Main presentations of sexually transmitted infections in men
http://www.100md.com
《英国医生杂志》
Royal Free and University College Medical School, London (jrichens@gum.ucl.ac.uk)
Introduction
Some sexually transmitted infections, such as gonorrhoea and chlamydial infection, have different presentations in the two sexes because of differences in genital anatomy. This chapter focuses on infections of the male urethra, epididymis, testis, and prostate. Anal and oral symptoms are also covered because these are encountered more often among men, especially men who have sex with men.
Urethral discharge and dysuria
Spontaneous discharge of fluid from the urethral meatus, usually most noticeable after holding urine overnight and often accompanied by burning discomfort during urination (dysuria), strongly indicates a sexually acquired urethral infection.
Management of urethritis
Symptomatic gonorrhoea usually develops within a few days of exposure. Chlamydial infections take slightly longer. Mild infections may cause urethral discomfort and dysuria without discharge and may be confused with cystitis.
Causes of urethritis in men
In clinics with laboratory facilities, the usual approach is to test for gonorrhoea and chlamydial infection. The first step is microscopy of a urethral smear. Optimal results for this are obtained from patients who have held their urine for four hours or more.
Gonococcal urethral discharge
Urethritis is confirmed if the urethral smear shows five or more polymorphs per high power field. If the smear shows Gram negative intracellular diplococci, the patient is treated for gonorrhoea and chlamydia to cover the possibility of a mixed infection. Meanwhile, confirmatory tests for gonorrhoea and chlamydia are carried out (see bmj.com).
World Health Organization flow chart for managing urethral discharge
Patients without evidence of gonorrhoea receive doxycycline (100 mg twice daily for one week), erythromycin (500 mg twice daily for two weeks), or azithromycin (1 g single dose), which are active against chlamydial infection and most other pathogens associated with non-gonococcal urethritis. Doxycycline can cause photosensitivity. Absorption is impaired by antacids, iron, calcium, and magnesium salts. Gastrointestinal upset is common with erythromycin and azithromycin.
This approach will relieve symptoms in most patients, but some will report persistent symptoms or show a persistently abnormal smear without symptoms. The options are then to investigate for treatment failure or reinfection or for infection by less common pathogens (for example, Trichomonas vaginalis) and to repeat, continue, or change the antibiotic therapy or await spontaneous resolution of symptoms.
This article is adapted from the fifth edition of the ABC of Sexually Transmitted Diseases, which is published by BMJ Books (www.bmjbooks.com)
An overview of chlamydial infection and gonorrhoea is available on bmj.com
When access to laboratory testing is not available, the simplest approach to managing urethritis is to administer blind treatment for gonorrhoea and chlamydia.
Gram negative intracellular diplococci
Scrotal swelling and pain
Mild testicular discomfort in the absence of abnormal physical signs is encountered commonly in young men attending STI clinics. Many patients can be reassured if testicular examination and a screen for STIs give normal results. In some cases, anxiety about infection, sexual function, or cancer is present. More marked scrotal pain has various causes.
Causes of scrotal swelling and pain
Acute inflammation of the scrotal contents (usually unilateral) in young men is usually caused by gonorrhoea or chlamydia. In older men, Escherichia coli, Klebsiella, Pseudomonas, and Proteus infections are found more often. The first consideration in diagnosis is to exclude acute torsion, which requires emergency surgery. Torsion predominates in the teenage years, usually has an acute onset, and is often accompanied by vomiting. An immediate surgical opinion should be sought for any possible case. Doppler scanning is useful to show impaired blood flow.
The distinguishing features of mumps orchitis (severe testicular pain and marked systemic symptoms) usually appear a few days after parotid swelling, although the parotitis may be absent. Useful tests for cases of suspected epididymo-orchitis are a urethral smear, mid stream urine culture, and investigations for gonorrhoea and chlamydia. Presumptive treatment for gonorrhoea and chlamydia is appropriate in younger men when investigation is not feasible. Severe cases require treatment in hospital with parenteral antibiotics. Analgesia, scrotal support, and elevation may reduce discomfort and promote recovery.
Acute epididymo-orchitis due to STI
Painless swellings in the scrotum are common. Most of these are small, round, epididymal cysts or spermatoceles that require no investigation or treatment. Lesions in the testis can be due to tuberculosis, syphilis, or malignancy and require urgent ultrasound examination. Varicoceles feel like a bag of worms in the scrotum and can be associated with infertility. Therefore, referral to a urologist is advised if pain, testicular atrophy, infertility, or the threat of infertility are concerns.
