View Article PDF

Sexually transmitted infections (STIs) are a major cause of morbidity worldwide.1 A global prevalence survey in 1999 estimated that more than 340 million new cases occurred throughout the world in that year.2Urethral discharge is a common presentation of STI in men and known pathogens causing urethral discharge include Neisseria gonorrhoeae (or gonococcus) and Chlamydia trachomatis. These infections can also be asymptomatic while on the other hand, urethral discharge may be a clinical presentation of conditions other than STIs. A survey of pregnant women attending antenatal clinics in 2004 found that 29% were infected with chlamydia, 1.7% with gonorrhoea and 2.6% with syphilis.3 However, there are no peer-reviewed publications of the burden of STIs, including of urethral discharge, among men in Fiji.STIs are treated syndromically in Fiji according to the national guidelines.4 Urethral swab and cultures are available but the practice of obtaining a sample is highly variable. There is therefore limited knowledge of the common causes and treatment response of urethral discharge in Fijian men. Further, the demographic profile and risk behaviour associated with urethral discharge in men has not been studied.The aim of this study was to evaluate urethral discharge among men in Fiji to determine the incidence as well as the frequency of recurrence and reported at-risk behaviour.MethodologyStudy design—We conducted a retrospective descriptive study of urethral discharge among males in Fiji presenting to the reproductive health clinics over a 1-year period.Study setting—Fiji is an island nation in the South Pacific Ocean that consists of 322 islands with two major islands and a total population of approximately 837,000. The Ministry of Health divides Fiji into three divisions for administrative purposes: the Central and Eastern Division; the Western Division; and the Northern Division. There are three specialised reproductive health clinics that cater for the majority of STI cases in each division, although patients also present to other general outpatient clinics or private clinics.Study population—All patients who presented for the first time from January to December 2011 and were recorded with the diagnosis of urethral discharge syndrome in the patient register were included in the study. Upon presentation to these clinics all patient with urethral discharge have a full clinical assessment including history taking and examination of urethral discharge.Laboratory diagnosis of N. gonorrhoeae in Fiji includes microscopy of a direct smear of the discharge stained with Gram stain to reveal Gram-negative diplococci within polymorphonuclear leucocytes. The modified Thayer Martin medium is the selective media used in Fiji to culture N. gonorrhoeae. Diagnosis of syphilis in Fiji is made by VDRL (venereal disease research laboratory) and TPHA (Treponema pallidum haemagglutination) tests. In the case of C. trachomatis, a nucleic acid amplification method (NAAT) is used for detection.The syndromic treatment guideline for STI recommends single dose of amoxicillin, augmentin, probenecid and azithromycin (AAPA).Data collection and analysis—Data were collected retrospectively from the clinical files and outpatient register of all initial visits by male patients presenting with urethral discharge to the two reproductive health clinics; Central/ Eastern Hub and Western Hub between 1 January and 31 December 2011. Northern Reproductive Health Clinic data was not included due to insignificant data found during data collection (only 5 clinical data were found).The following were recorded: name of medical division, patient registration number, age, treatment received, reported at-risk behaviour and result of syphilis test. A patient who was listed more than once in the 2011 register was listed as a recurrent episode. The patient register for 2012 was also reviewed to identify patients who had presented during the study period and have re-presented to the clinics with recurrent episodes. All patients with recurrent episodes had duration between episodes recorded along with result of urethral swab culture where available.Frequencies were calculated, and Chi-squared test was used to assess differences in proportions between groups with OR and 95% CI indicated where appropriate. The level of significance was set at 5%.Ethics—Ethics approval was obtained from the Union Ethics Advisory Group (EAG), the National Health Research Committee and the Fiji National Research Ethics Committee.ResultsA total of 748 males presented with new urethral discharge in a 1-year period to the two of the three STI clinics in Fiji. The median age of presenting with urethral discharge was 25 (IQR: 34) years. Using national population census data to obtain the total population of adult males (>14 years) in the Central and Western divisions, it is estimated that the incidence rate of urethral discharge among adult males in Fiji is at least 295 per 100,000 per year.5Table 1 presents characteristics of the study group and the proportion that had recurrent urethral discharge. In the following 1 to 2 years, 102 (13.6%) men presented with recurrence of urethral discharge and 42 (41.2%) of these had urethral swabs for laboratory diagnosis. Only 8 (19%) were positive for N. gonorrhoeae alone and an additional one was positive for both N. gonorrhoeae and C. trachomatis.First void urine was also collected for recurrent cases and 8 were positive; 5 (56%) for both N. gonorrhoeae and C. trachomatis, 3 (33%) for N. gonorrhoeae alone and 1 (11%) was positive for C. trachomatis alone. There were no risk factors for recurrence identified among the study population. Recurrence was significantly more common in those that presented to the clinic for Central Division than those that presented to Western Division (p=0.01).Out of the 748, 560(74.9%) were tested for syphilis apart from receiving syndromic treatment for urethral discharge and 29(5.2%) had positive results for syphilis, either VDRL, TPHA or both.During the study period, the syndromic treatment guideline for STI recommended a single dose of amoxicillin, augmentin, probenecid and azithromycin (AAPA). However, it was noted that AAPD (doxycycline, 100mg twice daily for 7 days) was still widely used by practitioners for the presumptive treatment of gonococcal and chlamydial infection. Table 1 New urethral discharge cases among men in Fiji in 2011, and recurrent urethral discharge between 2011 and 2012 DiscussionThis study provides original data of the very high incidence of urethral discharge among males in Fiji. The majority of cases occurred among young adults (14 to 34 years). The majority of cases reported more than one sexual partner and did not always use a condom. Recurrence was recorded in 14% over the next 1 to 2 years. These data compare to findings of a systemic review by Fung which showed repeat chlamydial infection among men had a median re-infection probability of 11% whereas repeat gonococcal infection among men had a median re-infection probability of 7%.6No association was noted between at-risk behaviors and recurrence. This may be due to the fact that the reported risk factors relied on a subjective view of the client's own sexual behaviors. A large proportion of the men did not disclose sexual orientation or these data were not recorded. Further, it was observed that most specimens sent for laboratory investigation did not identify a pathogen.Improving specimen collection with efficient Gram staining may improve the aetiological diagnosis of gonococcal infection as the yield from Gram stain is usually higher than from culture for this fastidious organism. Improving specimen collection of first void urine test can also potentially improve the diagnosis of C. trachomatis. NAAT of first void urine (FVU) has become the test of choice for the diagnosis of urethral C. trachomatis infection in men, since it is noninvasive and allows the detection of infected epithelial cells and associated C. trachomatis particles.7It was noted that majority (87%) of the cases were treated with AAPD. It is not known whether adapting the current recommended guidelines of AAPA would reduce the rate of recurrence. There is a need to educate STI clinicians about national guidelines and once practice is changed, it would be worthwhile to conduct a prospective study of recurrence.There are a number of important limitations. The data do not represent the full national burden of disease in 2011 as the Northern Clinic was excluded due to low availability of records for evaluation. Nonetheless the data do represent the population of the two largest divisions in Fiji, representing 79% of the total male population (301,531) of the age greater than 14. Further, published literature states that reported disease rates underestimate the true burden of infection because the majority of STIs are asymptomatic and because of underreporting.8Data were collected retrospectively and relied on self-reporting, accurate disclosure and clinician accurately entering data. Therefore, there are many potential opportunities for inaccuracy of data that cannot be validated. Data of important risk factors such as HIV infection were not available. The overall prevalence of HIV among adults 15–49 years of age in Fiji is 0.2%,10 with 0.5% prevalence among men having sex with men.9The large burden of disease suggests that there should be a major focus on strategies that could prevent STIs such as gonococcal and chlamydial infections—known strategies that are also likely to reduce the risk of other important STIs such as syphilis and HIV.\r\n

