What is Nongonococcal Urethritis?
Non-gonococcal urethritis (NGU) is an inflammation of the urethra, the tube carrying urine from the bladder out of the body, and it’s the most common sexually transmitted disease in men. Urethritis can be caused by an infection or other non-infectious factors. Infectious causes are almost always sexually transmitted.
Sexually transmitted urethritis is generally split into two types: gonococcal urethritis, which is caused by a specific type of bacteria, and non-gonococcal urethritis (NGU), which is not.
Most men with urethritis will have a discharge from the penis. Doctors can tell the difference between gonococcal urethritis and NGU by doing a gram stain test, a type of laboratory test that uses a special dye to identify the bacteria. If the test shows certain types of bacteria called gram-negative diplococci, then the urethritis is gonococcal. If no such bacteria are found, then the urethritis is classified as NGU.
What Causes Nongonococcal Urethritis?
The most common cause of Non-gonococcal urethritis (NGU) – a condition where the tube that carries urine from the body (urethra) becomes irritated or inflamed – is a bacteria called Chlamydia trachomatis. It’s responsible for 15% to 40% of all NGU cases. Another bacteria, Mycoplasma genitalium, is the second most common cause, accounting for 15% to 20% of NGU cases, but testing for this bacteria isn’t widely available.
Less common causes of NGU include various infections with organisms like Trichomonas vaginalis, the herpes simplex virus, the Epstein Barr virus, and the Adenovirus. Enteric bacteria, which are related to the digestive tract, are a rare cause of NGU. This is typically seen in men who engage in a specific sexual practice, insertive anal intercourse.
In about half of all cases of NGU, doctors can’t identify what’s causing the condition.
Risk Factors and Frequency for Nongonococcal Urethritis
Urethritis, a common sexual infection in men, is typically caused by gonorrhea and chlamydia. The Center for Disease Control and Prevention (CDC) doesn’t track urethritis cases directly, instead focusing on the infections that cause it. In terms of particular infections, chlamydia is the most common in the United States, with over 1.5 million new cases in 2016 alone, and the rate of diagnoses increases each year. Chlamydia is twice as common in females, and is most often seen in young adults and teenagers. It is also more common among African Americans than whites. Gonorrhea, on the other hand, is more prevalent in males, with around 468,000 new cases in 2016. Like chlamydia, gonorrhea rates are highest in young adults, and is working class African Americans more frequently.
- Urethritis, primarily caused by gonorrhea and chlamydia, is a common sexual infection in men.
- The Center for Disease Control and Prevention (CDC) tracks infection rates of gonorrhea and chlamydia instead of urethritis itself.
- Chlamydia is the most reported sexual infection in the United States, with over 1.5 million new cases reported in 2016.
- Diagnoses of chlamydia are on the rise, with an estimated increase of 4.7% from 2015 to 2016.
- Chlamydia rates are twice as high in women than in men, and it’s most common in young adults and teenagers.
- Chlamydia is more common amongst African Americans than whites.
- Gonorrhea, which is more common in men, had an estimated 468,000 new cases in 2016.
- Like chlamydia, young adults are the most affected by gonorrhea, and it is more prevalent in African Americans.
Signs and Symptoms of Nongonococcal Urethritis
Urethritis is a condition where the urethra (the tube that carries urine from the body) becomes inflamed. Some people with urethritis show no symptoms, but others may experience:
- Pain during urination
- Itchy genitals
- Burning sensation in the penis
- A discharge from the urethra which can be pus-like, mucus-like, or watery
- Fever
- Pain or swelling in the testicles
- Sore throat
- Pain in the rectum or rectal discharge
Some people may have swollen lymph nodes near the groin or symptoms such as blisters, which could indicate that the urethritis is caused by the herpes simplex virus. In some cases, the condition may be distinguished by the type of discharge, but it’s not always reliable — discharge in non-gonococcal urethritis tends to be clear or mucus-like, compared to more pus-like discharge in gonococcal urethritis. It’s also possible for urethritis to be accompanied by conditions like conjunctivitis or reactive arthritis — the latter typically involves urethritis, inflammation of the eye (uveitis), and joint inflammation (arthritis), especially in people with the HLA-B27 gene.
The symptoms can be similar to other health conditions like epididymitis, a swollen tube at the back of the testicle, pharyngitis, or sore throat, prostatitis, or inflammation of the prostate gland. So, correct diagnosis is crucial for appropriate treatment.
Testing for Nongonococcal Urethritis
Urethritis is a condition that can be diagnosed using several different methods. These might include, for example, identifying various types of discharge during an examination or through the detection of certain white blood cells in urethral secretions on a laboratory slide, both of which indicate inflammation or infection. A test on your urine can also be carried out. If it shows an enzyme called leukocyte esterase or large amounts of white blood cells, this could be a sign of urethritis.
When diagnosing urethritis, doctors must also make sure the symptoms are not being caused by gonorrhea, a specific type of sexually transmitted infection. This involves performing a test that checks for bacteria associated with gonorrhea in your bodily fluids. If the test is negative, meaning the bacteria are not present, this furthers the suspicion of urethritis.
