EUF-619; No.

of Pages 7

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available at www.sciencedirect.com
journal homepage: www.europeanurology.com/eufocus

Review – Infections

Management of Urethritis: Is It Still the Time for Empirical

Antibiotic Treatments?

Riccardo Bartoletti a,*, Florian M.E. Wagenlehner b, Truls Erik Bjerklund Johansen c,d,
Bela Köves e, Tommaso Cai f, Zafer Tandogdu g, Gernot Bonkat h
a b
Department of Translational Research and New Technologies, University of Pisa, Pisa, Italy; Clinic und Polyclinic for Urology, Pediatric Urology and
c d
Andrology, Justus-Liebig-University Giessen, Giessen, Germany; Dept. of Urology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine,
University of Oslo, Oslo, Norway; e Department of Urology, South-Pest Teaching Hospital, Budapest, Hungary; f Department of Urology, Santa Chiara Regional
Hospital, Trento, Italy; g Northern Institute for Cancer Research, Newcastle University, Newcastle Upon Tyne, UK; h Alta Uro AG, Merian Iselin Klinik, Center of
Biomechanics & Calorimetry (COB), University of Basel, Basel, Switzerland

Article info Abstract

Article history: Context: Urethritis prevalence in Europe changed in the last years due to both the
Accepted October 5, 2018 increase of migratory streams from North Africa and the more frequent exposition of
males to relevant risk factors. Owing to these reasons, urethritis treatment should be
Associate Editor: optimized by accurate microbiological investigations to avoid the risk of persistence,
Christian Gratzke recurrence, or reinfection.
Objective: The aim of this systematic review is to optimize the treatments for urethritis
and investigate the applicability of nucleic acid amplification test (NAAT) as the primary
Keywords: microbiological investigation.
Urethritis Evidence acquisition: A literature search in Medline, Cochrane, and Google Scholar
databases was conducted up to June 2018. Subject headings were selected as follows:
Urethral inflammation
Urethritis OR gonococcal urethritis OR non-gonococcal urethritis AND Antibiotics OR
Gonococcal urethritis Recurrence. A total of 528 abstracts were identified and selected. Finally, 12 full-text
Nongonococcal urethritis articles were selected for a qualitative synthesis. The Preferred Reported Items for
Nucleic acid amplification test Systematic Reviews and Meta-Analyses statement was used to perform an accurate
Empirical treatment research checklist and report.
Evidence synthesis: Empirical treatments are no more recommended, although a broad
spectrum of antibiotic therapy may be initiated while awaiting the results from patho-
gens’ microbiological characterization. First-line treatment for gonococcal urethritis
consists of a single dose of ceftriaxone/azithromycin combined therapy. Specific thera-
pies should be initiated for nongonococcal urethritis according to each single pathogen
involved in the infection process. Owing to this reason, NAAT is mandatory in the clinical
approach to the disease, although the Gram stain of urethral discharge or smear remains
applicable for some less frequent nongonococcal urethritis. Moreover, the urethritis
“modern view” also includes noninfectious etiologies that occurred after traumas or
injection of irritating compounds. Sexual abstinence of at least 7 d should be observed
from the start of treatment to avoid reinfection, while sexual partners should evenly be
treated.
Conclusions: The treatment of urethritis implies accurate determination of pathogens
involved in the infection process by NAAT with subsequent appropriate antibiotic
therapy, thus avoiding the risk of antibiotic resistance and overuse of antibiotics

* Corresponding author. University Urology Unit, Cisanello Hospital Blg. 30, Via Paradisa 4, 56124 Pisa,
Italy. Tel.: +39 3483630658.
E-mail addresses: riccardo.bartoletti@hotmail.com, riccardo.bartoletti@unipi.it (R. Bartoletti).

https://doi.org/10.1016/j.euf.2018.10.006
2405-4569/© 2018 Published by Elsevier B.V. on behalf of European Association of Urology.

