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Drs Shamanesh and Radcliffe on the one hand and Dr Horner on the other provide finely balanced arguments for and against screening of asymptomatic men for non-specific urethritis (NSU). Drs Shamanesh and Radcliffe, in addition, slip in their recommendation to abandon examining asymptomatic men and this needs to be challenged. Dr Ross suggests that individual departments may chose whether to continue with...
Drs Shamanesh and Radcliffe on the one hand and Dr Horner on the other provide finely balanced arguments for and against screening of asymptomatic men for non-specific urethritis (NSU). Drs Shamanesh and Radcliffe, in addition, slip in their recommendation to abandon examining asymptomatic men and this needs to be challenged. Dr Ross suggests that individual departments may chose whether to continue with the urethral smear (US) but that may result in some difficulties and it is the pragmatic implications of the change in practice which I would like to address.
It is hard to understand the logic that suggests that a finding in an asymptomatic patient should be interpreted differently in a symptomatic patient. If a man has a discharge and his tests for N gonorrhoeae and C
trachomatis are negative but he has a urethritis, as evidenced by a significant number of pus cells on a US, we would call this NSU. We might believe that M genitalium could be a cause, but clearly according to current data, that infection cannot account for all symptomatic patients.
We would treat him, and in the past would have treated his partner. Our rationale for doing this is to remove his symptoms and to prevent re-infection from his partner and possible harm to her. If he is minimally symptomatic, presumably the same argument applies. At what point does the
argument no longer apply? Can we assume that truly asymptomatic men who do not have a visible urethral discharge but have urethritis on a US do not have M genitalium or any other pathogen? Clearly that is not the case, although the likelihood is relatively small. The pathogenic potential of M genitalium is becoming increasingly apparent and it seems wrong to abandon
the only routine test, albeit a surrogate marker, we have. Thinking back to the early to mid 1980s, we might have made a similar decision about C trachomatis then when we had relatively little evidence of the potential
pathogenicity of C trachomatis. The widespread availability of testing for M genitalium would make a huge difference in progressing this argument but we seem to be someway away from that at the moment.
However the pragmatic problem is how we deal with patients who have had a urethral smear in the past and have been told they had NSU. Are we now to tell them that we no longer believe in that diagnosis, that their
treatment and partner assessment was unnecessary (unless of course they had symptoms, in which case we still believe in the diagnosis). What new evidence can we point to, to enable us to reject our previously held views or are we just seeking to abandon a difficult diagnosis to push people
through our clinics faster and meet DH targets of doubtful value?
If the US is abandoned, clinicians have the option of diagnosing gonorrhoea by taking a urethral culture or using a NAAT urine test. If we continue to test for male gonorrhoea using urethral culture, an examination will be necessary and this will therefore make little
difference to the clinic throughput. Using the “pee and go” approach, men will not be examined. Dr Horner points out that it may be wrong to assume that men who say there are asymptomatic, do not have a urethral discharge. We are all aware of examining men with obvious discharges who are unaware that a discharge is abnormal. How should we manage such men- clearly we should not risk missing a diagnosis of gonorrhoea, so a US is necessary. If we find only NSU, do we ignore the findings?
Furthermore, some men, particularly young men, may be reluctant to express their concerns about particular issues during an interview or in completing a questionnaire and want the opportunity to explore these at the time of examination. Sometimes they don’t have the words to explain
what they perceive might be a problem. While it may not be important in public health terms to reassure a young man that his pearly penile papules are normal or that the dimensions of his penis are perfectly adequate, a
professional opinion may alleviate months of anxiety. Conversely, men with significant disease such as lichen sclerosus, often claim to be asymptomatic. Genital warts may be little more than a cosmetic problem, but the virus is sexually transmitted and we surely have a responsibility
to make the diagnosis, if only to provide reassurance and advice about risk reduction. Finally the opportunity for health promotion, for example teaching testicular self examination, is lost. While “pee and go” may be
ideal for outreach sessions especially in areas of high N gonorrhoeae prevalence where the positive predictive value of the test is likely to be more acceptable, I believe an examination is an integral part of a level 3 specialist service.
Another issue which we may need to consider is the implications of some clinics continuing to test for NSU when other clinics have abandoned the practice as the following recent case illustrates. A young man and his partner presented for a screen before staring a new relationship. He had previously had a negative screen in another clinic a
few weeks after the end of his previous relationship and was only attending at the request of his girl friend who had asked that they should do the tests together. His urethral smear showed more than 20 pus cells. Tests for chlamydial infection and gonorrhoea were negative. We assumed
that the first clinic had used a “pee and go” screening procedure thus missing the diagnosis of asymptomatic NSU.While it could be argued that it would have been better if we had not done a urethral smear and the diagnosis not made, my concern is that inconsistency in practice will make
it very difficult to sustain the confidence of patients in such scenarios. I think we will all need to agree on what constitutes a sexual health screen.
Drs Shamanesh and Radcliffe dismiss the small delay likely to occur if asymptomatic chlamydia positive patients are not detected at their first visit. In most real life settings this is likely to be at least a week, allowing for specimen transport, test performance, result generation, result transmission to the clinician and then the patient and the return of the patient for treatment. During this time the patient may transmit the infection to others. It should be noted that we (and the Department of Health) believe that more than two days is too long to wait
for a GUM appointment in case the patient transmit to others while he is waiting for the appointment. Is there a little hypocrisy here? It should also be noted that the second visit will generate another PBR fee, making the service not only more costly but less cost effective per infection
diagnosis made. The US is our oldest near patient test (apart from the 2 glass test) and at a time when others are seeking to develop near patient testing in order to incorporate treatment into a single visit (one stop
shop) it seems strange that we should be moving away from the concept.
Finally, are we producing “urethral cripples” by diagnosing NGU? A lot depends on what we say to our patients. Clearly in the first instance we do not know whether the patient has chlamydial infection or possibly
gonorrhoea and this needs to be stated. But we could move away from the practice of stating that NGU is almost always sexually transmitted and advise men that if their tests for GC and NG are negative they have a urethritis which may or may not be sexually transmitted. We would then
advise a screen for the partner (which would pick up those cases of NG and CT missed in the index case) and offer treatment, explaining that we are unable to test for M genitalium. This of course, takes a bit more time
than “pee and go”, but seems to me a better way forward than abandoning a diagnosis without firm evidence to do so.
Consultant Genitourinary Physician