If you are considered high risk for infection and have symptoms of urethritis, but none of the common indicators are detected, doctors can still conclude you have the condition and start treatment. Such treatment would typically include medications targeting both chlamydia and gonorrhea – two common sexually transmitted infections that can cause urethritis.
It’s also advised that patients undergo a test called nucleic acid amplification (NAAT) for chlamydia, gonorrhea, and trichomoniasis, another type of sexually transmitted infection. In urethritis, the NAAT test is preferred as it is highly accurate at detecting these. There is an NAAT test for a lesser-known sexually transmitted infection, M. genitalium, but it is not widely used.
Treatment Options for Nongonococcal Urethritis
When you’re diagnosed with urethritis, which is inflammation of the urethra (the tube through which urine exits the body from the bladder), the doctors would usually start treatment immediately, even before it’s confirmed what’s causing the inflammation. This is known as empiric treatment.
This treatment would depend on whether there is presence of a gonococcal infection, which is an infection caused by the bacteria Neisseria gonorrhoeae, also known as gonorrhea. Doctors can check this using a microscope.
If a microscope is available and no gonococcal infection is detected, medication like azithromycin (an antibiotic) or doxycycline (an anti-infective medicine) may be prescribed. These drugs are highly effective for treating a chlamydial urethritis which is urethritis caused by the bacteria Chlamydia. If Mycoplasma genitalium bacteria, another possible cause of urethritis, is suspected, azithromycin is proven to be a better treatment choice.
If a microscope is not available, and doctors can’t rule out a gonococcal infection, they may prescribe a combination of ceftriaxone (a cephalosporin antibiotic) and azithromycin or doxycycline. This approach ensures treatment for both chlamydia and gonorrhea.
In some cases, symptoms of urethritis can persist or come back after treatment. This can be common following treatment, and in such cases, the doctors would first check whether the patient had properly followed through with the initial treatment and also if there has been a re-exposure to the disease. If urethritis symptoms continue, and Mycoplasma genitalium is suspected, azithromycin, or an antibiotic called moxifloxacin may be used. In certain areas where Trichomonas vaginalis, a protozoan parasite, is prevalent, metronidazole may also be given.
What else can Nongonococcal Urethritis be?
If someone reports pain during urination, doctors might need to rule out different possible causes that can have similar symptoms:
- Prostatitis (Inflammation of the prostate)
- Epididymitis (Inflammation of the tube at the back of the testicle)
- Vaginitis (Inflammation of the vagina)
- Cystitis (Inflammation of the bladder)
Usually, these conditions would come with some other specific symptoms, but it’s also possible for any of them to occur alongside urethritis – inflammation of the urethra.
What to expect with Nongonococcal Urethritis
NGU, or non-gonococcal urethritis, typically clears up on its own and doesn’t cause any complications, even if it’s not treated in most instances.
Possible Complications When Diagnosed with Nongonococcal Urethritis
Complications arising from non-gonococcal urethritis (NGU) in men are fairly uncommon. However, possible issues may include inflammation of the epididymis or prostate, formation of an abscess, or reactive arthritis. Epididymitis, an inflammation of the tubes at the back of the testicles, can occur in about 1% to 2% of men with NGU. Similarly, conjunctivitis, or pink eye, also develops in approximately 1% to 2% of these cases. Rarely, men with NGU may experience narrowing of the urethra due to inflammation-induced scarring.
The likelihood of complications in women from urethritis is more significant than in men, with occurrence rates between 10% and 40%. Potential complications for women with urethritis include pelvic inflammatory disease, infertility, or ectopic pregnancy, where the embryo attaches outside the uterus.
Babies born to mothers suffering from chlamydia urethritis may face risks like conjunctivitis, iritis, an inflammation of the iris, or pneumonia. Thankfully, routine treatment of newborns with antibiotic eye ointment has considerably reduced such instances.
Chlamydia urethritis can also lead to a sexually transmitted infection called lymphogranuloma venereum. This disease manifests as genital ulcers and may cause inflammation of the lymphatic system, potentially leading to obstructions, strictures, or abnormal connections between an organ, vessel, or intestine and another structure.
Common Complications:
- Epididymitis (inflamed tubes at the back of the testicles)
- Prostatitis (inflamed prostate)
- Abscess formation
- Reactive arthritis
- Conjunctivitis (pink eye)
- Narrowing of the urethra due to inflammation-induced scarring
- Pelvic inflammatory disease (in women)
- Infertility (in women)
- Ectopic pregnancy (in women)
- Issues in newborns, including conjunctivitis, iritis, and pneumonia
- Lymphogranuloma venereum (an STI causing genital ulcers)
Preventing Nongonococcal Urethritis
Here’s what patients need to be aware of:
1. After undergoing therapy, patients and their partners should refrain from sexual activities for a week. This helps ensure the treatment is fully effective.
2. For patients taking doxycycline, which is a type of antibiotic, it is recommended to limit exposure to the sun. This is because the medicine can make the skin more sensitive to sunlight, resulting in sunburn more easily.
3. Lastly, individuals taking a medication called metronidazole should avoid consuming alcohol. Drinking alcohol while taking this medicine could cause unpleasant effects.
