Warning:

This document is being maintained for historical purposes, but is now out of date. To view current guidelines please visit:

• STD Treatment Guidelines   at http://www.cdc.gov/STD/treatment

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1993 Sexually Transmitted Diseases Treatment Guidelines

09/24/1993

SUGGESTED CITATION
Centers for Disease Control and Prevention. 1993 Sexually
transmitted diseases treatment guidelines. MMWR 1993;42(No. RR-14):
{inclusive page numbers}.

CIO Responsible for this publication:
National Center for Prevention Services,
Division of Sexually Transmitted Diseases and HIV Prevention

Nongonococcal Urethritis
     
     NGU, or inflammation of the urethra not caused by gonococcal
infection, is characterized by a mucoid or purulent urethral
discharge. In the presence or absence of a discharge, NGU may be
diagnosed by greater than or equal to 5 polymorphonuclear
leukocytes per oil immersion field on a smear of an intraurethral
swab specimen. Increasingly, the leukocyte esterase test (LET) is
being used to screen urine from asymptomatic males for evidence of
urethritis (either gonococcal or nongonococcal). The diagnosis of
urethritis among males tested with LET should be confirmed with a
Gram-stained smear of a urethral swab specimen. C. trachomatis is
the most frequent cause of NGU (23%-55% of cases); however,
prevalence varies among age groups, with lower prevalence found
among older men. Ureaplasma urealyticum causes 20%-40% of cases,
and Trichomonas vaginalis 2%-5%. HSV is occasionally responsible
for cases of NGU. The etiology of the remaining cases of NGU is
unknown.

     Complications of NGU among men infected with C. trachomatis
include epididymitis and Reiter's syndrome. Female sex partners of
men who have NGU are at risk for chlamydial infection and
associated complications.

Recommended Regimen -
     Doxycycline 100 mg orally 2 times a day for 7 days. *

Alternative Regimens -
     Erythromycin base 500 mg orally 4 times a day for 7 days
                           or
     Erythromycin ethylsuccinate 800 mg orally 4 times a day for 7
     days.

     If a patient cannot tolerate high-dose erythromycin schedules,
one of the following regimens may be used:
     Erythromycin base 250 mg orally 4 times a day for 14 days
                            or
     Erythromycin ethylsuccinate 400 mg orally 4 times a day for 14
     days.

     Treatment with the recommended regimen has been demonstrated
in most cases to result in alleviation of symptoms and in
microbiologic cure of infection. If the etiologic organism is
susceptible to the antimicrobial agent used, sequelae specific to
that organism will be prevented, as will further transmission; this
is especially important for cases of NGU caused by C. trachomatis.

Follow-Up
     Patients should be instructed to return for evaluation if
symptoms persist or recur after completion of therapy. Patients
with persistent or recurrent urethritis should be re-treated with
the initial regimen if they failed to comply with the treatment
regimen or if they were re-exposed to an untreated sex partner.
Otherwise, a wet mount examination and culture of an intraurethral
swab specimen for T. vaginalis should be performed; if negative,
the patient should be retreated with an alternative regimen
extended to 14 days (e.g., erythromycin base 500 mg orally 4 times
a day for 14 days). The use of alternative regimens ensures
treatment of possible tetracycline-resistant U. urealyticum.

     Effective regimens have not been identified for treating
patients who experience persistent symptoms or frequent recurrences
following treatment with doxycycline and erythromycin. Urologic
examinations do not usually reveal a specific etiology. Such
patients should be assured that, although they have persistent or
frequently recurring urethritis, the condition is not known to
cause complications among them or their sex partners and is not
known to be sexually transmitted. However, men exposed to a new sex
partner should be re-evaluated. Symptoms alone, without
documentation of signs or laboratory evidence of urethral
inflammation, are not a sufficient basis for re-treatment.

Management of Sex Partners
     Patients should be instructed to refer sex partners for
evaluation and treatment. Since exposure intervals have received
limited evaluation, the following recommendations are somewhat
arbitrary. Sex partners of symptomatic patients should be evaluated
and treated if their last sexual contact with the index patient was
within 30 days of onset of symptoms. If the index patient is
asymptomatic, sex partners whose last sexual contact with the index
patient was within 60 days of diagnosis should be evaluated and
treated. If the patient's last sexual intercourse preceded the time
intervals previously described, the most recent sex partner should
be treated. A specific diagnosis may facilitate partner referral
and partner cooperation. Therefore, testing for both gonorrhea and
chlamydia is encouraged.

     Patients should be instructed to abstain from sexual
intercourse until patient and partners are cured. In the absence of
microbiologic test-of-cure, this means when therapy is completed
and patient and partners are without symptoms or signs.

Special Considerations

HIV Infection -
     Persons with HIV infection and NGU should receive the same
treatment as patients without HIV infection.

* Azithromycin 1 g in a single dose, according to manufacturer's
data, is equivalent to doxycycline. However, this study has not
been published in a peer-reviewed journal. For a discussion
comparing azithromycin and doxycyline, refer to Chlamydial
Infections.

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