You have two clinic patients today with urinary complaints. Let’s see what you recommend!
30M presents with 1 penile ulcer and complains that he cannot urinate. He also notes some numbness in the perineal region. What is at the top of your ddx of these choices?
In GU infection, impt to differentiate dysuria vs acute urinary retention
Genital ulcers are often associated w/dysuria, which can lead to UTI tx and missed concurrent sexually transmitted urethritis
🗝️Presence of true urinary retention is suggestive of sacral radiculitis
Pt has sxs concerning for lumbosacral radiculitis ➡️ acute urinary retention + loss of sacral sensation
Sacral radiculitis in this setting is suggestive of complicated HSV infection, which could be primary or reactivation disease ➡️ also can be known as Elsberg syndrome
Elsberg syndrome describes acute or subacute bilateral lumbosacral radiculitis, often accompanied by localized myelitis
This complication is often transient, but might require urinary catheterization temporarily
So a consideration with acute cauda equina syndrome!
This is mostly described in case reports and small series, such as this one with 17 pts: https://pubmed.ncbi.nlm.nih.gov/76228/
This paper attempted to describe criteria in Elsberg syndrome after reviewing 30 cases 👇
Check out paper for more details as well:
Clinic patient 2
30 yo M with urethral discharge and pruritis, painful urination. Completed a dose of azithromycin 1g ~1-2 wks ago for gonococcal urethritis. No sex since treatment. Gram stain shows PMNs, and NAAT for NG/CT/trich negative. Cause of sxs?
A: Mycoplasma genitalium
🗝️Consider this in men with persistent urethritis, especially after treatment with doxycycline ➡️Likely accounts ~1/5 nongonococcal urethretitis in men
Next question coming up
Ok so you’ve decided to treat this M.genitalium infection, patient already received Azithromycin 1g. What medication would you recommend?
🗝️Resistance to Doxy and Azithro is common with M.genitalium
💊Moxi would be best choice given highest cure rates. Clinical and MIC data suggest that levo likely isn't active; and would expect moxi to be superior to doxy
Check out a review:
Here is a paper on resistance in M.genitalium as well (doxy led to cure in only 22-45%):
Link CDC STI guidelines (2015, new ones hopefully coming soon): https://www.cdc.gov/std/tg2015/tg-2015-print.pdf
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