This article is adapted from the fifth edition of the ABC ofSexually Transmitted Diseases, which is published by BMJBooks (www.bmjbooks.com).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

Richens, J

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ABC of sexually transmitted infectionsMain presentations of sexually transmitted infections in menJohn RichensSome sexually transmitted infections, such as gonorrhoea andchlamydial infection, have different presentations in the twosexes because of differences in genital anatomy. This chapterfocuses on infections of the male urethra, epididymis, testis, andprostate. Anal and oral symptoms are also covered becausethese are encountered more often among men, especially menwho have sex with men.Urethral discharge and dysuriaSpontaneous discharge of fluid from the urethral meatus,usually most noticeable after holding urine overnight and oftenaccompanied by burning discomfort during urination (dysuria),strongly indicates a sexually acquired urethral infection.Symptomatic gonorrhoea usually develops within a few daysof exposure. Chlamydial infections take slightly longer. Mildinfections may cause urethral discomfort and dysuria withoutdischarge and may be confused with cystitis.In clinics with laboratory facilities, the usual approach is totest for gonorrhoea and chlamydial infection. The first step ismicroscopy of a urethral smear. Optimal results for this areobtained from patients who have held their urine for four hoursor more.Urethritis is confirmed if the urethral smear shows five ormore polymorphs per high power field. If the smear showsGram negative intracellular diplococci, the patient is treated forgonorrhoea and chlamydia to cover the possibility of a mixedinfection. Meanwhile, confirmatory tests for gonorrhoea andchlamydia are carried out (see bmj.com).Patients without evidence of gonorrhoea receive doxycycline(100 mg twice daily for one week), erythromycin (500 mg twicedaily for two weeks), or azithromycin (1 g single dose), which areactive against chlamydial infection and most other pathogensassociated with non-gonococcal urethritis. Doxycycline cancause photosensitivity. Absorption is impaired by antacids, iron,calcium, and magnesium salts. Gastrointestinal upset iscommon with erythromycin and azithromycin.This approach will relieve symptoms in most patients, butsome will report persistent symptoms or show a persistentlyCauses of urethritis in menCommon diagnosesx Gonorrhoeax Chlamydial infectionx Non-specific urethritisLess common diagnosesx Ureaplasma urealyticum infectionx Mycoplasma genitalium infectionx Trichomoniasisx Herpes simplex virus infectionx Escherichia coli infectionx Bacteroides infectionx Cystitisx Pyelonephritisx Traumax Foreign bodyx Reactive arthritis, Reiter’s syndrome, and allied conditionsGonococcal urethral dischargeWorld Health Organization flow chart for managing urethraldischargeThis article is adapted from the fifth edition of the ABC ofSexually Transmitted Diseases, which is published by BMJBooks (www.bmjbooks.com)An overview of chlamydial infection and gonorrhoea isavailable on bmj.comManagement of urethritis1 Take history, including sexual history2 Examine, looking especially for evidence of discharge3 Take samples from urethra4 Treat for gonorrhoea and chlamydia if urethral Gram stain ispositive for Gram negative intracellular diplococci5 Give treatment for chlamydia if the urethral smear shows five ormore polymorphs per high power field and the Gram stain doesnot suggest gonorrhoea6 Explain diagnosis, treatment, and methods of prevention7 Advise to avoid sex until treatment and follow up are completed8 Advise treatment of partners9 Review patient after treatment for symptoms, adherence, treatmentof partners, and test of cure if gonorrhoea has been diagnosedWhen laboratory investigation is not feasible, steps 3, 5, and the test ofcure can be omittedClinical review1251 BMJ VOLUME 328 22 MAY 2004 bmj.comabnormal smear without symptoms. The options are then toinvestigate for treatment failure or reinfection or for infectionby less common pathogens (for example, Trichomonas