Summary

Abstract

Introduction: Urethral discharge is a common presentation of sexually transmitted infection (STI) in men and known pathogens include Neisseria gonorrhoeae and Chlamydia trachomatis. There are no published data of the burden of urethral discharge among men in Fiji.-Objective: To evaluate urethral discharge among men to determine the incidence, the frequency of recurrence and reported at-risk behaviour.-Methods: We conducted a retrospective, descriptive study of clinical records of all men presenting with urethral discharge to two major reproductive health clinics. Data collected included self-reported at-risk behaviours, results of abnormal syphilis serology and antibiotics prescribed. The frequency of recurrence in the following 1-2 years of initial presentation was determined along with microbiological findings from urethral swab in this group.-Results: A total of 748 males presented with urethral discharge to the clinic in one year. This represents an incidence rate of at least 295 per 100 000 adult males per year in the study population. Within the next 1-2 years of the initial presentation, 102 (14%) of these re-presented out of which 42 had urethral swab taken for etiological diagnosis. The commonest isolate was Neisseria gonorrhoeae. Results of syphilis tests were available for 560 (75%) of patients and 29 (5%) were positive. Recurrence was not associated with self-reported at-risk behaviours. -Conclusion: The incidence of urethral discharge among males in Fiji is very high and prevention strategies are urgently needed.

