abstain from sexual contact for seven days after they and their partners complete treatment, clinical symptoms of NGU resolve, and negative laboratory test results (for STIs) are obtained [43].
GCR CLEL 5Grade of Recommendations C (Level of Evidence 5)
Management of sex partners of patients with NGU
It is recommended to examine and, if necessary, treat all sex partners of a patient with NGU. It is suggested to examine partners with whom the patient had unprotected contact 4 weeks prior to the onset of clinical symptoms of urethritis. The necessity of examining and treating the sex partner of a patient with an STI to reduce overall morbidity has been proven, in particular, for all STIs [46].
GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)
Comments: examination and treatment of the sexual partner of a patient with suspected STI is an important component of any STI control programs.
6. Organization of Medical Care
Reporting of diagnosed STI cases
The legislation of the Russian Federation defines STI reporting forms to be completed by physicians of any specialty who diagnose an STI:
Two forms of state statistical surveillance: No. 9 — "Information on sexually transmitted infections, fungal skin diseases, and scabies" and No. 34 — Order of Rosstat dated 29.12.2011 No. 520 (as amended on 24.12.2018) "On Approval of Statistical Tools for Organizing Federal Statistical Surveillance by the Ministry of Health and Social Development of the Russian Federation over the Activities of Healthcare System Institutions"
Form No. 089/u-kv — "Notification of a patient with a newly established diagnosis of syphilis, gonococcal infection, trichomoniasis, chlamydiosis, urogenital herpes, anogenital warts, microsporia, favus, trichophytosis, foot mycosis, scabies", approved by the Russian Ministry of Health dated 02.03.2015 No. 13-2/25 On accounting form No. 089/u-kv "Notification of a patient with a newly established diagnosis of: syphilis, gonococcal infection, chlamydial infections, trichomoniasis, anogenital herpesviral infection, anogenital (venereal) warts, mycosis, scabies"; sent within 3 days to the territorial dermatovenereological dispensary. The territorial dermatovenereological dispensary sends the received notifications to the head dispensary of the subject of the Russian Federation monthly no later than the 5th day of the month following the expired month.
Employees of institutions receiving this information are legally responsible for ensuring information confidentiality and maintaining medical secrecy.
7. Additional Information
Requirements for obtaining biological material for laboratory testing in the diagnosis of urethritis.
To obtain reliable laboratory test results, a number of requirements are observed, which include:
timing of obtaining biological material taking into account the use of medicinal products: PCR — (in 3-4 weeks).
obtaining biological material from the urethra no earlier than 3 hours after the last urination; in the presence of abundant urethral discharge – 15-20 minutes after urination;
compliance with the conditions for sample delivery to the laboratory.
For laboratory testing in men in the diagnosis of NGU, the following is used:
urethral biological material
and/or
first portion of urine
Factors affecting therapy efficacy:
The efficacy of NGU therapy may decrease in the presence of adverse negative reactions (vomiting or diarrhea).
The outcome of the disease is also influenced by patient adherence to treatment, i.e., clarity in following the doctor's recommendations regarding the frequency of antimicrobial administration and the duration of the treatment course. Low patient adherence is associated with younger age and a history of STIs [102].
Detection and treatment of the patient's sexual partners reduces the likelihood of reinfection [43].
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Grade of Recommendation | Level of evidence | ||
|---|---|---|---|---|---|
1 | Laboratory diagnostic tests were performed on the patient (microscopic, molecular biological, microbiological/culture tests for STI pathogens) | C | 5 | ||
2. | Systemic antibacterial therapy has been prescribed (in the absence of contraindications) | C | 5 | ||
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Horner P, Blee K, O"Mahony C, Muir P, Evans C, Radcliffe K; Clinical Effectiveness Group of the British Association for Sexual Health and HIV. 2015 UK National Guideline on the management of non-gonococcal urethritis. Int J STD AIDS. 2016 Feb;27(2):85-96. doi: 10.1177/0956462415586675. Epub 2015 May 22. PMID: 26002319.
Taylor-Robinson D, Gilroy CB, Thomas BJ, et al. Mycoplasma genitalium in chronic non-gonococcal urethritis. Int J STD AIDS 2004; 15: 21–25.
Sena AC, Lensing S, Rompalo A, et al. Chlamydia trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis infections in men with nongonococcal urethritis: predictors and persistence after therapy. J Infect Dis 2012; 206: 357–365.
Horner P, Thomas B, Gilroy C, et al. Antibodies to Chlamydia trachomatis heat-shock protein 60 kDa and detection of Mycoplasma genitalium and Ureaplasma urealyticum are associated independently with chronic nongonococcal urethritis. Sex Transm Dis 2003; 30:129–133.
Lomas DA, Natin D, Stockley RA, et al. Chemotactic activity of urethral secretions in men with urethritis and the effect of treatment. J Infect Dis 1993; 167: 233–236
Hawkins DA, Fontaine EA, Thomas BJ, Boustouller YL, Taylor-Robinson D. The enigma of non-gonococcal urethritis: role for Bacteroides ureolyticus. Genitourin Med. 1988 Feb;64(1):10-3.