vaginalis)and to repeat, continue, or change the antibiotic therapy orawait spontaneous resolution of symptoms.When access to laboratory testing is not available, thesimplest approach to managing urethritis is to administer blindtreatment for gonorrhoea and chlamydia.Scrotal swelling and painMild testicular discomfort in the absence of abnormal physicalsigns is encountered commonly in young men attending STIclinics. Many patients can be reassured if testicular examinationand a screen for STIs give normal results. In some cases, anxietyabout infection, sexual function, or cancer is present. Moremarked scrotal pain has various causes.Acute inflammation of the scrotal contents (usuallyunilateral) in young men is usually caused by gonorrhoea orchlamydia. In older men, Escherichia coli, Klebsiella, Pseudomonas,and Proteus infections are found more often. The firstconsideration in diagnosis is to exclude acute torsion, whichrequires emergency surgery. Torsion predominates in theteenage years, usually has an acute onset, and is oftenaccompanied by vomiting. An immediate surgical opinionshould be sought for any possible case. Doppler scanning isuseful to show impaired blood flow.The distinguishing features of mumps orchitis (severetesticular pain and marked systemic symptoms) usually appeara few days after parotid swelling, although the parotitis may beabsent. Useful tests for cases of suspected epididymo-orchitisare a urethral smear, mid stream urine culture, andinvestigations for gonorrhoea and chlamydia. Presumptivetreatment for gonorrhoea and chlamydia is appropriate inyounger men when investigation is not feasible. Severe casesrequire treatment in hospital with parenteral antibiotics.Analgesia, scrotal support, and elevation may reduce discomfortand promote recovery.Painless swellings in the scrotum are common. Most of theseare small, round, epididymal cysts or spermatoceles that requireno investigation or treatment. Lesions in the testis can be due totuberculosis, syphilis, or malignancy and require urgentultrasound examination. Varicoceles feel like a bag of worms inthe 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 painThe prostate can be affected by a variety of infectious andpoorly defined non-infectious conditions that present as acuteor chronic pelvic pain with a range of accompanying urinaryand systemic symptoms. Gonorrhoea, chlamydial infections, andtrichomoniasis can affect the prostate, but most acute infectionsare caused by other bacteria such as E coli, Proteus, Streptococcusfaecalis, Klebsiella, and Pseudomonas.STIs and non-sexually transmitted bacterial infections of theprostate account for only a few painful prostatic syndromes.Most patients with prostatic pain fall into a category recentlydesignated “chronic pelvic pain syndrome” by the newlyadopted National Institutes of Health classification of prostatitissyndromes.In patients who present with pelvic pain, the prostate shouldbe examined for enlargement and tenderness. Patients withprostatitis should be screened for STIs. The value of subjectingGram negative intracellular diplococciCauses of scrotal swelling and painx Infections of testis and epididymis: gonorrhoea, chlamydia,tuberculosis, mumps, and Gram negative bacteriax Torsion of testis (mainly adolescents) or appendix testis (mainly 3-7year olds)x Pain after vasectomyx Fournier’s gangrenex Vasculitis: Henoch-Schönlein purpura, Kawasaki disease, andBuerger’s diseasex Amiodarone therapyx Tumourx Herniax TraumaAcute epididymo-orchitis due to STIDifferential diagnosis of prostatic painNIH classification of prostatitis syndromesI Acute bacterial prostatitisII Chronic bacterial prostatitisIII Chronic pelvic pain syndrome (CPPS):IIIA Inflammatory (leucocytes in prostatic secretion, semen, orurine after prostatic massage)IIIB Non-inflammatory (as above without leucocytes)IV Asymptomatic inflammatory prostatitisOther causes of pain in region of prostatex Pudendal neuralgia (sometimes due to tumour)x Bladder outlet obstructionx Bladder tumoursx Urinary stone diseasex Inguinal ligament enthesopathyx Obstruction of ejaculatory ductx Seminal vesicle