Aim

Method

Results

Conclusion

Author Information

Lavenia Gaunavinaka1, Dashika Balak1, Sumanthla Varman2, Sharan Ram2, Stephen M Graham3,4 1. National Family Health Unit, Ministry of Health, Suva, Fiji2. Fiji National University, Suva, Fiji3. Centre for International Child Health, University of Melbourne and Murdoch Childrens Research Institute, Royal Childrens Hospital, Melbourne, Australia4. International Union Against Tuberculosis and Lung Disease (The Union), Paris, France

Acknowledgements

Acknowledgements: This research was conducted through the Structured Operational Research and Training Initiative (SORT IT). The training was run in Fiji by the College of Medicine, Nursing and Health Sciences, Fiji National University, Fiji and The Union. Additional support for running the course was provided by the Public Health Division of the Secretariat of the Pacific Community, New Caledonia; Centre for International Child Health, the University of Melbourne, Australia; School of Population Health, University of Queensland, Australia; Regional Public Health, Hutt Valley District Health Board, New Zealand; the National TB Programme, Fiji Ministry of Health, Fiji.Funding: Funding for the course was provided by the Global Fund to fight AIDS, TB and Malaria, with co-funding by The Union; the Special Programme for Research and Training in Tropical Diseases (TDR); Public Health Division of the Secretariat of the Pacific Community, New Caledonia; Centre for International Child Health, the University of Melbourne, Australia; School of Population Health, University of Queensland, Australia.

Correspondence

Lavenia Gaunavinaka, Naviti Street Sexual and Reproductive Health Clinic, PO Box 45, Naviti Street, Lautoka, Fiji.

Correspondence Email

lageey@gmail.com

Competing Interests

Nil.

1. Lewis DA, Latif AS, Ndowa F.WHO global strategy for the prevention and control of sexually transmitted infections: time for action. Sexually Transmitted Infections. 2007;83(7):508-509.

2. World Health Organization. Global prevalence and incidence of curable STIs. World Health Organization, Geneva, 2001. (WHO/CDS/CDR/EDC/2001.101)

3. World Health Organization. Second Generation Surveillance Surveys of HIV, other STIs and Risk Behaviors in 6 Pacific Island Countries (2004 - 2005). World Health Organization, 2006.

4. Ministry of Health of Fiji. Comprehensive Management of Sexually Transmitted Infections Guideline. Ministry of Health. 2010.

5. Fiji Bureau of Statistics. Key Statistics : Population by Age, Sex and Province of Enumeration. Fiji Bureau of Statistics, 2012.

6. Fung M, Scott KC, Kent CK, Klausner JD. Chlamydial and gonococcal reinfection among men: a systemic review of data to evaluate the need for retesting. Sexually Transmitted Infections. 2007;83(4):304-309.

7. Buimer M, van Doornum GJ, Ching S, et al. Detection of Chlamydia trachomatis and Neisseria gonorrhoeae by ligase chain reaction-based assays with clinical specimens from various sites: implications for diagnostic testing and screening. Journal of Clinical Microbiology. 1996;34:2395-2400.

8. Warkowski KA, Berman SM. Center for Disease Control and Prevention Sexually Transmitted Disease Treatment Guidelines. Clinical Infectious Disease. 2007;44:S73-76

