Sizemore, James M. JR., MD*; Sanders, Willa M.*; Lackey, Phillip C. MD‡; Ennis, David M. MD§; Hook, Edward W. III, MD*†
*Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama; †Jefferson County Department of Health, Birmingham, Alabama; ‡I. D. Consultants, PA, Charlotte, North Carolina; and §Internal Medicine Education, Baptist Health System, Inc., Birmingham, Alabama
Supported by the UAB Sexually Transmitted Diseases Cooperative Research Center Grant 5 U19 AI38514-07, and the UAB GCRC, RR00032.
Correspondence: James M. Sizemore, Jr., MD, The University of Alabama at Birmingham, 703 19th Street South, 242 Zeigler Research Building, Birmingham, AL 35294-0007. E-mail: email@example.com
Received for publication September 4, 2003, and accepted December 1, 2003.
SYMPTOMS OF URETHRITIS are one of the most common reasons men present for evaluation at sexually transmitted diseases (STD) clinics. Understanding the complex issues surrounding behaviors that put men at risk for STD, as well as the decision process leading them to seek care once symptoms are present, are understudied.
In general, health care-seeking has been described as the cognitive and behavioral response during the time period encompassed by recognition of a health problem and its clinical resolution. One author has defined the interval between symptom onset and recognition of symptoms as a health problem as the “appraisal” period. 1 This construct is followed by the “procrastination” interval defined as the time between symptom recognition and actually presenting for evaluation. 1 Depending on how the symptoms associated with urethritis are processed cognitively, one could hypothesize that among symptomatic men, those reporting prior urethritis would have a shortened appraisal period when compared with those without a similar history. Similarly, depending on the perceived seriousness of repeated urethritis symptoms, the procrastination interval might be shortened or prolonged. Furthermore, whether these men differ with regard to curtailing sexual activity once symptoms are noted could be influenced by STD counseling received at the time of prior evaluation for urethritis episodes.
To address these issues, we compared randomly selected males attending an STD clinic divided on the basis of whether they reported a urethritis history, asking the following questions: 1) Do men attending an STD clinic who report a urethritis history differ demographically and behaviorally from those men who do not report a urethritis history? 2) Do men diagnosed with urethritis who also report a urethritis history recognize symptoms as a possible STD sooner than men who do not report prior urethritis? 3) Do men with urethritis who also report prior urethritis curtail sex on symptom recognition more often than those without a urethritis history? 4) Do men with urethritis who report a urethritis history seek care sooner than those men without a urethritis history?
The study was conducted at the Jefferson County Department of Health STD Clinic in Birmingham, Alabama. Men presenting to the STD clinic for evaluation were randomly selected to be approached for study enrollment. Exclusion criteria included men who were attending the clinic for follow up of a previously diagnosed problem or men attending the STD clinic solely for HIV testing. Most participants were attending the clinic for perceived STD symptoms, as partners to a person with a previously diagnosed STD, or for STD screening.
Following description of study goals and procedures, patients were asked to provide written informed consent for participation. Consenting participants were then administered a standardized questionnaire collecting demographic data, STD history, sexual partner history, as well as information on social and attitudinal variables potentially relevant to health-seeking behaviors. Included in the questionnaire were separate questions about symptom duration and when symptoms were first considered as a possible STD, as well as, in different sections, questions about prior STDs and when the patient was most recently sexually active. After questionnaire administration, participants received routine clinical care and counseling per STD clinic protocol as described previously. 2
Data Management and Statistical Analysis
Questionnaire and laboratory data were entered into a Microsoft Access database (Microsoft Inc., Redmond, WA) with appropriate checks to ensure accuracy.