calculix Bowel disordersClinical review1252 BMJ VOLUME 328 22 MAY 2004 bmj.compatients to prostatic massage to examine prostatic secretions forbacteria and inflammatory cells is now questioned by manyexperts. Transrectal ultrasonography and urodynamic studiesare helpful in some patients. Confirmed infections respond wellto antibiotics, the first choice often being a 28 day course of aquinolone or tetracycline, which have better prostaticpenetration than other antibiotics.Treating the more common causes of chronic pelvic pain isdifficult. None of the treatments is well validated, and responserates are often poor. A recently published NIH symptoms indexfor chronic prostatitis is a useful way to record and monitorsymptoms.Anal symptomsAnorectal STIsSexually transmitted infections can be transmitted bypenile-anal contact, oroanal contact, or fingering, resulting inasymptomatic infection, ulceration (for example, herpes andsyphilis) warts, or proctitis, the main manifestations of which arepain, tenesmus, bleeding, and discharge. Ulceration isinvestigated in the same way as genital ulceration. Dischargesrequire investigation by proctoscopy, during which samples canbe taken from the rectum to test for gonorrhoea and chlamydia.The management of a sexually acquired rectal dischargeparallels that of urethritis. Anorectal infections are a potentcofactor for HIV transmission.Anal intercourse can lead to the transmission of a widevariety of other organisms normally transmitted by thefaeco-oral route. These include hepatitis A virus, Shigella,Salmonella, and Giardia. Anal intraepithelial neoplasia andinvasive carcinoma may follow infection with certain subtypesof human papillomavirus.Non-infectious anal conditionsPatients who practise receptive anal sex often present to STIservices with anal fissure, haemorrhoids, perianal haematomas,and pruritus ani. It is important to provide training andguidelines for the management and referral of these commonconditions in clinics that see clients who practise anal sex.Oral and perioral symptomsOral STIs usually are asymptomatic. Neisseria gonorrhoeae andChlamydia infect the pharyngeal mucosa readily but rarely causeacute inflammation. Primary syphilis may present on thetongue or lips, and secondary syphilis can produce an oralmucositis. HIV has an important array of oral manifestationsthat include oral candidiasis (both erythematous andpseudomembranous), angular cheilitis, gingivitis, oral hairyleucoplakia, and Kaposi’s sarcoma. Warts may develop in andaround the mouth as a result of orogenital sexual activity.Measures occasionally found helpful in men with chronicpelvic pain syndromex Simple analgesiax Non-steroidal anti-inflammatory drugsx 2-4 weeks of ciprofloxacin or doxycyclinex Alpha blocking drugs (alfuzosin, terazosin, tamsulosin)x Finasteridex Quercetinx Low dose amitriptylinex Repetitive prostatic massage (contraindicated in bacterialprostatitis)x Regular ejaculationRectal gonorrhoeaPerioral warts. Reproduced with permission of the Wellcome TrustFurther readingx Galejs LE. Diagnosis and treatment of the acute scrotum. Am FamPhysician 1999;59:817-24x Krieger JN, Ross SO, Deutsch L, Riley DE. The NIH consensusconcept of chronic prostatitis/chronic pelvic pain syndromecompared with traditional concepts of nonbacterial prostatitis andprostatodynia. C u r rU r o lR e p2002;3:301-6x Holmes KK, Mårdh PA, Sparling PF, Lemon S, Stamm W, Piot P, etal. Sexually transmitted diseases. 3rd ed. New York: McGraw Hill, 1999x Morton RS, ed. Gonorrhoea. 3rd ed. London: WB Saunders, 1977x Ostrow DG, Sandholzer TA, Felman YM, eds. Sexually transmitteddiseases in homosexual men:diagnosis,treatment,and research. New York:Plenum, 1983John Richens is lecturer in sexually transmitted diseases, Royal Freeand 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 UniversityCollege Medical School, LondonCompeting interests: None declaredBMJ 2004;328:1251–3Clinical review1253 BMJ VOLUME 328 22 MAY 2004 bmj.com

ABC of sexually transmitted infections - Main presentations of sexually transmitted infections in men

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