9. UNAIDS. Global AIDS Progress Report: Fiji Islands (2010-2011). UNAIDS, 2012.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Sexually transmitted infections (STIs) are a major cause of morbidity worldwide.1 A global prevalence survey in 1999 estimated that more than 340 million new cases occurred throughout the world in that year.2Urethral discharge is a common presentation of STI in men and known pathogens causing urethral discharge include Neisseria gonorrhoeae (or gonococcus) and Chlamydia trachomatis. These infections can also be asymptomatic while on the other hand, urethral discharge may be a clinical presentation of conditions other than STIs. A survey of pregnant women attending antenatal clinics in 2004 found that 29% were infected with chlamydia, 1.7% with gonorrhoea and 2.6% with syphilis.3 However, there are no peer-reviewed publications of the burden of STIs, including of urethral discharge, among men in Fiji.STIs are treated syndromically in Fiji according to the national guidelines.4 Urethral swab and cultures are available but the practice of obtaining a sample is highly variable. There is therefore limited knowledge of the common causes and treatment response of urethral discharge in Fijian men. Further, the demographic profile and risk behaviour associated with urethral discharge in men has not been studied.The aim of this study was to evaluate urethral discharge among men in Fiji to determine the incidence as well as the frequency of recurrence and reported at-risk behaviour.MethodologyStudy design—We conducted a retrospective descriptive study of urethral discharge among males in Fiji presenting to the reproductive health clinics over a 1-year period.Study setting—Fiji is an island nation in the South Pacific Ocean that consists of 322 islands with two major islands and a total population of approximately 837,000. The Ministry of Health divides Fiji into three divisions for administrative purposes: the Central and Eastern Division; the Western Division; and the Northern Division. There are three specialised reproductive health clinics that cater for the majority of STI cases in each division, although patients also present to other general outpatient clinics or private clinics.Study population—All patients who presented for the first time from January to December 2011 and were recorded with the diagnosis of urethral discharge syndrome in the patient register were included in the study. Upon presentation to these clinics all patient with urethral discharge have a full clinical assessment including history taking and examination of urethral discharge.Laboratory diagnosis of N. gonorrhoeae in Fiji includes microscopy of a direct smear of the discharge stained with Gram stain to reveal Gram-negative diplococci within polymorphonuclear leucocytes. The modified Thayer Martin medium is the selective media used in Fiji to culture N. gonorrhoeae. Diagnosis of syphilis in Fiji is made by VDRL (venereal disease research laboratory) and TPHA (Treponema pallidum haemagglutination) tests. In the case of C. trachomatis, a nucleic acid amplification method (NAAT) is used for detection.The syndromic treatment guideline for STI recommends single dose of amoxicillin, augmentin, probenecid and azithromycin (AAPA).Data collection and analysis—Data were collected retrospectively from the clinical files and outpatient register of all initial visits by male patients presenting with urethral discharge to the two reproductive health clinics; Central/ Eastern Hub and Western Hub between 1 January and 31 December 2011. Northern Reproductive Health Clinic data was not included due to insignificant data found during data collection (only 5 clinical data were found).The following were recorded: name of medical division, patient registration number, age, treatment received, reported at-risk behaviour and result of syphilis test. A patient who was listed more than once in the 2011 register was listed as a recurrent episode. The patient register for 2012 was also reviewed to identify patients who had presented during the study period and have re-presented to the clinics with recurrent episodes. All patients with recurrent episodes had duration between episodes recorded along with result of urethral swab culture where available.Frequencies were calculated, and Chi-squared test was used to assess differences in proportions between groups with OR and 95% CI indicated where appropriate. The level of significance was set at 5%.Ethics—Ethics approval was obtained from the Union Ethics Advisory Group (EAG), the National Health Research Committee and the Fiji National Research Ethics Committee.ResultsA total of 748 males presented with new urethral discharge in a 1-year period to the two of the three STI clinics in Fiji. The median age of presenting with urethral discharge was 25 (IQR: 34) years. Using national population census data to obtain the total population of adult males (>14 years) in the Central and Western divisions, it is estimated that the incidence rate of urethral discharge among adult males in Fiji is at least 295 per 100,000 per year.5Table 1 presents characteristics of the study group and the proportion that had recurrent urethral discharge. In the following 1 to 2 years, 102 (13.6%) men presented with recurrence of urethral discharge and 42 (41.2%) of these had urethral swabs for laboratory diagnosis. Only 8 (19%) were positive for N. gonorrhoeae alone and an additional one was positive for both N. gonorrhoeae and C. trachomatis.First void urine was also collected for recurrent cases and 8 were positive; 5 (56%) for both N. gonorrhoeae and C. trachomatis, 3 (33%) for N. gonorrhoeae alone and 1 (11%) was positive for C. trachomatis alone. There were no risk factors for recurrence identified among the study population. Recurrence was significantly more common in those that presented to the clinic for Central Division than those that presented to Western Division (p=0.01).Out of the 748, 560(74.9%) were tested for syphilis apart from receiving syndromic treatment for urethral discharge and 29(5.2%) had positive results for syphilis, either VDRL, TPHA or both.During the study period, the syndromic treatment guideline for STI recommended a single dose of amoxicillin, augmentin, probenecid and azithromycin (AAPA). However, it was noted that AAPD (doxycycline, 100mg twice daily for 7 days) was still widely used by practitioners for the presumptive treatment of gonococcal and chlamydial infection. Table 1 New urethral discharge cases among men in Fiji in 2011, and recurrent urethral discharge between 2011 and 2012 DiscussionThis study provides original data of the very high incidence of urethral discharge among males in Fiji. The majority of cases occurred among young adults (14 to 34 years). The majority of cases reported more than one sexual partner and did not always use a condom. Recurrence was recorded in 14% over the next 1 to 2 years. These data compare to findings of a systemic review by Fung which showed repeat chlamydial infection among men had a median re-infection probability of 11% whereas repeat gonococcal infection among men had a median re-infection probability of 7%.6No association was noted between at-risk behaviors and recurrence. This may be due to the fact that the reported risk factors relied on a subjective view of the client's own sexual behaviors. A large proportion of the men did not disclose sexual orientation or these data were not recorded. Further, it was observed that most specimens sent for laboratory investigation did not identify a pathogen.Improving specimen collection with efficient Gram staining may improve the aetiological diagnosis of gonococcal infection as the yield from Gram stain is usually higher than from culture for this fastidious organism. Improving specimen collection of first void urine test can also potentially improve the diagnosis of C. trachomatis. NAAT of first void urine (FVU) has become the test of choice for the diagnosis of urethral C. trachomatis infection in men, since it is noninvasive and allows the detection of infected epithelial cells and associated C. trachomatis particles.7It was noted that majority (87%) of the cases were treated with AAPD. It is not known whether adapting the current recommended guidelines of AAPA would reduce the rate of recurrence. There is a need to educate STI clinicians about national guidelines and once practice is changed, it would be worthwhile to conduct a prospective study of recurrence.There are a number of important limitations. The data do not represent the full national burden of disease in 2011 as the Northern Clinic was excluded due to low availability of records for evaluation. Nonetheless the data do represent the population of the two largest divisions in Fiji, representing 79% of the total male population (301,531) of the age greater than 14. Further, published literature states that reported disease rates underestimate the true burden of infection because the majority of STIs are asymptomatic and because of underreporting.8Data were collected retrospectively and relied on self-reporting, accurate disclosure and clinician accurately entering data. Therefore, there are many potential opportunities for inaccuracy of data that cannot be validated. Data of important risk factors such as HIV infection were not available. The overall prevalence of HIV among adults 15–49 years of age in Fiji is 0.2%,10 with 0.5% prevalence among men having sex with men.9The large burden of disease suggests that there should be a major focus on strategies that could prevent STIs such as gonococcal and chlamydial infections—known strategies that are also likely to reduce the risk of other important STIs such as syphilis and HIV.\r\n