Analyses were conducted with SAS software (SAS Institute, Cary, NC). Participants were stratified based on whether they reported a history of urethritis. Men who reported a history of gonorrhea, chlamydial infection, or nongonococcal urethritis (NGU) were included in the group with a urethritis history. Once stratified, a subset of men in each group was identified; these men had urethritis symptoms at the study visit and were diagnosed with urethritis at the study visit. Men were included in this subset if they first reported symptoms of drip, discharge, frequency, or dysuria and second, had a diagnosis of NGU or gonorrhea based on urethral Gram stain criteria. For univariate analyses, chi-square or Fisher exact tests were used to analyze dichotomous variables. Continuous variables were analyzed using a t test.
Between August 1992 and September 1995, 466 men were enrolled (Table 1). The majority were young (mean age, 28 years), heterosexual (97%), black (90%), single (never married; 68%), at least high school (or GED) educated (70%), and employed (65%). Reasons for clinic visit have been reported previously. 2 Sixty-four percent (298 of 466) of participants acknowledged a history of urethritis.
Self-reported behaviors potentially associated with STD risk were relatively common in study participants. Forty-three percent of men reported more than 1 sexual partner in the preceding 30 days, as did 75% during the previous 6 months. Approximately one fourth acknowledged prior prostitute exposure and approximately half reported incarceration at some time in the past. Substantial substance use was acknowledged within the preceding 30 days: tobacco 57%, alcohol 83%, and marijuana 36%.
At the study visit, 88% (n = 410) of participants were diagnosed with a STD. Seventy-six percent (n = 312) of those with an STD had urethritis. Of those with urethritis, 54% had gonorrhea, of whom 20 (5%) were coinfected with Chlamydia trachomatis. Of 145 participants with nongonococcal urethritis, 21% had a positive culture or polymerase chain reaction for C. trachomatis.
In univariate analyses, men with prior urethritis did not significantly differ from those without a urethritis history in their age, education, current employment status, marital status, tobacco use, sexual preference, number of recent partners, or illicit drug use (see Table 1). Men reporting a history of urethritis were significantly more likely to be black (97% vs. 78%, P <0.0001), to have recently smoked marijuana (P = 0.04), and to have been incarcerated (P = 0.0007).
Sexual Risk Comparison
With regard to sexual risk behavior (Table 2), men reporting a urethritis history trended toward having more lifetime partners and prostitute exposure, although these associations were not significant. The 2 groups did not differ with regard to recent number of sexual partners, age of sexual debut, or condom use with last sexual encounter (27% vs. 28%, P = 0.87). However, men with a history of urethritis were significantly more likely to have used alcohol or drugs with their last sexual encounter (57% vs. 45%, P = 0.009); this association persisted when substance use was subdivided into alcohol use (54% vs. 43%, P = 0.02) or otherwise “got high” (19% vs. 8%, P = 0.002).
Health-Seeking Behavior and Risk-Taking Among Symptomatic Men With Urethritis at Study Visit
Seventy-five percent (234 of 314) of men diagnosed with urethritis at the study visit reported symptoms consistent with that diagnosis (ie, urethral discharge or dysuria). Among these symptomatic men, those reporting a history of urethritis (n = 166) did not differ significantly from those without (n = 68) about total interval of time between symptom onset and presentation to the clinic (5.5 vs. 6.1 day, P = 0.64), time interval between symptoms recognized as STD and presentation to the clinic (4.1 day vs. 3.3 days, P = 0.19), or the difference between the 2 (1.5 vs. 2.8 days, P = 0.19). Furthermore, there was no difference in the use of antibiotics in the 2 weeks before the visit (17% vs. 10%, P = 0.17), nor was there a difference in those who continue to engage in sexual acts once symptoms were present (22% vs. 33%, P = 0.19).
