Will urethritis show up in urine test?

emedicine.medscape.com - Urethritis Workup: Laboratory Studies, Imaging Studies, Procedures

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Previously, urethritis was diagnosed based on Gram stain of urethral discharge demonstrating ≥ 5 white blood cells (WBC) per high power field (hpf). More recent studies suggest that utilizing a threshold of ≥ 5 WBC hpf could miss a significant proportion of infections due to Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma genitalium. [23, 24] According to the current Centers for Disease Control and Prevention (CDC) guidelines, urethritis can be documented on the basis of any of the following signs or laboratory test results [4] :

Mucoid, mucopurulent, or purulent discharge on examination

Gram stain of urethral secretions demonstrating ≥ 2 WBC per oil immersion field on microscopy The microscopy diagnostic cutoff might vary, depending on background prevalence (≥2 WBCs/high power field [HPF] in high-prevalence settings [STI clinics] or ≥5 WBCs/HPF in lower-prevalence settings).

Positive leukocyte esterace test from a first-void urine

Microscopic examination of sediment from a spun first-void urine demonstrating ≥ 10 WBC/hpf All patients with urethritis should be tested for N gonorrhoeae and C trachomatis. M. genitalium testing should be performed for men who have persistent or recurrent symptoms after initial empiric treatment. Testing for T. vaginalis should be considered in areas or among populations with high prevalence, in cases where a partner is known to be infected, or for men who have persistent or recurrent symptoms after initial empiric treatment. [4]

Gram stain

Traditionally, treatment was based on Gram stain results. Patients with gram-negative intracellular diplococci on urethral smear received treatment for gonococcal urethritis, and those without gram-negative intracellular diplococci received treatment for nongonococcal urethritis (NGU). Because current recommendations suggest concomitant treatment for both, and with the success of nucleic acid amplification tests (NAATs), a Gram stain may be unnecessary. Of note, the sensitivity of urethral Gram stain is highly dependent on the method of collection and the experience of the provider. A negative Gram stain does not rule out gonococcal urethritis.

Urethral culture for N gonorrhoeae and C trachomatis

Endourethral culture (obtained by gently inserting a malleable cotton-tipped swab 1-2 cm into the urethra), rather than culture of the expressible discharge, is necessary to test for C trachomatis infection. Endocervical cultures should be obtained in women. This culture may be a useful screening tool for penicillinase-producing N gonorrhoeae or chromosomally mediated resistance to multiple antibiotics. However, the results do not influence the initial antibiotic therapy, and performing this screening may not be cost-effective. Cultures for N gonorrhoeae should be obtained in cases of sexual assault, developing antimicrobial resistance, or suspected gonorrhea treatment failures.

Urine studies

Urinalysis is not a useful test in patients with urethritis, except for helping exclude cystitis or pyelonephritis, which may be necessary in cases of dysuria without discharge. Patients with gonococcal urethritis may have leukocytes in a first-void urine specimen and fewer or none in a midstream specimen. More than 30% of patients with NGU do not have leukocytes in urine specimens. Many nucleic acid–based tests for C trachomatis and N gonorrhoeae can be performed on urine specimens (see below). These require a first-voided specimen. For Chlamydia species, endourethral samples are more accurate.

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Nucleic acid amplification tests

Polymerase chain reaction (PCR) assays are available for gonococcal urethritis and Chlamydia infection. NAATs are also available for Mycoplasma species, Ureaplasma species, and Trichomonas vaginalis, but these are not recommended, as they are expensive and do not alter the choice of treatment. NAATs are the preferred test for both C trachomatis and N gonorrhoeae due to their higher sensitivity and specificity. NAATs can be performed on urethral swabs or first-void urine samples. In males, first-void urine is the preferred specimen for NAATs. To prevent false-negative findings, obtain urethral swabs at least 2 hours after micturition using a calcium-alginate swab on a non-wooden stick inserted at least 1 cm in depth. If patients meet diagnostic criteria for urethritis, but Gram stain is unavailable or inconclusive, administer NAAT testing for C trachomatis and N gonorrhoeae. DNA-based tests, unlike culture, do not allow for antibiotic susceptibility testing, but this is unnecessary in most patients as the initial antibiotic therapy will be unchanged.

Other tests

The following additional tests may be considered:

Potassium hydroxide (KOH) preparation: This is used to evaluate for fungal organisms

Wet preparation: Secretions reveal the movement of trichomonal organisms, if present

[4] Sexually transmitted disease (STD) testing: Patients with urethritis should be counseled about the risk for more serious STDs and should be offered syphilis serology (Venereal Disease Research Laboratory [VDRL] test or Rapid Plasma Reagin [RPR] test) and HIV serology. Men who receive a diagnosis of NGU should be tested for HIV and syphilis [25] Nasopharyngeal and/or rectal swabs: Men who have sex with men (and perhaps other patients) should undergo gonorrhea screening with nasopharyngeal and/or rectal swabs; validation of NAATs for these specimens is still in progress Pregnancy testing: Women who have had unprotected intercourse should be offered pregnancy testing Reactive arthritis is diagnosed on the basis of the presence of NGU and clinical findings of uveitis and arthritis. HLA-B27 testing is of limited value. More readily available laboratory findings, such as elevated erythrocyte sedimentation rate (ESR) in the absence of rheumatoid factor, may be helpful.

emedicine.medscape.com - Urethritis Workup: Laboratory Studies, Imaging Studies, Procedures

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