Summary

Abstract

Introduction: Urethral discharge is a common presentation of sexually transmitted infection (STI) in men and known pathogens include Neisseria gonorrhoeae and Chlamydia trachomatis. There are no published data of the burden of urethral discharge among men in Fiji.-Objective: To evaluate urethral discharge among men to determine the incidence, the frequency of recurrence and reported at-risk behaviour.-Methods: We conducted a retrospective, descriptive study of clinical records of all men presenting with urethral discharge to two major reproductive health clinics. Data collected included self-reported at-risk behaviours, results of abnormal syphilis serology and antibiotics prescribed. The frequency of recurrence in the following 1-2 years of initial presentation was determined along with microbiological findings from urethral swab in this group.-Results: A total of 748 males presented with urethral discharge to the clinic in one year. This represents an incidence rate of at least 295 per 100 000 adult males per year in the study population. Within the next 1-2 years of the initial presentation, 102 (14%) of these re-presented out of which 42 had urethral swab taken for etiological diagnosis. The commonest isolate was Neisseria gonorrhoeae. Results of syphilis tests were available for 560 (75%) of patients and 29 (5%) were positive. Recurrence was not associated with self-reported at-risk behaviours. -Conclusion: The incidence of urethral discharge among males in Fiji is very high and prevention strategies are urgently needed.

Aim

Method

Results

Conclusion

Author Information

Lavenia Gaunavinaka1, Dashika Balak1, Sumanthla Varman2, Sharan Ram2, Stephen M Graham3,4 1. National Family Health Unit, Ministry of Health, Suva, Fiji2. Fiji National University, Suva, Fiji3. Centre for International Child Health, University of Melbourne and Murdoch Childrens Research Institute, Royal Childrens Hospital, Melbourne, Australia4. International Union Against Tuberculosis and Lung Disease (The Union), Paris, France

Acknowledgements

Acknowledgements: This research was conducted through the Structured Operational Research and Training Initiative (SORT IT). The training was run in Fiji by the College of Medicine, Nursing and Health Sciences, Fiji National University, Fiji and The Union. Additional support for running the course was provided by the Public Health Division of the Secretariat of the Pacific Community, New Caledonia; Centre for International Child Health, the University of Melbourne, Australia; School of Population Health, University of Queensland, Australia; Regional Public Health, Hutt Valley District Health Board, New Zealand; the National TB Programme, Fiji Ministry of Health, Fiji.Funding: Funding for the course was provided by the Global Fund to fight AIDS, TB and Malaria, with co-funding by The Union; the Special Programme for Research and Training in Tropical Diseases (TDR); Public Health Division of the Secretariat of the Pacific Community, New Caledonia; Centre for International Child Health, the University of Melbourne, Australia; School of Population Health, University of Queensland, Australia.

Correspondence

Lavenia Gaunavinaka, Naviti Street Sexual and Reproductive Health Clinic, PO Box 45, Naviti Street, Lautoka, Fiji.

Correspondence Email

lageey@gmail.com

Competing Interests

Nil.

1. Lewis DA, Latif AS, Ndowa F.WHO global strategy for the prevention and control of sexually transmitted infections: time for action. Sexually Transmitted Infections. 2007;83(7):508-509.