Please cite this article in press as: Bartoletti R, et al. Management of Urethritis: Is It Still the Time for Empirical Antibiotic
Treatments?. Eur Urol Focus (2018), https://doi.org/10.1016/j.euf.2018.10.006
EUF-619; No. of Pages 7

2 E U R O P E A N U R O L O GY F O C U S X X X ( 2 0 18 ) X X X– X X X

indicated for empirical treatments. The population exposed to relevant risk factors
should be adequately informed about the increased risk of developing infections and
motivated toward the intensive use of condoms during sexual intercourses.
Patient summary: Urethritis is a sexually transmitted disease generally characterized
by urethral discharge or other symptoms such as itching, tingling, and apparent
difficulties in having a regular urinary flow. Microbiological investigations are manda-
tory to obtain satisfactory results from the treatment. Multiple antibiotic treatments are
often necessary due to the high risk of multiple pathogens responsible for the disease.
Similarly, sexual partners should be investigated and treated in the same way. Several
risk factors such as immunodeficiency, multiple sexual partners, homo- and bisexuality,
and alcohol abuse may be related to the disease. In these cases, the use of condom is
strongly recommended.
© 2018 Published by Elsevier B.V. on behalf of European Association of Urology.

1. Introduction although the nucleic acid amplification test (NAAT)

1.1. Background
Historically, the term urethritis collects all pathologies
characterized by urethral discharge. However, recent liter-
ature has shown that urethritis is more often found in men
without discharge, but with symptoms such as itching,
tingling, or dysuria. Urethritis can also be asymptomatic
[1]. Recent literature supported the theory that empirical
treatments should be avoided or just temporarily used due
to both the presence of unusual microorganisms and the
risk of antibiotic resistance phenomena [2–4]. As a conse-
quence, urethritis may represent a true diagnostic and
therapeutic challenge for the urologist.
Several risk factors such as multiple and simultaneous
sexual partners, lack of consistent and proper use of con-
doms, increased susceptibility to infection due to limited
immunocompetence, and homo- and bisexual relationships
having more than three different partners, may contribute
to the development of urethritis. Furthermore, alcohol
abuse and/or consumption of other substances such as
drugs or pharmacological compounds tends to occur or
precede sexual risk behaviors among young people [5–7].
The epidemiology of urethritis in Europe has seen impor-
tant changes during the last decade due to the recent
increase of migratory streams from North Africa [8]. The
entrance of a large number of migrants to all the European
countries has had relevant implications on the urethritis
prevalence, also increasing the risk of diffusion among
young people.
Urethritis “modern view” includes noninfectious etiolo-
gies due to external or iatrogenic factors such as urethral
inflammation that occurred after traumas or intraurethral
inoculation of irritating compounds [9,10]. Conversely,
infectious urethritis may be generated by bacterial, viral,
or parasitic microorganisms and is generally sexually
transmitted.
Infectious urethritis is currently classified according to
the microorganisms involved in the inflammatory process
as gonococcal urethritis (GU) and nongonococcal urethritis
(NGU).
This kind of classification based on the traditional Gram
stain for diplococci found at patient’s urethral discharge
collection has been maintained in daily clinical practice,
replaced Gram staining in the identification of Neisseria
gonorrhoeae and Chlamydia trachomatis, although it seems
to be less efficient in the characterization of other micro-
organisms involved in the infective process [11–13]. The
most common pathogens isolated from patients with NGU
are represented in Table 1. N. gonorrhoeae and C. tracho-
matis are the more frequent causes of urethritis, and
microbiological diagnosis by NAATs is far superior when
compared with culture and nonculture diagnostic methods
with >90% sensitivity and 99% specificity [11]. Similarly,
Gram staining is 95% sensitive and 99.9% specific, although
C. trachomatis investigation test may easily be found to be
false negative due to extended testing turnaround time,
difficulties in standardization, labor intensity, technical
complexity, stringent specimen collection transport
requirements, and relatively high cost [11]. Owing these
reasons, the level of evidence (LE) of NAATs on the first
urine stream for the diagnosis of gonococcal or chlamydial
infections is 2a with strong strength rating (strong)
[14]. For other microorganisms, the Gram stain of urethral
discharge or a urethral smear remains applicable with LE
3b and strong strength rating [14]. Mycoplasma genitalium
may be identified easily by both the investigation methods,
although microorganism identification by microscopy
should be performed no later than 2 h from the sample
collection [15]. On the contrary, several studies have dem-
onstrated that a substantial number of pathogen-positive
NGU cases are missed with the Gram stain criteria
[16]. Based on recent data, a threshold of 2 polymorpho-
nuclear neutrophils per high-power field on the urethral
Gram stain could be considered as a criterion to diagnose
NGU in high-risk settings, particularly in venues where the
rate of loss to follow-up is high [16].
Table 1 – Prevalence of the most common pathogens isolated from
patients with NGU.
C. trachomatis 11–50%
M. genitalium 5–50%
T. vaginalis 1–20%
Ureaplasma 5–26%
Adenovirus 2–4%
Herpes simplex virus 2–3%
NGU = nongonococcal urethritis. Adapted from Horner et al [13].

