Bull Rheum Dis 1987;37:1; Ann Intern Med 1984;100:207; N Engl J Med 1983;309:1606

Cause: Autoimmune

Epidem: Most common polyarthritis in men. Sometimes the first manifestation of HIV infection. Systemic illness associated with preceding urethritis due to gc or Chlamydia or enteritis due to Yersinia, Salmonella, Shigella, Campylobacter, Neisseria, or Ureaplasma (Bull Rheum Dis 1990;39:1). HLA B27 genotype is a predisposing factor in more than 2/3 of pts.

Sx: There is a 2-4 wk incubation period (urethritis or enteritis). First urethritis (85%), cervicitis, and/or prostatitis; then red eye (conjunctivitis); then, weeks later, arthritis, arthralgias (99%), especially peripheral and lower extremities, especially heels, ankles, knees, low back.

Si: Classic triad of arthritis, urethritis, and conjunctivitis does not occur in all pts. Peripheral arthritis and purulent urethral discharge (95%); red eye from conjunctivitis (40%) or uveitis (8%); fever (37%); painless skin or mucous membrane lesions (32%), especially circinate balanitis and keratodermia blennorrhagia (looks like pustular psoriasis). In females, nonspecific cervicitis may occur.

Crs: Most cases (80%) resolve after 4-12 mo; 20% chronic

Cmplc: Aortitis (1%), heart block (1%)

Diff Dx: R/o chronic lyme arthritis, gc, erythema multiforme, Behçet’s syndrome, psoriasis, ankylosing spondylitis, gonococcal urethritis, Still’s disease, rheumatic fever.

Joint fluid: Wbc 5000-50,000; mostly polys, but lower percentage than gc with more monos, occasionally with ingested polys (Ann Intern Med 1967;66:677)

Serol: RA titer (−), HLA B 27 (+) in 60-75%, but only 8% of people with (+) titer have Reiter’s (Ann Intern Med 1982;96: 70).

Xray: Periosteal new bone formation along shafts (phalanges)

Rx: Initial: potent NSAIDs such as indomethacin 75 mg sustained release bid or tid or doxycycline 100 mg po bid for 3 mo if chlamydial origin strongly suspected or confirmed. Subsequent rx for persistent disease: sulfasalazine 1 g po bid or tid. Rx for chronic, erosive, deforming disease: methotrexate 7.5-25 mg po per wk, azathioprine 100-150 mg po qd (Am Fam Physician 1999;60:2).

Cause: Neisseria gonorrhoeae

Epidem: Venereal. Common in teenagers and racial and ethnic minorities. Risk increases as number of sexual contacts with infected partners increase. Coincident infection in 15% male heterosexuals, 25% females (N Engl J Med 1984;310:545).

Pathophys: Infects mucous membranes of gu tract (N Engl J Med 1985; 312:1683)

Male: Urethral discharge, usually profuse and purulent, but up to 2/3 asx (N Engl J Med 1974;290:117)

Female: Bartholin cyst (80% acute Bartholin’s gland cyst infections are due to gc); vaginal discharge, dysuria, pelvic inflammatory disease, pain typically occurring with menses or pregnancy, abnormal menstrual bleeding due to endometriosis

Si: Urethral discharge. In female, abdominal distention, Chandelier’s sign (severe pain with cervical motion), pus in cervix

Crs: Incubation period 3-10 d

Diff Dx: Trichomonas, Candida, Chlamydia (N Engl J Med 1974;291: 1175), syphilis, Reiter’s syndrome, appendicitis in female

Bact: Gram stain, in male first, culture only if unclear on Gram stain; in female, smear of cleanly wiped cervix to look for more than 3 polys/hpf with intracellular gram-neg cocci has 67% sens, 98% specif. If h/o oral genital contact: pharyngeal specimen; in homosexual males and all women: rectal swab.

Culture: In male, only if unclear on smear. In female, Gram stain more difficult to interpret and less sensitive than smears from male urethra; thus culture on selective media still often necessary (J Clin Pathol 1998;51:564). Reculture all after rx and recheck VDRL if neg first time. Penicillinase-producing strains now in United States.

Urine: Urine tests for gonorrhea and Chlamydia may be performed via the use of NAAT (nucleic acid amplification tests). Three NAATs are available: PCR, transcription-mediated amplification, and strand displacement amplification. To improve test results, the pt should not void for 1 hr before giving a urine sample. All 3 NAATs have > 95% specificity for both gonorrhea and chlamydial infections in urine, cervical, and urethral samples. Transcription-mediated amplification and strand displacement amplification have sensitivities between 80-90%. PCR of urine, however, detected only 56% of gonococcal infections in women, compared with 94% for cervical samples (Ann Intern Med 2005;142:914).

Rx: CDC recommendations for rx of gonococcal urethritis: ceftriaxone 125 mg im is first choice for uncomplicated gc infections of pharynx, anorectum, cervix, and urethra. Alternative is single-dose spectinomycin 2 g im. Only oral agent currently recommended by CDC for treatment of uncomplicated urogenital gc is single-dose cefixime 400 mg. Also treat for possible coexisting Chlamydia (MMWR 1989;38:1).

Cause: Chlamydia trachomatis accounts for 30-50% of cases; 20-50% men with nongonococcal urethritis (NGU) may have Ureaplasma urealyticum.

Epidem: Incidence 2.5 times that of gc urethritis (Epidemiol Rev 1983; 5:96)

Pathophys: Smoking may be a risk factor (Sex Transm Dis 1988;15: 119) as well as being circumcised (Am J Pub Health 1987;77: 452)

Crs: Incubation period usually 1-5 wk

Sx: Dysuria, urethral discharge

Lab: Gram stain urethral swab: more than 4 polys/hpf suggestive of urethritis. Endourethral swab rather than urethral exudates or urine; place 2-4 mm inside urethra; preliminary culture available in 2-3 d. Direct fluorescent ab (DFA): rapidly detects C. trachomatis elementary bodies. Enzyme immunoassay (EIA) can also be used: pos test color changes when viewed with spectrophotometer, results in 24 hr. PCR: highly specif test for fluorescence of chlamydial nucleic acids; contamination by foreign DNA a problem (Gen Clin Pathol 1991;44:1).

Rx: CDC recommendations: tetracycline 500 mg qid for 7 d, doxycycline 100 mg po bid, or erythromycin 500 mg po qid for 7 d;
rx partners. Single 1-g dose of azithromycin found to be therapeutically equivalent to tetracyclines and may improve compliance. If recurrent or persistent, r/o other causes of urethritis; if no cause found or Ureaplasma urealyticum present, erythromycin base 500 mg qid for 14 d (Urol Clin North Am 1984; 11:55).