Appendix A1. Working Group Composition
Potekaev N.N. – Doctor of Medical Sciences, Professor, President of the National Alliance of Dermatovenereologists and Cosmetologists LLC, Member of the European STI/HIV Research Society (IUSTI/WHO), Honorary President of the Euro-Asian Association of Dermatovenereologists (EAAD), Member of the Board of Directors of the European Academy of Dermatology and Venereology (EADV), Corresponding Member of the German Dermatological Society (DDG), Honored Doctor of the Russian Federation, Chief Freelance Specialist in Dermatovenereology and Cosmetology of the Russian Ministry of Health, Chief Freelance Specialist in Dermatovenereology and Cosmetology of the Moscow Health Department, Director of the Moscow Scientific and Practical Center for Dermatovenereology and Cosmetology of the Moscow Health Department, Head of the Department of Skin Diseases and Cosmetology at the Faculty of Postgraduate Education of the Pirogov Russian National Research Medical University of the Russian Ministry of Health
Gomberg M.A. – Doctor of Medical Sciences, Professor, President of the Guild of Specialists in Sexually Transmitted Infections "IUSTI RU", Member of the Royal College of Physicians (RCP), Member of the American Academy of Dermatology (AAD), Member of the European Academy of Dermatology and Venereology (EADV), Senior Advisor of the International Union against Sexually Transmitted Infections (IUSTI), Member of the National Alliance of Dermatovenereologists and Cosmetologists LLC, Chief Researcher at the Moscow Scientific and Practical Center for Dermatovenereology and Cosmetology of the Moscow Health Department
Akhvlediani N.D. – Doctor of Medical Sciences, Professor at the Department of Urology, Yevdokimov Moscow State University of Medicine and Dentistry of the Russian Ministry of Health, Member of the Russian Society of Urology LLC
Gushchin A.E. – Candidate of Biological Sciences, Member of the Microbiology Committee of the Federation of Laboratory Medicine, Member of the European STI/HIV Research Society (IUSTI/WHO), Member of the Guild of Specialists in Sexually Transmitted Infections "IUSTI RU", Member of the National Alliance of Dermatovenereologists and Cosmetologists LLC, Leading Researcher at the Moscow Scientific and Practical Center for Dermatovenereology and Cosmetology of the Moscow Health Department
Dolya O.V. – Doctor of Medical Sciences, Member of the National Alliance of Dermatovenereologists and Cosmetologists LLC, Member of the European STI/HIV Research Society (IUSTI/WHO), Member of the European Academy of Dermatology and Venereology (EADV), Member of the Guild of Specialists in Sexually Transmitted Infections "IUSTI RU", Deputy Director for Science at the Moscow Scientific and Practical Center for Dermatovenereology and Cosmetology of the Moscow Health Department
Zhukova O.V. – Doctor of Medical Sciences, Professor, Executive Director of the National Alliance of Dermatovenereologists and Cosmetologists LLC, Member of the European STI/HIV Research Society (IUSTI/WHO), Member of the Guild of Specialists in Sexually Transmitted Infections "IUSTI RU", Chief Freelance Specialist in Dermatovenereology and Cosmetology of the Central Federal District of the Russian Ministry of Health, Chief Physician of the Moscow Scientific and Practical Center for Dermatovenereology and Cosmetology of the Moscow Health Department, Head of the Department of Dermatovenereology and Allergology with a Course of Immunology at the Medical Institute of the Peoples' Friendship University of Russia
Zabirov K.I. – Doctor of Medical Sciences, Professor, Honored Doctor of the Russian Federation, Member of the Russian Society of Urology LLC
Kim D.G. – Member of the National Alliance of Dermatovenereologists and Cosmetologists LLC, Member of the European STI/HIV Research Society (IUSTI), Head of the Center for Viral Skin Pathology at the Moscow Scientific and Practical Center for Dermatovenereology and Cosmetology of the Moscow Health Department
Kisina V.I. – Doctor of Medical Sciences, Professor, Member of the National Alliance of Dermatovenereologists and Cosmetologists LLC, Member of the European STI/HIV Research Society (IUSTI/WHO), Member of the Guild of Specialists in Sexually Transmitted Infections "IUSTI RU", Member of the Russian Interregional Society of Evidence-Based Medicine Specialists, Member of the Interdisciplinary Association of Reproductive Medicine Specialists (MARS), Chief Researcher at the Moscow Scientific and Practical Center for Dermatovenereology and Cosmetology of the Moscow Health Department
Kovalyk V.P. – Candidate of Medical Sciences, Member of the European STI/HIV Research Society (IUSTI), Member of the Guild of Specialists in Sexually Transmitted Infections "IUSTI RU", Member of the National Alliance of Dermatovenereologists and Cosmetologists LLC, Associate Professor, Professor at the Department of Dermatovenereology and Cosmetology of the Academy of Postgraduate Education of the Federal Scientific and Clinical Center of Specialized Medical Care and Medical Technologies of the Federal Medical-Biological Agency
Kozlov R.S. – Corresponding Member of the Russian Academy of Sciences, Doctor of Medical Sciences, Professor, President of the Interregional Association for Clinical Microbiology and Antimicrobial Chemotherapy (MACMAH), Member of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Member of the American Society for Microbiology (ASM), Member of the European Respiratory Society (ERS), Member of the Federation of European Societies of Chemotherapy and Infection (FESCI), Director of the Research Institute of Antimicrobial Chemotherapy of the Smolensk State Medical University of the Russian Ministry of Health, Chief Freelance Specialist of the Russian Ministry of Health in Clinical Microbiology and Antimicrobial Resistance