Please cite this article in press as: Bartoletti R, et al. Management of Urethritis: Is It Still the Time for Empirical Antibiotic
Treatments?. Eur Urol Focus (2018), https://doi.org/10.1016/j.euf.2018.10.006
EUF-619; No. of Pages 7
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The 2016 annual report of the Center for Disease Control
and Prevention (CDC) on the incidence of cases of urethritis
in the USA shows an increase of N. gonorrhoeae and C.
trachomatis infections, with a peak of incidence in the
age range of 25–29 yr [1]. The same trend of increasing
incidence of GU and NGU was shown in Europe by the
European Centre for Disease Prevention and Control report
[17].
Sonnenberg and other authors [12] stated that urethritis
was distributed heterogeneously in the British population,
with an increasing incidence of the Chlamydia infection
from 2010 to 2012. In addition, they found a higher inci-
dence of N. gonorrhoeae infection in patients positive to
Chlamydia infection. This connection can be explained by
the fact that patients with risky sexual behavior are exposed
to different pathogens [5]. Owing to this reason, gonococcal
and nongonococcal infections often coexist, generating an
additional confounding factor and limiting the use of empir-
ical treatments.
Previous urethritis or other sexually transmitted diseases
(STDs) occurring during adolescence or human immunodefi-
ciency virus (HIV) infections are other significant factors that
could increase the risk of recurrent urethritis episodes [18].
Newbern et al [19] conducted a cohort study comparing one
group of adolescents with previous STDs with another with no
previous STDs and found that the first group had double the
risk of developing subsequent HIV infection. Similarly, previ-
ous Herpes genitalium infection can increase the risk of devel-
oping subsequent urethritis episodes by Chlamydia, N. gonor-
rhoeae, and human papillomavirus infections [20].
In men with urethral symptoms, a proper objective
examination involves the search for inguinal lymphadenop-
athy, ulcers, or urethral discharge. The urethra should gently
be “milked” with palpation from the bottom to the distal
end of the penis. Any discharge thus obtained should be
tested with laboratory methods available for gonorrhea and
chlamydial infections.
Currently, urethritis is diagnosed by the presence of at
least one of the following signs or symptoms: the presence of
urethral discharge, a positive result of the leukocyte esterase
test in the first-void urine, or at least 10 white blood cells per
high power field in the first-void urine sediment [21]. In the
absence of urethral discharge, the urine of the first void needs
to be tested for documenting pyuria and DNA-based tests for
Chlamydia and gonorrhea. Scrotum palpation is necessary to
identify concomitant epididymitis or orchitis; rectal explora-
tion is a useful evaluation in case of rectal pain. Other possible
sites of sexual exposure, such as the oropharynx and anus,
should also be evaluated.
If the clinical suspicion based on history (the patient
reports severe dysuria, hematuria, nocturia, urgency in the
absence of sexual exposure), examination (lack of dis-
charge), or laboratory results (nitrite present in the urinal-