2. World Health Organization. Global prevalence and incidence of curable STIs. World Health Organization, Geneva, 2001. (WHO/CDS/CDR/EDC/2001.101)

3. World Health Organization. Second Generation Surveillance Surveys of HIV, other STIs and Risk Behaviors in 6 Pacific Island Countries (2004 - 2005). World Health Organization, 2006.

4. Ministry of Health of Fiji. Comprehensive Management of Sexually Transmitted Infections Guideline. Ministry of Health. 2010.

5. Fiji Bureau of Statistics. Key Statistics : Population by Age, Sex and Province of Enumeration. Fiji Bureau of Statistics, 2012.

6. Fung M, Scott KC, Kent CK, Klausner JD. Chlamydial and gonococcal reinfection among men: a systemic review of data to evaluate the need for retesting. Sexually Transmitted Infections. 2007;83(4):304-309.

7. Buimer M, van Doornum GJ, Ching S, et al. Detection of Chlamydia trachomatis and Neisseria gonorrhoeae by ligase chain reaction-based assays with clinical specimens from various sites: implications for diagnostic testing and screening. Journal of Clinical Microbiology. 1996;34:2395-2400.

8. Warkowski KA, Berman SM. Center for Disease Control and Prevention Sexually Transmitted Disease Treatment Guidelines. Clinical Infectious Disease. 2007;44:S73-76

