Indian J Sex Transm Dis Indian J Sex Transm Dis
Official Publication of the Indian Association for the Study of Sexually Transmitted Diseases
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Year : 2008  |  Volume : 29  |  Issue : 1  |  Page : 29-31

Mixed urethral infection in patients with urethral discharge in the southern region of Kuwait

1 Department of Dermatology, Adan Hospital, State of Kuwait, Kuwait
2 Department of Microbiology, Adan Hospital, State of Kuwait, Kuwait

Correspondence Address:
Sultan RS Al-Otaibi
P. O. Box: 2193, Al-Qurain 47372
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Although chlamydial and gonorrheal urethritis are the most prevalent sexually transmitted diseases, the frequency of the co-occurrence of both the diseases is still not well established. The aim of this study was to determine the frequency of the co-occurrence of the two diseases in the southern region of Kuwait State among men with a past history of heterosexual intercourse who sought medical care for urethral discharge. Over a period from October 2005 till October 2006, a total of 475 patients were selected for the study from among the patients attending the OPD clinics of Al-Adan Hospital for treatment of sexually transmitted diseases. The subjects were screened for both gonorrhea and chlamydia with polymerase chain reaction and Gram's stain, using specimens from the urethral discharge. Out of the total of 475 patients, 125 (26.3%) had gonorrhea, 47 (9.8%) had chlamydia, and 11 (7.31%) had both diseases. We concluded that co-occurrence of chlamydia and gonorrhea may be common among males presenting with urethral discharge.

Keywords: Gonorrhea, chlamydia

How to cite this article:
El-Gamal AHF, Al-Otaibi SR, Alshamali A, Abdulrazzaq A, Najem N, Al Fouzan A. Mixed urethral infection in patients with urethral discharge in the southern region of Kuwait. Indian J Sex Transm Dis 2008;29:29-31

How to cite this URL:
El-Gamal AHF, Al-Otaibi SR, Alshamali A, Abdulrazzaq A, Najem N, Al Fouzan A. Mixed urethral infection in patients with urethral discharge in the southern region of Kuwait. Indian J Sex Transm Dis [serial online] 2008 [cited 2023 Dec 10];29:29-31. Available from:

   Introduction Top

Chlamydial urethritis and gonorrhea are the leading reportable sexually transmitted diseases in the United States. In the UK, gonorrhea is considered the second most common bacterial sexually transmitted infection. In France, the average number of cases of  Neisseria More Details gonorrhea isolated per laboratory per year decreased from 10.6 in 1986 to 0.6 in 1997 but then increased yearly to reach 1.9 in 2000. Gonococcal and nongonococcal urethritis have been the most commonly reported sexually transmitted diseases in China since the reemergence of STDs in the late 1970s and early 1980s. [5]

In another study Among individuals infected with gonorrhea, 3.3-37% were concurrently infected with Chlamydia, and 12-28% of men infected with chlamydia were concurrently infected with gonorrhea. Although gonorrhea and chlamydial infections can be easily diagnosed and treated, the undetected and untreated infections can lead to severe health problems such as pelvic inflammatory disease (PID), ectopic pregnancy, and infertility in females and testicular and prostate infections and infertility in males. [8]

In Kuwait, data on the incidence of gonorrhea and chlamydial infections is limited and often missing. Our aim was to determine the co-occurrence of the two diseases among men with urethral discharge attending STD clinics in southern Kuwait.

   Materials and Methods Top

This study was conducted in the STD clinics of Al-Adan hospital, which is the referral center for the whole southern region of the State of Kuwait. Men attending the STD clinics, with a history of heterosexual intercourse and with complaints of urethral discharge (which was confirmed by clinical examination and, if necessary, by milking the urethra), were included in this study. After a thorough physical examination, two urethral swab samples were taken. The swab was inserted 1-2 cm into the urethra and rotated for 30 s before being withdrawn. One sample was smeared on a slide and examined with Gram's stain and the other was stored at −200C to be tested later for N. gonorrhea and C. trachomatis by polymerase chain reaction (PCR) assay.

   Results Top

From October 2005 to October 2006, a total of 475 newly registered male patients complaining of urethral discharge, and with a past history of heterosexual intercourse, were included in this study. The mean age of the patients was 32.5 years (standard deviation 7.62 years; range: 17-61 years). Out of the 475 patients, 125 (26.3%) had gonococcal urethritis, 47 (9.8%) had chlamydial urethritis, and 11 (2.31%) were diagnosed as having coinfection with both N. gonorrhea and C. trachomatis [Table 1]. Coinfection with C. trachomatis was seen in 11/136 (8.09%) patients with gonococcal urethritis, whereas coinfection with N. gonorrhea was seen in 11/58 (18.97%) patients with chlamydial urethritis [Table 2].

[Table 3] shows the agreement between the results of Gram's stain and PCR in the diagnosis of gonorrhea. They agree in 134 (98.52%) of the 136 cases of gonorrhea and disagree in 2 cases (1.48%) only. The overall correlation between the two methods was (99.4%).