ysis) points to a urinary tract infection, a medium-flow
urine sample should be obtained [22].
According to the 2017 European guidelines, microscopic
examination of urethral discharge in pyogenic urethritis is
always recommended and should be performed with Gram
stain or validated NAATs [14].
Please cite this article in press as: Bartoletti R, et al. Management of Urethritis: Is It Still the Time for Empirical Antibiotic
Treatments?. Eur Urol Focus (2018), https://doi.org/10.1016/j.euf.2018.10.006
3
The microscopic diagnosis of NGU is made when five or
more polymorphonuclear leucocytes (PMNLs) are observed
in high-power field, in the absence of intracellular diplo-
cocci in the urethral discharge. However, in the latest CDC
guidelines, this cutoff has been reduced to 2 PMNLs with an
improvement in the number of diagnoses and a logical
increase of antibiotic resistance rates. A false urethritis
diagnosis may also have an impact on interpersonal rela-
tionships. Moi and Hartgill [23] studied this aspect and
concluded that standardization of urethral smear micros-
copy seems to be impossible.
Based on these premises, optimal treatment in patients
with urethritis should always be microbiologically oriented,
avoiding useless empirical therapies and the risk of early
recurrences with subsequently increased rates of antibiotic
resistance.
1.2. Study aim
The aim of this systematic review is to optimize the treat-
ments for urethritis and investigate the applicability of
NAATs as a microbiological investigation in the case of
patients with urethral discharge or unjustified urethral
symptoms.
2. Evidence acquisition
We performed a search of the literature up to June 2018 using
the Medline computerized database of the US National
Library of Medicine, the Cochrane database, and the Google
Scholar database. The search was carried out using Medical
Subject Headings and free text meshed terms plus Boolean
connectors as follows: Urethritis OR gonococcal urethritis OR
non gonococcal urethritis AND Antibiotics OR Recurrence.
The number of records identified was 528, which were lim-
ited to systematic reviews, randomized controlled trials,
prospective nonrandomized studies, and retrospective non-
randomized studies. A total of 286 abstracts including editor-
ials, letters, and non-English articles have been excluded at
the first screening done by the authors for relevance to the
specific research question. The preferred reported items were
compiled to list the number of papers identified and included
in the manuscript. The Preferred Reported Items for System-
atic Reviews and Meta-Analyses (PRISMA) guidelines for the
reporting of this present study were used to perform an
accurate research checklist and report. The number of full-
text articles assessed foreligibility was 242, of which 230 were
not relevant to the research question and/or were data dupli-
cates. Finally, 12 full-text articles were selected for a qualita-
tive synthesis (Fig. 1).
3. Evidence synthesis
3.1. Empirical treatment
The aim of treatment is to reduce symptoms, prevent
complications, and reduce sexual transmission of the
microorganism involved in the inflammatory process.
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4 E U R O P E A N U R O L O GY F O C U S X X X ( 2 0 18 ) X X X– X X X

