A randomised controlled trial to assess pain with urethral swabs

Apoola, Ade; Herrero-Diaz, Maite; FitzHugh, Elley; Rajakumar, R.; Fakis, Apostolos; Oakden, Jayne

doi:10.1136/sti.2010.042861

Cited by 14 publications

(14 citation statements)

References 12 publications

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“…1,2 Either a 5 mm plastic loop or cotton tipped swab can be used, which should be introduced about 1 cm into the urethra. 38 (1b) Other methods are also used, including a sterile blunt curette or spatula. 39…”

Section: Aetiologymentioning

confidence: 99%

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2016 European guideline on the management of non-gonococcal urethritis

et al. 2016

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We present the updated International Union against Sexually Transmitted Infections (IUSTI) guideline for the management of non-gonococcal urethritis in men. This guideline recommends confirmation of urethritis in symptomatic men before starting treatment. It does not recommend testing asymptomatic men for the presence of urethritis. All men with urethritis should be tested for Chlamydia trachomatis and Neisseria gonorrhoeae and ideally Mycoplasma genitalium using a nucleic acid amplification test (NAAT) as this is highly likely to improve clinical outcomes. If a NAAT is positive for gonorrhoea, a culture should be performed before treatment. In view of the increasing evidence that azithromycin 1 g may result in the development of antimicrobial resistance in M. genitalium, azithromycin 1 g is no longer recommended as first line therapy, which should be doxycycline 100 mg bd for seven days. If azithromycin is to be prescribed an extended course of 500 mg stat, then 250 mg daily for four days is to be preferred over 1 g stat. In men with persistent NGU, M. genitalium NAAT testing is recommended if not previously undertaken, as is Trichomonas vaginalis NAAT testing in populations where T. vaginalis is detectable in >2% of symptomatic women.

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Section: Aetiologymentioning

confidence: 99%

“…4,[39][40][41] • If a urethral discharge is present the smear can be sampled without placing the device inside the meatus. 38…”

Section: (C)mentioning

confidence: 99%

2016 European guideline on the management of non-gonococcal urethritis

et al. 2016

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“… 2 3 Taking urethral swabs for GSUS is uncomfortable for patients. 4 Furthermore, microscopy requires skilled personnel and possesses significant inter-user and intra-user variability, 5 6 variable sensitivity and low specificity for predicting infection. 7 Reduced use of microscopy for asymptomatic patients and the expansion of ‘test and treat’ community-based sexually transmitted infection screening programmes for Chlamydia trachomatis infection only reduce the potential for empirically treating other infective causes of NGU, such as Mycoplasma genitalium .…”

Section: Introductionmentioning

confidence: 99%

Performance evaluation of automated urine microscopy as a rapid, non-invasive approach for the diagnosis of non-gonococcal urethritis

et al. 2015

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ObjectivesGram-stained urethral smear (GSUS), the standard point-of-care test for non-gonococcal urethritis (NGU) is operator dependent and poorly specific. The performance of rapid automated urine flow cytometry (AUFC) of first void urine (FVU) white cell counts (UWCC) for predicting Mycoplasma genitalium and Chlamydia trachomatis urethral infections was assessed and its application to asymptomatic infection was evaluated.MethodsReceiver operating characteristic curve analysis, determining FVU-UWCC threshold for predicting M. genitalium or C. trachomatis infection was performed on 208 ‘training’ samples from symptomatic patients and subsequently validated using 228 additional FVUs obtained from prospective unselected patients.ResultsAn optimal diagnostic threshold of >29 UWC/µL gave sensitivities and specificities for either infection of 81.5% (95% CI 65.1% to 91.6%) and 85.8% (79.5% to 90.4%), respectively, compared with 86.8% (71.1% to 95%) and 64.7% (56.9% to 71.7%), respectively, for GSUS, using the training set samples. FVU-UWCC demonstrated sensitivities and specificities of 69.2% (95% CI 48.1% to 84.9%) and 92% (87.2% to 95.2%), respectively, when using validation samples. In asymptomatic patients where GSUS was not used, AUFC would have enabled more infections to be detected compared with clinical considerations only (71.4% vs 28.6%; p=0.03). The correlation between UWCC and bacterial load was stronger for M. genitalium compared with C. trachomatis (τ=0.426, p≤0.001 vs τ=0.295, p=0.022, respectively).ConclusionsAUFC offers improved specificity over microscopy for predicting C. trachomatis or M. genitalium infection. Universal AUFC may enable non-invasive diagnosis of asymptomatic NGU at the PoC. The degree of urethral inflammation exhibits a stronger association with pathogen load for M. genitalium compared with C. trachomatis.