9. UNAIDS. Global AIDS Progress Report: Fiji Islands (2010-2011). UNAIDS, 2012.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Sexually transmitted infections (STIs) are a major cause of morbidity worldwide.1 A global prevalence survey in 1999 estimated that more than 340 million new cases occurred throughout the world in that year.2Urethral discharge is a common presentation of STI in men and known pathogens causing urethral discharge include Neisseria gonorrhoeae (or gonococcus) and Chlamydia trachomatis. These infections can also be asymptomatic while on the other hand, urethral discharge may be a clinical presentation of conditions other than STIs. A survey of pregnant women attending antenatal clinics in 2004 found that 29% were infected with chlamydia, 1.7% with gonorrhoea and 2.6% with syphilis.3 However, there are no peer-reviewed publications of the burden of STIs, including of urethral discharge, among men in Fiji.STIs are treated syndromically in Fiji according to the national guidelines.4 Urethral swab and cultures are available but the practice of obtaining a sample is highly variable. There is therefore limited knowledge of the common causes and treatment response of urethral discharge in Fijian men. Further, the demographic profile and risk behaviour associated with urethral discharge in men has not been studied.The aim of this study was to evaluate urethral discharge among men in Fiji to determine the incidence as well as the frequency of recurrence and reported at-risk behaviour.MethodologyStudy design—We conducted a retrospective descriptive study of urethral discharge among males in Fiji presenting to the reproductive health clinics over a 1-year period.Study setting—Fiji is an island nation in the South Pacific Ocean that consists of 322 islands with two major islands and a total population of approximately 837,000. The Ministry of Health divides Fiji into three divisions for administrative purposes: the Central and Eastern Division; the Western Division; and the Northern Division. There are three specialised reproductive health clinics that cater for the majority of STI cases in each division, although patients also present to other general outpatient clinics or private clinics.Study population—All patients who presented for the first time from January to December 2011 and were recorded with the diagnosis of urethral discharge syndrome in the patient register were included in the study. Upon presentation to these clinics all patient with urethral discharge have a full clinical assessment including history taking and examination of urethral discharge.Laboratory diagnosis of N. gonorrhoeae in Fiji includes microscopy of a direct smear of the discharge stained with Gram stain to reveal Gram-negative diplococci within polymorphonuclear leucocytes. The modified Thayer Martin medium is the selective media used in Fiji to culture N. gonorrhoeae. Diagnosis of syphilis in Fiji is made by VDRL (venereal disease research laboratory) and TPHA (Treponema pallidum haemagglutination) tests. In the case of C. trachomatis, a nucleic acid amplification method (NAAT) is used for detection.The syndromic treatment guideline for STI recommends single dose of amoxicillin, augmentin, probenecid and azithromycin (AAPA).Data collection and analysis—Data were collected retrospectively from the clinical files and outpatient register of all initial visits by male patients presenting with urethral discharge to the two reproductive health clinics; Central/ Eastern Hub and Western Hub between 1 January and 31 December 2011. Northern Reproductive Health Clinic data was not included due to insignificant data found during data collection (only 5 clinical data were found).The following were recorded: name of medical division, patient registration number, age, treatment received, reported at-risk behaviour and result of syphilis test. A patient who was listed more than once in the 2011 register was listed as a recurrent episode. The patient register for 2012 was also reviewed to identify patients who had presented during the study period and have re-presented to the clinics with recurrent episodes. All patients with recurrent episodes had duration between episodes recorded along with result of urethral swab culture where available.Frequencies were calculated, and Chi-squared test was used to assess differences in proportions between groups with OR and 95% CI indicated where appropriate. The level of significance was set at 5%.Ethics—Ethics approval was obtained from the Union Ethics Advisory Group (EAG), the National Health Research Committee and the Fiji National Research Ethics Committee.ResultsA total of 748 males presented with new urethral discharge in a 1-year period to the two of the three STI clinics in Fiji. The median age of presenting with urethral discharge was 25 (IQR: 34) years. Using national population census data to obtain the total population of adult males (>14 years) in the Central and Western divisions, it is estimated that the incidence rate of urethral discharge among adult males in Fiji is at least 295 per 100,000 per year.5Table 1 presents characteristics of the study group and the proportion that had recurrent urethral discharge. In the following 1 to 2 years, 102 (13.6%) men presented with recurrence of urethral discharge and 42 (41.2%) of these had urethral swabs for laboratory diagnosis. Only 8 (19%) were positive for N. gonorrhoeae alone and an additional one was positive for both N. gonorrhoeae and C. trachomatis.First void urine was also collected for recurrent cases and 8 were positive; 5 (56%) for both N. gonorrhoeae and C. trachomatis, 3 (33%) for N. gonorrhoeae alone and 1 (11%) was positive for C. trachomatis alone. There were no risk factors for recurrence identified among the study population. Recurrence was significantly more common in those that presented to the clinic for Central Division than those that presented to Western Division (p=0.01).Out of the 748, 560(74.9%) were tested for syphilis apart from receiving syndromic treatment for urethral discharge and 29(5.2%) had positive results for syphilis, either VDRL, TPHA or both.During the study period, the syndromic treatment guideline for STI recommended a single dose of amoxicillin, augmentin, probenecid and azithromycin (AAPA). However, it was noted that AAPD (doxycycline, 100mg twice daily for 7 days) was still widely used by practitioners for the presumptive treatment of gonococcal and chlamydial infection. Table 1 New urethral discharge cases among men in Fiji in 2011, and recurrent urethral discharge between 2011 and 2012 DiscussionThis study provides original data of the very high incidence of urethral discharge among males in Fiji. The majority of cases occurred among young adults (14 to 34 years). The majority of cases reported more than one sexual partner and did not always use a condom. Recurrence was recorded in 14% over the next 1 to 2 years. These data compare to findings of a systemic review by Fung which showed repeat chlamydial infection among men had a median re-infection probability of 11% whereas repeat gonococcal infection among men had a median re-infection probability of 7%.6No association was noted between at-risk behaviors and recurrence. This may be due to the fact that the reported risk factors relied on a subjective view of the client's own sexual behaviors. A large proportion of the men did not disclose sexual orientation or these data were not recorded. Further, it was observed that most specimens sent for laboratory investigation did not identify a pathogen.Improving specimen collection with efficient Gram staining may improve the aetiological diagnosis of gonococcal infection as the yield from Gram stain is usually higher than from culture for this fastidious organism. Improving specimen collection of first void urine test can also potentially improve the diagnosis of C. trachomatis. NAAT of first void urine (FVU) has become the test of choice for the diagnosis of urethral C. trachomatis infection in men, since it is noninvasive and allows the detection of infected epithelial cells and associated C. trachomatis particles.7It was noted that majority (87%) of the cases were treated with AAPD. It is not known whether adapting the current recommended guidelines of AAPA would reduce the rate of recurrence. There is a need to educate STI clinicians about national guidelines and once practice is changed, it would be worthwhile to conduct a prospective study of recurrence.There are a number of important limitations. The data do not represent the full national burden of disease in 2011 as the Northern Clinic was excluded due to low availability of records for evaluation. Nonetheless the data do represent the population of the two largest divisions in Fiji, representing 79% of the total male population (301,531) of the age greater than 14. Further, published literature states that reported disease rates underestimate the true burden of infection because the majority of STIs are asymptomatic and because of underreporting.8Data were collected retrospectively and relied on self-reporting, accurate disclosure and clinician accurately entering data. Therefore, there are many potential opportunities for inaccuracy of data that cannot be validated. Data of important risk factors such as HIV infection were not available. The overall prevalence of HIV among adults 15–49 years of age in Fiji is 0.2%,10 with 0.5% prevalence among men having sex with men.9The large burden of disease suggests that there should be a major focus on strategies that could prevent STIs such as gonococcal and chlamydial infections—known strategies that are also likely to reduce the risk of other important STIs such as syphilis and HIV.\r\n

