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The usual approach to sexually transmitted diseases (STDs) considers the causative agents, emphasizing different classes, genera, species, and microbiological characteristics. This fits with most medical school curricula since the causative agents span the full spectrum of medical microbiology (viruses, bacteria, protozoa, ectoparasites, and so on). This classical approach often proves difficult in clinical practice, where many different types of agents must be considered in the differential diagnosis of an individual patient.

This chapter takes a very selective and practical approach. Because patients present with symptoms and signs that may be caused by pathogens from different microbiological classes, we will emphasize diagnosis and treatment of clinical syndromes in contrast to traditional teaching (Table 16–1). This is a large subject with much active research and a huge literature. We stress the most important conditions encountered in urology: urethritis, epididymitis, genital ulcers, genital warts, plus a brief consideration of human immunodeficiency virus (HIV) infection.

Table 16–1. Sexually Transmitted Disease (STD) Syndromes.a

Urethritis in Men

Definition. Urethritis, or urethral inflammation, is frequently caused by infection.

Clinical presentation. Characteristically, patients complain of urethral discharge and dysuria. On examination, the discharge may be purulent or mucopurulent. Asymptomatic infections are common (CDCP, 2006; McCormack and Rein, 2000). The most important pathogens are bacteria, Neisseria gonorrhoeae, and Chlamydia trachomatis.

Laboratory testing. Testing is recommended to document a specific disease because both of these infections are reportable to health departments, and because specific diagnosis may improve compliance and partner notification (CDCP, 2006). The traditional diagnostic algorithm includes microscopic examination of the Gram-stained urethral smear for gram-negative intracellular diplococci and culture for N. gonorrhoeae. New nucleic acid amplification tests have proved accurate for detection of N. gonorrhoeae and C. trachomatis in first-void urine in high-risk populations (CDCP, 2006; Gaydos et al, 2009; McCormack and Rein, 2000). If diagnostic testing is unavailable, patients should be treated empirically for both infections (CDCP, 2006).

Complications. Complications of urethritis in men include epididymitis (see later), disseminated gonococcal infection, and Reiter's syndrome (CDCP, 2006; McCormack and Rein, 2000). Complications of urethritis in female sexual partners ...

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