We are not aware of prior studies that have systematically evaluated risk-taking and health-seeking behavior of men attending STD clinics in relationship to their reported history of urethritis. In this study of men seeking care at a public STD clinic, prior episodes or urethritis were common, as were urethritis diagnoses at the time of presentation. As one might expect, men reporting prior urethritis had higher rates of “risk” behaviors positively associated with STD, including significant increased likelihood of alcohol/drug use with their last sexual encounter, as well as trends toward more lifetime partners and prostitute exposure. With that stated, it is interesting to note that the 2 groups did not differ in their more recent behaviors, including mean number of partners or their reported condom use, which was uniformly low.TABLE
Furthermore, although there was a trend toward men who reported a history of urethritis recognizing their symptoms as a possible STD a day sooner than men without a history, the difference was not significant. Additionally, even earlier recognition did not significantly alter the timeliness in which men with prior urethritis presented for care. An even greater area of public health concern was the realization that 22% of these symptomatic men continued to have sex (again, with low rates of condom use) and delayed care similarly to men without a history of urethritis. Our findings confirm previous studies in both the developed 3–5 and developing 6 world demonstrating that a substantial percentage of men attending STD clinics continue to have sex after symptoms are present.
Although sorting through behavioral and biologic determinants of males seeking STD-related health care is a complex undertaking, several possible reasons are plausible to account for our observed data. First, regardless of a history of prior STD, men could struggle with barriers such as social stigmatization when seeking STD-related health care. Second, a perceived lack of seriousness might explain some delay in health care-seeking by men with symptomatic urethritis; despite educational efforts or lack thereof, men with prior urethritis who had been previously evaluated and cured with a single or few pills could potentially misunderstand these sorts of infection as trivial, not recognizing the need for timely evaluation or the potential consequences to their sexual partners. Third, one might hypothesize that those with prior episodes of urethritis might self-treat with antibiotics belonging to someone else or “left over” from prior episodes or illnesses; our data demonstrated no significant difference between those with and without prior urethritis reporting antibiotic use in the 2 weeks before the study visit, suggesting this was not a significant contributor to our results. Fourth, a prior study has suggested that symptomatic men with NGU experience symptoms longer than men with symptomatic gonorrhea (GC) 7; therefore, if men with prior episodes of urethritis were diagnosed with relatively more NGU than GC, one could expect that these men too would delay care-seeking, thus negating a possible difference gained from prior urethritis experience. In our study, men diagnosed with urethritis were equally as likely to have NGU or GC irrespective of prior urethritis, making this explanation an unlikely contributor to our findings. Finally, although we did not have data reporting in which men had sought care for previous episodes of urethritis, one can assume that a large proportion did so at a public STD clinic; if true, this suggests that preventive counseling efforts specifically regarding condom use, abstinence, and early self-referral with recurrence of symptoms are in general ineffective or absent.
Irrespective of how these factors contribute to delayed health-seeking among men with urethritis, they suggest new potential targets for intervention, ie, encouragement of prompt recognition of even mild urethritis symptoms as a potential STD and expeditious care-seeking without continued sexual activity. In addition to educational interventions, it is also possible that structural interventions in the provision of STD care such as urine testing for urethritis diagnoses (leukocyte esterase assays, urine-based nucleic acid amplification tests) rather than urethral swabs or oral therapy rather than injections might also reduce disincentives to care-seeking.
Several limitations of this study should be acknowledged and considered. First, these data were collected from a single STD clinic in the Southeastern United States and, thus, might not be generalizable to other populations. Second, stratification of participants based on self-reported history of STD lack objectivity. Patients might not have remembered prior episodes of urethritis; if this were the case, however, this would further support our observation that prior urethritis has little impact on subsequent STD care-seeking. Finally, our study did not have sufficient participants to permit further meaningful stratification into specific diagnoses (NGU vs. gonococcal urethritis) or 1 versus multiple episodes of prior urethritis. Future studies should examine in more detail why men seek (or delay) care for STD when they do and what barriers exist in providing STD-related care.
Our data suggest that among symptomatic men diagnosed with urethritis, those reporting an urethritis history did not recognize symptoms as a possible STD sooner than those men without a history of urethritis; furthermore, the 2 groups display similar behavioral responses with regard to self-treatment, continued sexual activity, and time to presentation for clinic evaluation. Future preventive public health measures and educational programs directed toward at-risk men need to reemphasize abstinence and early health care-seeking once symptoms are recognized as a possible STD.