Krupinov G.E. – Doctor of Medical Sciences, Professor at the Institute of Urology and Human Reproductive Health of the Sechenov First Moscow State Medical University of the Russian Ministry of Health (Sechenov University), Member of the Russian Society of Urology LLC
Senina M.E. – Member of the National Alliance of Dermatovenereologists and Cosmetologists LLC, Member of the Federation of Laboratory Medicine, Junior Researcher at the Moscow Scientific and Practical Center for Dermatovenereology and Cosmetology of the Moscow Health Department
Conflict of interest: none declared
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
Dermatovenerologists
Urologists
Table 1. Level of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | There is only a rationale for the mechanism of action or expert opinion |
Table 2. Level of Evidence (LoE) grading scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)
LoE | Definitions |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | There is only a rationale for the mechanism of action of the intervention (preclinical studies) or expert opinion |
Table 3. Grade of Recommendation (GoR) scale for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of evidence of proper quality; all considered efficacy criteria [outcomes] are unimportant, all studies have low methodological quality, and their conclusions regarding outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
1. Order of the Ministry of Health of the Russian Federation No. 924n dated November 15, 2012, "On Approval of the Procedure for Providing Medical Care to the Population in the Profile of 'Dermatovenereology'"
2. Order of the Ministry of Health of the Russian Federation No. 907n dated November 12, 2012, "On Approval of the Procedure for Providing Medical Care to the Adult Population in the Profile of 'Urology'"
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Non-gonococcal urethritis (NGU) is an inflammatory disease of the male urethra in which gonococci are not detected. Most cases of NGU are caused by sexually transmitted infections (STIs), of which chlamydia is the most common.
Men may notice urethral discharge, pain, itching, or discomfort during urination.
Most female sexual partners of patients with NGU do not report any symptoms of urogenital diseases.
Timely treatment of NGU is recommended to prevent serious complications. When chlamydia is the cause of NGU, the infection can spread to the scrotal organs in men, causing pain and swelling, and infertility may develop later.
Examination is available at any specialized dermatovenereological and urological medical facility.
If you have contracted NGU, you are advised to undergo screening for STIs, including syphilis and HIV.
What causes NGU?
About two-thirds of NSU cases are caused by STIs. The most common of these is chlamydia, which can be transmitted through unprotected vaginal, oral, or anal sex. A small number of cases are caused by protozoa (Trichomonas), and herpes simplex virus types 1 and 2.
In many cases, no infectious cause for NSU can be found. This may be due to an infection we do not yet know about. On the other hand, there may be no infection at all, and the problem may be caused by various chemical irritants.
You cannot contract NSU in a swimming pool, sauna, or by sharing personal hygiene items.
What would I notice if I had NSU?
Signs typically include:
urethral discharge
burning pain during urination
irritation or itching around the external urethral meatus
Women usually do not report any symptoms. However, if their sexual partner's NSU is caused by chlamydia, they may notice:
vaginal bleeding after sex or between periods
lower abdominal pain
unusual vaginal discharge
pain or burning during urination
How do I get tested for NSU?
Men
If you have symptoms, medical staff will take a urethral swab followed by microscopic examination. You may also be asked to provide a urine sample.
Women
Women are only tested if their partner is diagnosed with NSU. This involves taking a vaginal swab, which can be self-collected or taken by a physician.
How is NSU treated?
NSU is treated with systemic antibacterial drugs, usually in pill form. When taken correctly, systemic antibacterial drugs are very effective.
What about my partner?
Since NSU is sometimes caused by STIs, it is important that your sexual partners from the last 6 months are screened for STIs, including chlamydia. Based on the screening results, they will be prescribed appropriate treatment.
When can I have sex again?
During treatment and until post-treatment test results are back for both the patient with NSU and their sexual partner(s), you should not have unprotected sex in any form of sexual contact.
What happens if NSU is left untreated?
This depends on the cause of the NSU. The risk of complications increases when NSU is caused by chlamydia. The infection can spread to the scrotal contents, causing pain and swelling (epididymo-orchitis), which can lead to infertility as a complication.
In some cases, when NSU is caused by chlamydia, pain and swelling occur
in joints, such as the ankle and knee. This is called reactive arthritis. Redness and soreness of the eyes (conjunctivitis) may also occur.
Female partners infected with chlamydia may develop pelvic inflammatory disease (PID), which can lead to ectopic pregnancy and infertility as complications.
Can I get NSU again?
Yes, you can. To prevent this, make sure your partner has completed a full course of treatment. Protect yourself with new partners by using a condom during vaginal, oral, and anal sex. If you meet a new partner, make sure neither of you has an STI before having unprotected sex.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
No.