IdenƟficaƟon
Records idenƟfied through database searching as described in the methods secƟon (n = 528)

Screening
Records excluded because editorial, leƩers, non-English arƟcles (n = 286)

Eligibility
Not relevant to research quesƟon and/or data duplicates
Full-text arƟcles assessed for eligibility (n = 242)
removed (n = 230)

Included
Studies included in qualitaƟve synthesis (n = 12)

Fig. 1 – Preferred Reporting Items for Systematic Reviews and Meta-Analysis flow diagram showing the outcome of the initial and additional searches
resulting in the full studies included in the review.

Empirical treatments are no more recommended in the
latest CDC and European Guidelines, although a broad spec-
trum of antibiotic treatments (single-dose ceftriaxone 1 g
intramuscularly [IM] plus single-dose azithromycin 1.5 g
orally) can be initiated while waiting for the results of the
microbiological characterization of urethral discharge
[14,21,24] The use of a Gram stain of urethral discharge or
urethral smear to preliminarily diagnose GU is a useful point-
of-care diagnostic. Microbiological characterization by NAATs
through adequate urethral discharge collection to determi-
nate the most appropriate and efficient medical treatment is
always indicated and recommended. The risk of developing
infections by multiple microorganisms decreases the chance
of obtaining successful empirical treatments.
Stamm et al [25] described the use of azithromycin for
empirical treatment of the NGU syndrome in men. A total of
452 symptomatic patients were randomly treated with 1 g
azithromycin as a single oral dose or 100 mg doxycycline
taken orally twice a day for 7 d. They found comparable
results in both groups (clinical cure of 81% and 77%, and
microbiological eradication of 83% and 90%, respectively),
although pretreatment microbiological investigation
revealed the prevalence of Ureaplasma urealyticum in both
groups in comparison with C. trachomatis infection (38% and
16% in the azithromycin group and 28% and 24% in the
doxycycline group, respectively).
3.2. GU treatment
Owing to the widespread high levels of cephalosporin resis-
tance, first-line treatment consists of combined therapy
using a single dose of ceftriaxone 250 mg (1 g IM) plus
azithromycin 1 g (2 g orally), although the European
Association of Urology guideline recommendation indi-
cated the need to administer at least ceftriaxone 1 g in
combination with azithromycin 1 g to avoid the risk of
undertreatment (LE 2a) [2,14,21,26,27].
Azithromycin is preferred to doxycycline because of the
convenience and compliance advantages of single-dose
therapy and the substantially higher prevalence of gono-
coccal resistance to tetracycline than to azithromycin (LE
2a) [28,29]. Therefore, this dual therapy will not entirely
prevent the emerging resistance.
Among other cephalosporins, only cefixime, in a 400–
800 mg single oral dose, should be considered as an alter-
native to ceftriaxone, although it is not as effective due to
less favorable pharmacodynamics and probably leads to
emergence of resistance [2].
In case of cephalosporin allergy, alternative regimens
that can be considered consist of oral gemifloxacin
320 mg plus oral azithromycin 2 g, and dual treatment with
single doses of IM gentamicin 240 mg plus oral azithromy-
cin 2 g (LE 2a) [30]. The use of a single 2 g azithromycin oral
dose could be an option for treating uncomplicated GU if
patients are allergic to cephalosporins or are diagnosed as
being infected with an azithromycin-sensitive strain (LE 2a)
[28,31].
Lastly, aminocyclitol spectinomycin, with or without
other antibiotics, where available, can be a valid alternative
to the combined therapy of cephalosporin and macrolide
(LE 3b) [32].
The worldwide increase of gonorrheal antimicrobial
resistance to previous and current first-line recommended
antibiotics is a globally recognized problem. Furthermore,
the emergence of extensive drug-resistant gonorrheal
strains is especially alarming and underlines the

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importance of proper first-line treatment choices and
guideline adherence [2,26].
3.3. Nongonococcal urethritis
Several microorganisms are responsible for NGU, in partic-
ular, C. trachomatis, an obligate intracellular Gram-negative
bacterium; M. genitalium, a small Gram-positive bacterium,
and Trichomonas vaginalis, an anaerobic, flagellated proto-
zoan parasite. However, recent studies demonstrated the
contribution of U. urealyticum, herpes simplex virus, and
adenovirus to the etiology of NGU, owing in part to advance-
ments in NAATs for detection [1].
Men with severe symptoms should be treated immedi-
ately with broad-spectrum antibiotics, as already described
in the empirical treatment, while waiting for the results of
appropriate microbiological investigations. Species-ori-
ented treatment after NAATs, culture, and microscopy
should be considered mandatory in men with mild symp-
toms and less significant urethral discharge, although cur-
rently NAATs only give species identification but not sus-
ceptibility results to antibiotics. Sometimes, urethritis can
resolve without treatment [13].
Appropriate antibiotic treatment should be able to achieve
microbiological eradication (at least in 95% of cases), with a
low impact on patient’s quality of life. Persistence of inflam-
mation may not indicate the persistence of infection and may
persist for an unknown length of time, although microbio-
logical investigations should be repeated at least 10 d after the
completion of antibiotic treatment [13].
In the 2015 CDC guidelines, the association of M. geni-
talium and STDs was included among the “emerging issues”