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“…Meatal swabs are likely better tolerated than urethral swabs, as demonstrated in a comparison study of men who received both a urethral and meatal swab, which found that 76% of men preferred the meatal swab (4). Another study attempted to quantify, using a visual analogue pain scale, the discomfort associated with urethral swab collection and found that collection with a urethral swab using the standard technique (inserting a swab 2 cm into the distal urethra) elicited a median pain score of 52 mm (on a 100-mm pain scale), which correlated with moderate (Ͼ30 mm) to severe (Ͼ54 mm) pain (10). Furthermore, multiple studies have identified discomfort from urethral swabbing as a major factor that causes men to delay seeking health care (11)(12)(13), and participants in adolescent focus groups expressed strong negative emotions when asked about the urethral swab testing process (12,13).…”

Section: Discussionmentioning

confidence: 99%

Meatal Swabs Contain Less Cellular Material and Are Associated with a Decrease in Gram Stain Smear Quality Compared to Urethral Swabs in Men

et al. 2017

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Urethral swabs are the samples of choice for point-of-care Gram stain testing to diagnose Neisseria gonorrhoeae infection and nongonococcal urethritis (NGU) in men. As an alternative to urethral swabs, meatal swabs have been recommended for the collection of urethral discharge to diagnose N. gonorrhoeae and Chlamydia trachomatis infection in certain populations by nucleic acid amplification testing (NAAT), as they involve a less invasive collection method. However, as meatal swabs could be sampling a reduced surface area and result in fewer collected epithelial cells compared to urethral swabs, the adequacy of meatal swab specimens to collect sufficient cellular material for Gram stain testing remains unknown. We enrolled 66 men who underwent either urethral or meatal swabbing and compared the cellular content and Gram stain failure rate. We measured the difference in swab cellular content using the Cepheid Xpert CT/NG sample adequacy control crossing threshold (SAC CT ) and determined the failure rate of Gram stain smears (GSS) due to insufficient cellular material. In the absence of discharge, meatal smears were associated with a significant reduction in cellular content (P ϭ 0.0118), which corresponded with a GSS failure rate significantly higher than that for urethral swabs (45% versus 3%, respectively; P Ͻ 0.0001). When discharge was present, there was no difference among results from urethral and meatal swabs. Therefore, if GSS testing is being considered for point-of-care diagnosis of N. gonorrhoeae infection or NGU in men, meatal swabs should be avoided in the absence of a visible discharge.KEYWORDS Chlamydia trachomatis, Gram stain, meatal swabs, Neisseria gonorrhoeae, urethral swabs C hlamydia trachomatis and Neisseria gonorrhoeae infections continue to rise, with 1.4 million and Ͼ350,000 cases reported, respectively, in the United States in 2015 (1); nongonococcal urethritis (NGU) remains the most common form of urethritis in men (2). For screening at-risk individuals, the Centers for Disease Control and Prevention (CDC) recommends highly sensitive nucleic acid amplification testing (NAAT) of urine or a urethral swab of urethral secretions (3). Meatal swabs have been suggested as a less invasive alternative to urethral swabs for specimen collection for NAAT and are amenable to self-obtained patient collection because they elicit less discomfort (4). Although not yet FDA approved or CDC recommended for NAAT in men, meatal swabs are recommended for NAAT in prepubertal boys with discharge, given concerns about urethral trauma from swabs (3,5). In men, self-obtained meatal swabs appear to be equivalent to clinician-collected urethral swabs for diagnosing C. trachomatis/N. gonorrhoeae infection by NAAT, although there have been mixed reports of the sensitivity of this sample type (6, 7). Currently, no rapid (Ͻ30-min) point-of-care NAAT is available to diagnose N. gonorrhoeae infection or NGU, and Gram stain smear (GSS) testing of

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A randomised controlled trial to assess pain with urethral swabs

Abstract: Direct urethral sampling is associated with discomfort and/or pain in men, which was significantly greater with a swab than a plastic loop. Urine should therefore be the specimen type of choice. When direct urethral sampling is indicated a loop is preferable to a urethral swab.

Cited by 14 publications

References 12 publications

2016 European guideline on the management of non-gonococcal urethritis

2016 European guideline on the management of non-gonococcal urethritis

Performance evaluation of automated urine microscopy as a rapid, non-invasive approach for the diagnosis of non-gonococcal urethritis

Meatal Swabs Contain Less Cellular Material and Are Associated with a Decrease in Gram Stain Smear Quality Compared to Urethral Swabs in Men

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