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Letters

Urethral discharge

Fabrizio Dal Moro
CMAJ July 09, 2013 185 (10) 899-900; DOI: https://doi.org/10.1503/cmaj.113-2122
Fabrizio Dal Moro
Department of Surgical, Oncological and Gastroenterological Sciences — Urology, University of Padova, Padua, Italy
MD
Roles: Assistant professor
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I would like to congratulate Rebick and colleagues1 on their article on the treatment of urethral infections. In their elegant work, the authors describe the tests available for specific diagnosis of various causes of urethritis in men and conclude by analyzing the guidelines on medical treatment, stressing the high risk of relapse or reinfection and consequent recommendations for posttreatment tests.

Recommendations for follow-up cultures or tests of cure are essential in order to show possible recurring infections or re-infection, thus minimizing any late complications related to infection. As emphasized by Rebick and colleagues1 in case of failure of treatment, the patient should be referred to a specialist in sexually transmitted diseases for proper management of the infection.

To emphasize the need for correct management of urethral reinfections or the recurrence of previously treated urethritis, I would like to stress some points. First, many infections (and reinfections) of the urethra are asymptomatic, making the diagnosis of failure of treatment very difficult.

Second, failure of medical treatment may be due not only to inadequate therapy or resistance to antibiotics,2 but also to patient behaviour. Often when patients are instructed to abstain from sexual intercourse for at least 1 week after therapy is initiated and prompt treatment of partners is also recommended, many studies have shown that about 30% of cases are positive at rescreening and, in more than 60% of these, repeat infections occur (originating from re-exposure to an untreated or inadequately treated partner).3

Third, one of the most frequent and dramatic late complications of urethritis is inflammatory stricture of the urethra, which usually starts with meatal stenosis, later progressively involving the anterior and posterior urethra and often requiring long-term management. Optical urethrotomy, as described by Sachse in 1974, is still the initial treatment for the majority of men. Unfortunately, this treatment alone is associated with a significantly high recurrence rate, which may reach 50%.4

Management of recurrent stenoses is a complex dilemma for urologists.5 Given the expanding number of endoscopic techniques available, the choice of the best surgical option is often difficult, and urethral reconstruction has become an increasingly specialized urologic procedure. Because of the cost and invasiveness of some treatments (e.g., urethroplasty with buccal mucosa grafts), many urologists have limited experience performing more complicated repairs.

In addition, the very definition of success is hampered by nonstandardized follow-up methods, making understanding the outcome of some of these interventions difficult.6

Proper medical management of urethral infection is essential, in view of the possible late complications of untreated urethritis. Urethral discharge must never be underestimated.

References

  1. ↵
    1. Rebick GW,
    2. Allen VG,
    3. Gold WL
    . A 34-year-old man with urethral discharge. CMAJ 2013;185:414–5.
    OpenUrlFREE Full Text
  2. ↵
    1. Kirkcaldy RD,
    2. Zaidi A,
    3. Hook EW,
    4. et al
    . Neisseria gonorrhoeae antimicrobial resistance among men who have sex with men and men who have sex exclusively with women: the Gonococcal Isolate Surveillance Project, 2005–2010. Ann Intern Med 2013;158:321–8.
    OpenUrlCrossRefPubMed
  3. ↵
    1. Kissinger PJ,
    2. Reilly K,
    3. Taylor SN,
    4. et al
    . Early repeat chlamydia trachomatis and Neisseria gonorrhoeae infections among heterosexual men. Sex Transm Dis 2009;36:498–500.
    OpenUrlCrossRefPubMed
  4. ↵
    1. Meeks JJ,
    2. Erickson BA,
    3. Granieri MA,
    4. et al
    . Stricture recurrence after urethroplasty: a systematic review. J Urol 2009;182:1266–70.
    OpenUrlCrossRefPubMed
  5. ↵
    1. Wong SS,
    2. Aboumarzouk OM,
    3. Narahari R,
    4. et al
    . Simple urethral dilatation, endoscopic urethrotomy, and urethroplasty for urethral stricture disease in adult men. Cochrane Database Syst Rev 2012;(12): CD006934.
  6. ↵
    1. Wiegand LR,
    2. Brandes SB
    . The UREThRAL stricture score: A novel method for describing anterior urethral strictures. Can Urol Assoc J 2012;6:260–4.
    OpenUrlCrossRefPubMed
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Canadian Medical Association Journal: 185 (10)
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Vol. 185, Issue 10
9 Jul 2013
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Urethral discharge
Fabrizio Dal Moro
CMAJ Jul 2013, 185 (10) 899-900; DOI: 10.1503/cmaj.113-2122

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Urethral discharge
Fabrizio Dal Moro
CMAJ Jul 2013, 185 (10) 899-900; DOI: 10.1503/cmaj.113-2122
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