Summary

Abstract

Introduction: Urethral discharge is a common presentation of sexually transmitted infection (STI) in men and known pathogens include Neisseria gonorrhoeae and Chlamydia trachomatis. There are no published data of the burden of urethral discharge among men in Fiji.-Objective: To evaluate urethral discharge among men to determine the incidence, the frequency of recurrence and reported at-risk behaviour.-Methods: We conducted a retrospective, descriptive study of clinical records of all men presenting with urethral discharge to two major reproductive health clinics. Data collected included self-reported at-risk behaviours, results of abnormal syphilis serology and antibiotics prescribed. The frequency of recurrence in the following 1-2 years of initial presentation was determined along with microbiological findings from urethral swab in this group.-Results: A total of 748 males presented with urethral discharge to the clinic in one year. This represents an incidence rate of at least 295 per 100 000 adult males per year in the study population. Within the next 1-2 years of the initial presentation, 102 (14%) of these re-presented out of which 42 had urethral swab taken for etiological diagnosis. The commonest isolate was Neisseria gonorrhoeae. Results of syphilis tests were available for 560 (75%) of patients and 29 (5%) were positive. Recurrence was not associated with self-reported at-risk behaviours. -Conclusion: The incidence of urethral discharge among males in Fiji is very high and prevention strategies are urgently needed.

Aim

Method

Results

Conclusion

Author Information

Lavenia Gaunavinaka1, Dashika Balak1, Sumanthla Varman2, Sharan Ram2, Stephen M Graham3,4 1. National Family Health Unit, Ministry of Health, Suva, Fiji2. Fiji National University, Suva, Fiji3. Centre for International Child Health, University of Melbourne and Murdoch Childrens Research Institute, Royal Childrens Hospital, Melbourne, Australia4. International Union Against Tuberculosis and Lung Disease (The Union), Paris, France

Acknowledgements

Acknowledgements: This research was conducted through the Structured Operational Research and Training Initiative (SORT IT). The training was run in Fiji by the College of Medicine, Nursing and Health Sciences, Fiji National University, Fiji and The Union. Additional support for running the course was provided by the Public Health Division of the Secretariat of the Pacific Community, New Caledonia; Centre for International Child Health, the University of Melbourne, Australia; School of Population Health, University of Queensland, Australia; Regional Public Health, Hutt Valley District Health Board, New Zealand; the National TB Programme, Fiji Ministry of Health, Fiji.Funding: Funding for the course was provided by the Global Fund to fight AIDS, TB and Malaria, with co-funding by The Union; the Special Programme for Research and Training in Tropical Diseases (TDR); Public Health Division of the Secretariat of the Pacific Community, New Caledonia; Centre for International Child Health, the University of Melbourne, Australia; School of Population Health, University of Queensland, Australia.

Correspondence

Lavenia Gaunavinaka, Naviti Street Sexual and Reproductive Health Clinic, PO Box 45, Naviti Street, Lautoka, Fiji.

Correspondence Email

lageey@gmail.com

Competing Interests

Nil.

1. Lewis DA, Latif AS, Ndowa F.WHO global strategy for the prevention and control of sexually transmitted infections: time for action. Sexually Transmitted Infections. 2007;83(7):508-509.

2. World Health Organization. Global prevalence and incidence of curable STIs. World Health Organization, Geneva, 2001. (WHO/CDS/CDR/EDC/2001.101)

3. World Health Organization. Second Generation Surveillance Surveys of HIV, other STIs and Risk Behaviors in 6 Pacific Island Countries (2004 - 2005). World Health Organization, 2006.

4. Ministry of Health of Fiji. Comprehensive Management of Sexually Transmitted Infections Guideline. Ministry of Health. 2010.

5. Fiji Bureau of Statistics. Key Statistics : Population by Age, Sex and Province of Enumeration. Fiji Bureau of Statistics, 2012.

6. Fung M, Scott KC, Kent CK, Klausner JD. Chlamydial and gonococcal reinfection among men: a systemic review of data to evaluate the need for retesting. Sexually Transmitted Infections. 2007;83(4):304-309.

7. Buimer M, van Doornum GJ, Ching S, et al. Detection of Chlamydia trachomatis and Neisseria gonorrhoeae by ligase chain reaction-based assays with clinical specimens from various sites: implications for diagnostic testing and screening. Journal of Clinical Microbiology. 1996;34:2395-2400.

8. Warkowski KA, Berman SM. Center for Disease Control and Prevention Sexually Transmitted Disease Treatment Guidelines. Clinical Infectious Disease. 2007;44:S73-76

9. UNAIDS. Global AIDS Progress Report: Fiji Islands (2010-2011). UNAIDS, 2012.

Contact diana@nzma.org.nz
for the PDF of this article

Subscriber Content

The full contents of this pages only available to subscribers.

LOGINSUBSCRIBE