Table 2 – EBM-based medical treatment for urethritis.

Patients Pathogen Treatment Ref. no. LE

Empirical treatment ??? [14,19,22] 3b, weak

Broad-spectrum antibiotic while waiting for the NAAT result
Gonococcal urethritis N. gonorrhoeae [2,14,21,26–32] 2a, strong
2a, weak
- Ceftriaxone 250 mg–1 g single dose IM plus azithromycin 1–2 g orally 2a, strong
- Or cefixime 400–800 mg orally plus azithromycin 1–2 g orally
2a, strong
3b, weak
- Or gemifloxacin 320 mg orally plus azithromycin 2 g orally
- Or gentamycin 240 mg IM single dose plus azithromycin 2 g orally
- Or spectinomycin 2 g IM

Nongonococcal C. trachomatis [4,13,21,35–42] 2a, strong

urethritis 1b, strong
- Azithromycin 1 g single dose orally 3a, weak
- Or doxycycline 100 mg orally twice a day for 7 d
- Or erythromycin 500 mg 4 times a day for 7 d
- Or levofloxacin 500 mg orally a day for 7 d
- Ofloxacin 300 mg orally twice a day for 7 days

T. vaginalis 3b, weak

- Metronidazole or tinidazole 2 g single dose orally

- Metronidazole 4 g daily for 3–5 d
- Doxycycline 100 mg orally twice a day for 7 d

U. urealyticum 2a, strong

2a, strong
- Doxycycline 100 mg orally twice a day for 7 d 3a, weak
- Or azithromycin 1 g single dose orally
2a, weak

- Or clarithromycin 500 mg b.i.d. for 7 d

- Or azithromycin 500 mg a day for 6 d

M. genitalium 3a, weak

1b, strong
- Azithromycin 1 g single dose orally
- Or doxycycline 400 mg orally daily for 7–14 d
- Or josamycin 500 mg 3 times a day for 10 d

Persistent or ??? [13,15] 3b, weak

recurrent If azithromycin is used for initial episode: moxifloxacin 400 mg orally for 7 d
nongonococcal If doxycycline is used for initial episode: azithromycin 1 g orally single dose
urethritis For men who have sex with women who live in areas with a high prevalence
of T. vaginalis: metronidazole 2 g orally or tinidazole 2 g orally single dose

EBM = evidence-based medicine; IM = intramuscularly; LE = level of evidence; NAAT = nucleic acid amplification test.