   Discussion Top

Consistent with previous studies, we found high proportions of individuals who had coinfection with both organisms. [6]

Contrary to almost all studies that reported coinfection rates in both directions,[7],[9],[10],[11],[12] the chlamydial coinfection rate among individuals having gonorrhea was lower than the gonorrhea coinfection among individuals infected with chlamydia. We screened health care-seeking patients using nucleic acid amplification tests (NAATs) to detect both diseases in one laboratory sample besides doing a Gram's stain in another sample. Our findings may differ from those of previous studies because of differences in the methodology used for disease detection and sampling. Creighton et al. , [7] Lyss et al. , [9] and Hijazi et al. [12] utilized culture and nonamplification methods to detect both diseases; these techniques have been found to be less sensitive than NAATs. [13]

Some studies have shown that a higher or lower overall prevalence for gonorrhea and chlamydial infection do not necessarily translate into corresponding higher or lower prevalence of coinfection among those carrying either STD. [9],[14]

The sensitivity of Gram's stain for the diagnosis of gonococcal urethritis in symptomatic males was found to range from 89-95%, whereas the specificity has been reported to be between 94-97%. [15],[16],[17] Consistent with our results, Juchau et al. [18] concluded that the agreement between PCR and Gram's stain examination in the diagnosis of gonorrhea was 99.6%; since PCR is far more expensive, we felt that there was no practical reason to prefer it over Gram's stain for the diagnosis of gonorrhea in symptomatic males.

One limitation of our study is that it is not possible to generalize our findings to other geographic locations or other high-risk populations; we conducted our study on a small group of patients and the area where we conducted the study has only about 1/6 th of the total population of Kuwait state. We recommend that simultaneous screening for both chlamydia and gonorrhea should remain the first line of intervention. Also, more generalized studies, including subjects from all over Kuwait state, need to be conducted.

   References Top

1.Centers for disease control and prevention. Sexually transmitted disease surveillance, 2001. Atlanta: US Department of Health and Human Services; 2002.  Back to cited text no. 1    
2.The Hidden Epidemic. Confronting sexually transmitted disease. Washington DC: National Academy Press; 1997.  Back to cited text no. 2    
3.GRASP steering group. The gonococcal resistance to antimicrobial surveillance program (GRASP) year 2001 report. London: Public health laboratory service; 2002.   Back to cited text no. 3    
4.Herida M, Sednaoui P, Goulet V. Gronorrhea surveillance system in France: 1986-2000. Sex Trans Dis 2004;31:209-14.   Back to cited text no. 4    
5.Parish WL, Laumann EO, Cohen MS, Pan S, Zheng H, Hoffman I, et al . Population based study of Chlamydial infection in China: A hidden epidemic. JAMA 2003;289:1265-73.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Dragoric B, Gereaves K, Vashisht A, Straughair G, Sabin C, Smith NA. Chlamydia coinfection among patients with gonorrhea. Int J STD AIDS 2002;13:261-3.   Back to cited text no. 6    
7.Creightons S, Tenant-Flowers M, Taylor CB, Miller R, Low N. Coinfection with gonorrhea and Chlamydia: How much is there and what does it mean? Int J STD AIDS 2003;14:109-13.   Back to cited text no. 7    
8.Holmes KK, Sparling PF, Per Anders M, et al , editors. Sexually transmitted diseases, 3 rd ed. New York: McGrow - Hill; 1998.  Back to cited text no. 8    
9.Lyss SB, Kamb ML, Pelerman TA, Moran JS, Newman DR, Bolan G, et al . Chlamydia trachomatis among patients infected and treated for Neisseria gonorrhea in sexually transmitted disease clinic in United States. Ann Intern Med 2003;139:178-85.  Back to cited text no. 9    
10.Burstein GR, Waterfield G, Joffe A, Zenilman JM, Quinn TC, Gaydos CA. Screening for gonorrhea and Chlamydia by DNA amplification in adolescents attending middle school health centers: Opportunity for early intervention. Sex Trans Dis 1998;25:395-402.  Back to cited text no. 10    
11.Xu K, Gedawton V, Johnson SR, Beck-Saguι C, Bhullar V, Candal DH, et al . Detection of Neisseria gonorrhea infection by ligase chain reaction testing of urine among adolescent women with and without Chlamydia trachomatis infection. Sex Trans Dis 1998;25:533-8.  Back to cited text no. 11    
12.Hijazi L, Thow C, Winter AJ. Factors affecting coinfection with genital Chlamydia and genital gonorrhea in an urban genitourinary medicine clinic. Sex Trans Infect 2002;78:387.  Back to cited text no. 12    
13.Buimer M, Van Doornum GJ, Ching S, Peerbooms PG, Plier PK, Ram D, et al . Detection of Chlamydia trachomatis and Neisseria gonorrhea by ligase chain reaction based assay with clinical specimens from various sites: Implications for diagnostic testing and screening. J Clin Microbial 1996;34:2395-400.  Back to cited text no. 13    
14.Dicker LW, Mosure DJ, Berman ST, Levine WC. The regional infertility prevention program: Gonorrhea prevalence and coinfection with Chlamydia in women in united states, 2000. Sex Trans Dis 2003;30:472-6.  Back to cited text no. 14    
15.Burn MP, Ross DW, Cox T. A preliminary evaluation of the Geonozyme test. Sex Trans Dis 1983;19:180-3.   Back to cited text no. 15    
16.Good Hart ME, Ogden AA, Kraus SJ. Factors affecting the performance of smear and culture tests for detection of Neisseria gonorrhea . Sex Trans Dis 1982;9:63-9.  Back to cited text no. 16    
17.Manis RD, Horris HB, Greiseler PJ. Evaluation of geonozyme: An enzyme immunosay for rapid diagnosis of gonorrhea. J Clin Microbial 1984;20:742-6.  Back to cited text no. 17    
18.Juchau SV, Nakman R, Ruppard. Comparison of gram stain with DNA probe for detection of Neisseria gonorrhea in urethras of symptomatic males. J Clin Microbial 1995;33:3068-9.  Back to cited text no. 18    


  [Table 1], [Table 2], [Table 3]


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