Pelvic pain
The prostate can be affected by a variety of infectious and poorly defined non-infectious conditions that present as acute or chronic pelvic pain with a range of accompanying urinary and systemic symptoms. Gonorrhoea, chlamydial infections, and trichomoniasis can affect the prostate, but most acute infections are caused by other bacteria such as E coli, Proteus, Streptococcus faecalis, Klebsiella, and Pseudomonas.
Differential diagnosis of prostatic pain
STIs and non-sexually transmitted bacterial infections of the prostate account for only a few painful prostatic syndromes. Most patients with prostatic pain fall into a category recently designated "chronic pelvic pain syndrome" by the newly adopted National Institutes of Health classification of prostatitis syndromes.
In patients who present with pelvic pain, the prostate should be examined for enlargement and tenderness. Patients with prostatitis should be screened for STIs. The value of subjecting patients to prostatic massage to examine prostatic secretions for bacteria and inflammatory cells is now questioned by many experts. Transrectal ultrasonography and urodynamic studies are helpful in some patients. Confirmed infections respond well to antibiotics, the first choice often being a 28 day course of a quinolone or tetracycline, which have better prostatic penetration than other antibiotics.
Treating the more common causes of chronic pelvic pain is difficult. None of the treatments is well validated, and response rates are often poor. A recently published NIH symptoms index for chronic prostatitis is a useful way to record and monitor symptoms.
Measures occasionally found helpful in men with chronic pelvic pain syndrome
Anal symptoms
Sexually transmitted infections can be transmitted by penile-anal contact, oroanal contact, or fingering, resulting in asymptomatic infection, ulceration (for example, herpes and syphilis) warts, or proctitis, the main manifestations of which are pain, tenesmus, bleeding, and discharge. Ulceration is investigated in the same way as genital ulceration. Discharges require investigation by proctoscopy, during which samples can be taken from the rectum to test for gonorrhoea and chlamydia. The management of a sexually acquired rectal discharge parallels that of urethritis. Anorectal infections are a potent cofactor for HIV transmission.
Rectal gonorrhoea
Anal intercourse can lead to the transmission of a wide variety of other organisms normally transmitted by the faeco-oral route. These include hepatitis A virus, Shigella, Salmonella, and Giardia. Anal intraepithelial neoplasia and invasive carcinoma may follow infection with certain subtypes of human papillomavirus.
Non-infectious anal conditions
Patients who practise receptive anal sex often present to STI services with anal fissure, haemorrhoids, perianal haematomas, and pruritus ani. It is important to provide training and guidelines for the management and referral of these common conditions in clinics that see clients who practise anal sex.
Perioral warts. Reproduced with permission of the Wellcome Trust
Oral and perioral symptoms
Oral STIs usually are asymptomatic. Neisseria gonorrhoeae and Chlamydia infect the pharyngeal mucosa readily but rarely cause acute inflammation. Primary syphilis may present on the tongue or lips, and secondary syphilis can produce an oral mucositis. HIV has an important array of oral manifestations that include oral candidiasis (both erythematous and pseudomembranous), angular cheilitis, gingivitis, oral hairy leucoplakia, and Kaposi's sarcoma. Warts may develop in and around the mouth as a result of orogenital sexual activity.
Further reading
? Galejs LE. Diagnosis and treatment of the acute scrotum. Am Fam Physician 1999;59: 817-24
? Krieger JN, Ross SO, Deutsch L, Riley DE. The NIH consensus concept of chronic prostatitis/chronic pelvic pain syndrome compared with traditional concepts of nonbacterial prostatitis and prostatodynia. Curr Urol Rep 2002;3: 301-6
? Holmes KK, M?rdh PA, Sparling PF, Lemon S, Stamm W, Piot P, et al. Sexually transmitted diseases. 3rd ed. New York: McGraw Hill, 1999
? Morton RS, ed. Gonorrhoea. 3rd ed. London: WB Saunders, 1977
? Ostrow DG, Sandholzer TA, Felman YM, eds. Sexually transmitted diseases in homosexual men: diagnosis, treatment, and research. New York: Plenum, 1983
John Richens is lecturer in sexually transmitted diseases, Royal Free and University College Medical School, London (jrichens@gum.ucl.ac.uk
The ABC of Sexually Transmitted Diseases is edited by Michael Adler, professor of genitourinary medicine, Royal Free and University College Medical School, London(John Richens, lecturer in)
Introduction
Some sexually transmitted infections, such as gonorrhoea and chlamydial infection, have different presentations in the two sexes because of differences in genital anatomy. This chapter focuses on infections of the male urethra, epididymis, testis, and prostate. Anal and oral symptoms are also covered because these are encountered more often among men, especially men who have sex with men.
