7.7 Therapy

The following guidelines for therapy comply with the recommendations of the Center for Disease Control and Prevention (8). The following antimicrobials can be recommended for the treatment of gonorrhoea:

• Cefixime, 400 mg orally as a single dose

• Ceftriaxone, 250 mg intramuscularly (with local anaesthetic) as a single dose

• Ciprofloxacin, 500 mg orally as single dose

• Ofloxacin, 400 mg orally as single dose

As gonorrhoeae is frequently accompanied by chlamydial infection, an anti-chlamydial active therapy should be added. The following treatments have been successfully applied in С trachomatis infections. First choice:

• Azithromycin, 1 g orally as single dose

• Doxycycline, 100 mg orally twice daily for 7 days Second choice:

• Erythromycin, 500 mg orally four times daily for 7 days

• Ofloxacin, 200 mg orally twice daily for 7 days

Doxycycline and azithromycin are considered to be equally effective in the treatment of chlamydial infections. Erythromycin is less effective and causes more side effects. If therapy fails, one should consider treating infections by T vaginalis and/or Mycoplasma with a combination of metronidazole (2 g orally as single dose) and erythromycin (500 mg four times daily orally for 7 days). As in other STD, the treatment of sexual partners is necessary.

7.8 Prevention

Patients with sexual transmitted urethritis should avoid unprotected sexual contact for the duration of the treatment and until symptoms have disappeared.

7.9 REFERENCES

1. Ebo DG, Mertens AV, De-Clerck LS, Gentens P, Daelemans R.

Relapse of Wegener's granulomatosis presenting as a destructive urethritis and penile ulceration. Clin Rheumatol 1998; 17: 239-241.

2. Friese K, Naber KG, Bredt W, Kuhn J.

Urethritis. In: Klinische Infektiologie. Marre R, Mertens T, Trautmann M, Vanek E (eds). Munich, Germany: Urban & Fischer, 2000; 472-477.

3. Borchardt KA, al-Haraci S, Maida N.

Prevalence of Trichomonas vaginalis in a male sexually transmitted disease clinic population by interview, wet mount microscopy, and the In-Pouch TV test. Genitourin Med 1995; 71: 405-406.

4. Busolo F, Camposampiero D, Bordignon G, Bertollo G.

Detection of Mycoplasma genitalium and Chlamydia trachomatis DNAs in male patients with urethritis using the polymerase chain reaction. New Mikrobiol 1997; 20: 325-332.

5. Evans BA, Bond RA, MayRae KD.

Racial origin, sexual behaviour, and genital infection among heterosexual men attending a genitourinary medicine clinic in London (1993-1994). Sex Transm Infect 1998; 74: 40-44.

6. Evans BA, Kell PD, Bond RA, MacRae KD.

Racial origin, sexual lifestyle, and genital infection among women attending a genitourinary medicine clinic in London (1992). Sex Transm Infect 1998; 74: 45-49.

7. Krieger JN.

Trichomoniasis in men: old issues and new data. Sex Transm Dis 1998; 22: 83-96.

8. Center for Disease Control and Prevention.

1998 Guidelines for treatment of sexually transmitted diseases. Morb Mortal Wkly Rep 1998; 47:1 -111.

8. PROSTATITIS, EPIDIDYMITIS AND ORCHITIS

8.1 SUMMARY

Prostatitis is a disease entity that is diagnosed by symptoms, the microscopy of expressed prostaticsecretion (EPS), and the culture of EPS and segmented urine samples. According to the duration of symptoms, prostatitis is described as either acute or, where symptoms are present for at least 3 months, chronic. We recommend the classification of prostatitis suggested by the National Institute of Diabetes, Digestive and Kidney Diseases (NIDDK)/National Institutes of Health (NIH), in which bacterial prostatitis (acute and chronic) is distinguished from chronic pelvic pain syndrome (CPPS).

Acute bacterial prostatitis (ABP) can be a serious infection and parenteral administration of high doses of bactericidal antibiotics, such as aminoglycosides and a penicillin derivative or a third-generation cephalosporin, are required until defeverescence and the normalization of infection parameters. In less severe cases, a fluoroquinolone may be given orally for 10 days.

In chronic bacterial prostatitis (СВР) and CPPS, a fluoroquinolone or TMP should be given orally for 2 weeks after the initial diagnosis. The patient should then be re-assessed and antibiotics continued only if pre-treatment cultures were positive or if the patient reports a positive effect of the treatment in terms of pain relief. A total treatment period of 4-6 weeks is then recommended.

Inflammatory processes of the testis (orchitis) and epididymis (epididymitis) have to be classified as acute or chronic processes according to the onset and clinical course. The majority of cases of epididymitis are due to common urinary pathogens. Bladder outlet obstruction and urogenital malformations are risk factors for this type of infection. Orchitis of the child and mumps-orchitis are of haematogenous origin. Epididymo-orchitis is also seen in systemic infections, such as tuberculosis, lues, brucellosis and cryptococcus disease. Antimicrobials should be selected on the empirical basis that in young, sexually active men C. trachomatis is usually the causative agent, and that in older men with BPH or other micturition disturbances, the most common uropathogens are involved.

Prior to antimicrobial therapy, a urethral swab and MSU should be obtained for microbiological investigation. Fluoroquinolones, preferably those with good activity against С trachomatis (e.g. ofloxacin, levofloxacin), should be the drugs of first choice, because of their broad antibacterial spectra and their favourable penetration into the tissues of the urogenital tract. If C. trachomatis has been detected as the aetiological agent, treatment could also be continued with doxycycline, 200 mg/day, for a total treatment period of at least 2 weeks. Macrolides may also be considered. For cases of С trachomatis epididymitis, the sexual partner should also be treated.