Please cite this article in press as: Bartoletti R, et al. Management of Urethritis: Is It Still the Time for Empirical Antibiotic
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and is estimated to have an incidence between 6% and 50% Estonia, Finland, Hungary, Italy, Latvia, Norway, Romania,
in patients with NGU [21]. Among the reasons for this and Sweden.
alarmism is the lack of international consensus on treat-
ment, coinfection with HIV, injudicious use of macrolide for
4. Conclusions
community-acquired pneumonia, and inadequate treat-
ment adherence in patients and their partners. M. genita-
Treatment of urethritis seems to be less easy than it was
lium is devoid of peptidoglycan, and therefore it is not
several years ago. The improvement of microbiological
possible to use antibiotics that act on the cell wall. If proved
investigations such as the NAAT at point of care plays a
to be useful, doxycycline (200 mg once daily; LE1b, strong),
decisive role in determining appropriate antibiotic treat-
macrolides (LE 3a, weak), and moxifloxacin (LE 3b, weak)
ments, thus avoiding the risk of antibiotic resistance and
can be used [32–34]. The dosage and regimens used with
improper use of antibiotics indicated for empirical treat-
these drugs differ in various parts of the world, giving rise to
ments, but successful treatment of patients with multiple
an increasing resistance to these antibiotics, in particular to
pathogen infection.
macrolides and quinolones [4,13,35–37].
Combined antibiotic treatment seems to be adequate to
Similarly, C. trachomatis and Ureaplasma infections may
achieve microbiological eradication of different pathogens
easily be treated by azithromycin or doxycycline for a period
and immediate clinical relief. On the contrary, patients with
of at least 7 d (LE2a, strong) [38–40]. Fluoroquinolones, such
risk factors such as immunodeficiency, multiple sexual
as ofloxacin or levofloxacin, may be used as second-line
partners, and homosexual or bisexual relationships should
treatment only in selected cases [4,13].
be adequately informed about the increased risk of devel-
On the contrary, T. vaginalis infection in males may be
oping STDs and motivated for intensive use of condoms
treated by a single dose of metronidazole (LE3b, weak;
during sexual intercourses.
Table 2) [13,41,42].

3.4. Persistent or recurrent NGU
Diagnosis of persistent or recurrent NGU should be made
before considering additional antimicrobial therapy. It is
estimated that 20–40% of NGU cases do not respond to
first-line treatment, with up to 20% of men with chlamyd-
ial NGU and 30–50% of men with nonchlamydial NGU
experiencing persistence/recurrence [13,32]. The differen-
tial diagnosis for recurrence includes reinfection, nonad-
herence, drug resistance, persistent postinfectious immu-
nologic response, and complicated infection. In all cases
with persistent or recurrent symptoms, anatomical urinary
tract abnormalities should be investigated by urethro-
scopy, while concomitant urothelial tumors should be
excluded by urinary cytology, cystoscopy, and urinary tract
ultrasound.
3.5. Follow-up and management of sexual partner
To avoid reinfection, abstinence of at least 7 d should be
observed from the start of therapy. All sex partners of men
with NGU within the preceding 60 d should be referred for
evaluation, testing, and treatment with a drug regimen
effective against C. trachomatis.
If N. gonorrhoeae or T. vaginalis is documented, all part-
ners should be evaluated and treated properly.
Patients who have been diagnosed with a new STD
should receive testing for other STDs, including syphilis
and HIV [5–7,12,18,19].
In case of Chlamydia, N. gonorrhoeae, or Trichomonas
infections, partner services should be offered and partners
should be instructed to return 3 mo after treatment to
repeat testing because of high rates of reinfection.
Compulsory notification of STD to sexual partners is
regulated by national laws for public health purposes in
the USA and some European countries such as Bulgaria,
Author contributions: Riccardo Bartoletti had full access to all the data
in the study and takes responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Bartoletti.
Acquisition of data: Cai, Tandogdu.
Analysis and interpretation of data: Bartoletti, Cai.
Drafting of the manuscript: Bartoletti.
Critical revision of the manuscript for important intellectual content:
Johansen, Wagenlehner.
Statistical analysis: None.
Obtaining funding: None.
Administrative, technical, or material support: None.
Supervision: Köves, Bonkat.
Other: None.
Financial disclosures: Riccardo Bartoletti certifies that all conflicts of
interest, including specific financial interests and relationships and
affiliations relevant to the subject matter or materials discussed in the
manuscript (eg, employment/affiliation, grants or funding, consultan-
cies, honoraria, stock ownership or options, expert testimony, royalties,
or patents filed, received, or pending), are the following: None.
Funding/Support and role of the sponsor: None.
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Treatments?. Eur Urol Focus (2018), https://doi.org/10.1016/j.euf.2018.10.006
EUF-619; No. of Pages 7
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