Urethral discharge and dysuria
Spontaneous discharge of fluid from the urethral meatus, usually most noticeable after holding urine overnight and often accompanied by burning discomfort during urination (dysuria), strongly indicates a sexually acquired urethral infection.
Management of urethritis
Symptomatic gonorrhoea usually develops within a few days of exposure. Chlamydial infections take slightly longer. Mild infections may cause urethral discomfort and dysuria without discharge and may be confused with cystitis.
Causes of urethritis in men
In clinics with laboratory facilities, the usual approach is to test for gonorrhoea and chlamydial infection. The first step is microscopy of a urethral smear. Optimal results for this are obtained from patients who have held their urine for four hours or more.
Gonococcal urethral discharge
Urethritis is confirmed if the urethral smear shows five or more polymorphs per high power field. If the smear shows Gram negative intracellular diplococci, the patient is treated for gonorrhoea and chlamydia to cover the possibility of a mixed infection. Meanwhile, confirmatory tests for gonorrhoea and chlamydia are carried out (see bmj.com).
World Health Organization flow chart for managing urethral discharge
Patients without evidence of gonorrhoea receive doxycycline (100 mg twice daily for one week), erythromycin (500 mg twice daily for two weeks), or azithromycin (1 g single dose), which are active against chlamydial infection and most other pathogens associated with non-gonococcal urethritis. Doxycycline can cause photosensitivity. Absorption is impaired by antacids, iron, calcium, and magnesium salts. Gastrointestinal upset is common with erythromycin and azithromycin.
This approach will relieve symptoms in most patients, but some will report persistent symptoms or show a persistently abnormal smear without symptoms. The options are then to investigate for treatment failure or reinfection or for infection by less common pathogens (for example, Trichomonas vaginalis) and to repeat, continue, or change the antibiotic therapy or await spontaneous resolution of symptoms.
This article is adapted from the fifth edition of the ABC of Sexually Transmitted Diseases, which is published by BMJ Books (www.bmjbooks.com)
An overview of chlamydial infection and gonorrhoea is available on bmj.com
When access to laboratory testing is not available, the simplest approach to managing urethritis is to administer blind treatment for gonorrhoea and chlamydia.
Gram negative intracellular diplococci
Scrotal swelling and pain
Mild testicular discomfort in the absence of abnormal physical signs is encountered commonly in young men attending STI clinics. Many patients can be reassured if testicular examination and a screen for STIs give normal results. In some cases, anxiety about infection, sexual function, or cancer is present. More marked scrotal pain has various causes.
Causes of scrotal swelling and pain
Acute inflammation of the scrotal contents (usually unilateral) in young men is usually caused by gonorrhoea or chlamydia. In older men, Escherichia coli, Klebsiella, Pseudomonas, and Proteus infections are found more often. The first consideration in diagnosis is to exclude acute torsion, which requires emergency surgery. Torsion predominates in the teenage years, usually has an acute onset, and is often accompanied by vomiting. An immediate surgical opinion should be sought for any possible case. Doppler scanning is useful to show impaired blood flow.
The distinguishing features of mumps orchitis (severe testicular pain and marked systemic symptoms) usually appear a few days after parotid swelling, although the parotitis may be absent. Useful tests for cases of suspected epididymo-orchitis are a urethral smear, mid stream urine culture, and investigations for gonorrhoea and chlamydia. Presumptive treatment for gonorrhoea and chlamydia is appropriate in younger men when investigation is not feasible. Severe cases require treatment in hospital with parenteral antibiotics. Analgesia, scrotal support, and elevation may reduce discomfort and promote recovery.
Acute epididymo-orchitis due to STI
Painless swellings in the scrotum are common. Most of these are small, round, epididymal cysts or spermatoceles that require no investigation or treatment. Lesions in the testis can be due to tuberculosis, syphilis, or malignancy and require urgent ultrasound examination. Varicoceles feel like a bag of worms in the scrotum and can be associated with infertility. Therefore, referral to a urologist is advised if pain, testicular atrophy, infertility, or the threat of infertility are concerns.
