title: Chlamydial and gonococcal infection in men without polymorphonuclear leukocytes on gram stain: implications for diagnostic approach and management.
abstract: BACKGROUND
  Gram stain is used to detect urethral inflammation, suggestive of infection, in men and guide therapeutic decisions. In the absence of signs, symptoms, or polymorphonuclear leukocytes (PMNs) on urethral Gram stain, treatment and sometimes testing is deferred.
  
  
  OBJECTIVE
  Determine the proportion of men with chlamydia or gonorrhea diagnosed by nucleic acid amplification testing (NAAT) or culture who lack Gram stain evidence of inflammation and compare their clinical characteristics to men with inflammation.
  
  
  METHODS
  Records from 2629 men presenting for routine sexually transmitted disease care with urethral PMN count and NAAT data were retrospectively analyzed. A subpopulation tested by NAAT and culture was analyzed. Men receiving antibiotics within the prior month or those reporting a sexual partner with trichomoniasis were excluded.
  
  
  RESULTS
  Among 2266 eligible men, 353 (16%) had chlamydia and 462 (20%) had gonorrhea. Among chlamydia-infected men, PMNs per oil-immersion field (oif) on Gram stain were > or =5 in 291 (82%), 1 to 4 in 20 (6%), and none in 42 (12%). In men with gonorrhea, PMNs/oif were > or =5 in 433 (94%), 1 to 4 in 6 (1%), and none in 23 (5%). Urethral symptoms, discharge, and/or > or =5 PMNs/oif were absent in 47 (13%) and 22 (5%) of chlamydial and gonococcal infections, respectively (including no PMNs/oif and 1-4 PMNs/oif). None of these 47 chlamydial-infected men and only 4 of 22 men with gonorrhea received therapy at the time of initial examination.
  
  
  CONCLUSIONS
  Twelve percent of chlamydial and 5% of gonococcal infections had no Gram stain evidence of urethral inflammation. Absence of symptoms and discharge is not uncommon in chlamydial infection detected by NAAT, and without testing, many infections will go untreated, furthering the possibility of complications or partner transmission.
authors.affiliation: Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA. wgeisler@uab.edu
authors.forename: William M
authors.initials: WM
authors.lastname: Geisler
authors.forename: Shuying
authors.initials: S
authors.lastname: Yu
authors.forename: Edward W
authors.initials: EW
authors.lastname: Hook
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000407:Alabama / Q000453:epidemiology; D002690:Chlamydia Infections / Q000175:diagnosis* / Q000453:epidemiology / Q000382:microbiology / Q000517:prevention & control; D002692:Chlamydia trachomatis / Q000302:isolation & purification*; D003663:Decision Trees; D006069:Gonorrhea / Q000175:diagnosis* / Q000453:epidemiology / Q000382:microbiology / Q000517:prevention & control; D006801:Humans; D007963:Leukocytes, Mononuclear; D008297:Male; D008403:Mass Screening / Q000379:methods*; D008499:Medical Records; D008875:Middle Aged; D009344:Neisseria gonorrhoeae / Q000302:isolation & purification*; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D014526:Urethritis / Q000175:diagnosis* / Q000453:epidemiology / Q000382:microbiology / Q000517:prevention & control