Pelvic pain
The prostate can be affected by a variety of infectious and poorly defined non-infectious conditions that present as acute or chronic pelvic pain with a range of accompanying urinary and systemic symptoms. Gonorrhoea, chlamydial infections, and trichomoniasis can affect the prostate, but most acute infections are caused by other bacteria such as E coli, Proteus, Streptococcus faecalis, Klebsiella, and Pseudomonas.
Differential diagnosis of prostatic pain
STIs and non-sexually transmitted bacterial infections of the prostate account for only a few painful prostatic syndromes. Most patients with prostatic pain fall into a category recently designated "chronic pelvic pain syndrome" by the newly adopted National Institutes of Health classification of prostatitis syndromes.
In patients who present with pelvic pain, the prostate should be examined for enlargement and tenderness. Patients with prostatitis should be screened for STIs. The value of subjecting patients to prostatic massage to examine prostatic secretions for bacteria and inflammatory cells is now questioned by many experts. Transrectal ultrasonography and urodynamic studies are helpful in some patients. Confirmed infections respond well to antibiotics, the first choice often being a 28 day course of a quinolone or tetracycline, which have better prostatic penetration than other antibiotics.
Treating the more common causes of chronic pelvic pain is difficult. None of the treatments is well validated, and response rates are often poor. A recently published NIH symptoms index for chronic prostatitis is a useful way to record and monitor symptoms.
Measures occasionally found helpful in men with chronic pelvic pain syndrome
Anal symptoms
Sexually transmitted infections can be transmitted by penile-anal contact, oroanal contact, or fingering, resulting in asymptomatic infection, ulceration (for example, herpes and syphilis) warts, or proctitis, the main manifestations of which are pain, tenesmus, bleeding, and discharge. Ulceration is investigated in the same way as genital ulceration. Discharges require investigation by proctoscopy, during which samples can be taken from the rectum to test for gonorrhoea and chlamydia. The management of a sexually acquired rectal discharge parallels that of urethritis. Anorectal infections are a potent cofactor for HIV transmission.
Rectal gonorrhoea
Anal intercourse can lead to the transmission of a wide variety of other organisms normally transmitted by the faeco-oral route. These include hepatitis A virus, Shigella, Salmonella, and Giardia. Anal intraepithelial neoplasia and invasive carcinoma may follow infection with certain subtypes of human papillomavirus.
Non-infectious anal conditions
Patients who practise receptive anal sex often present to STI services with anal fissure, haemorrhoids, perianal haematomas, and pruritus ani. It is important to provide training and guidelines for the management and referral of these common conditions in clinics that see clients who practise anal sex.
Perioral warts. Reproduced with permission of the Wellcome Trust
Oral and perioral symptoms
Oral STIs usually are asymptomatic. Neisseria gonorrhoeae and Chlamydia infect the pharyngeal mucosa readily but rarely cause acute inflammation. Primary syphilis may present on the tongue or lips, and secondary syphilis can produce an oral mucositis. HIV has an important array of oral manifestations that include oral candidiasis (both erythematous and pseudomembranous), angular cheilitis, gingivitis, oral hairy leucoplakia, and Kaposi's sarcoma. Warts may develop in and around the mouth as a result of orogenital sexual activity.
Further reading
? Galejs LE. Diagnosis and treatment of the acute scrotum. Am Fam Physician 1999;59: 817-24
? Krieger JN, Ross SO, Deutsch L, Riley DE. The NIH consensus concept of chronic prostatitis/chronic pelvic pain syndrome compared with traditional concepts of nonbacterial prostatitis and prostatodynia. Curr Urol Rep 2002;3: 301-6
? Holmes KK, M?rdh PA, Sparling PF, Lemon S, Stamm W, Piot P, et al. Sexually transmitted diseases. 3rd ed. New York: McGraw Hill, 1999
? Morton RS, ed. Gonorrhoea. 3rd ed. London: WB Saunders, 1977
? Ostrow DG, Sandholzer TA, Felman YM, eds. Sexually transmitted diseases in homosexual men: diagnosis, treatment, and research. New York: Plenum, 1983
John Richens is lecturer in sexually transmitted diseases, Royal Free and University College Medical School, London (jrichens@gum.ucl.ac.uk
The ABC of Sexually Transmitted Diseases is edited by Michael Adler, professor of genitourinary medicine, Royal Free and University College Medical School, London(John Richens, lecturer in)