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Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae in Turkey Among Men With Urethritis


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SEXUALLY TRANSMITTED DISEASES (STDs) are a major health problem, especially in parts of the developing world. 1 In many countries, the most common STD syndrome seen in men is probably urethritis. 2,3Chlamydia trachomatis and Neisseria gonorrhoeae are known to cause these infections. 4 The World Health Organization estimates that 89 million new cases of chlamydia and 62 million new cases of gonorrhea occur annually. 5

Epidemiologic data are very limited regarding the causes of urethritis in developing countries. 6,7 Because laboratory testing is lacking, an increased emphasis has been placed on “syndromic management” of STDs, particularly in resource-poor settings. This approach works well for men with urethritis and inpatients with genital ulcer disease. However, not much is known about STD prevalence, and only a small number of studies from Eastern European countries have been published. Turkey as a model among developing countries has only a moderate knowledge of its STD rates, except for reportable diseases such as syphilis and HIV/AIDS. 8

Because commercial sex workers (CSWs) and their clients are at high risk for urogenital chlamydial infection, 9,10 identification and treatment of chlamydia in this group could reduce the transmission of the disease. Few data are available regarding the prevalence of STDs in this group. In one study conducted in The Netherlands, 11C trachomatis was detected in 4.9% of CSW clients. The investigators used semen specimens to test by enzyme immunoassay (EIA).

The purpose of this study was to determine the prevalence of C trachomatis and N gonorrhoeae in symptomatic men, and to determine whether contact with a CSW increased the likelihood of C trachomatis infection.


Patients were seen in the Department of Urology at the Istanbul Faculty of Medicine’s hospital. This is a public STD clinic that provides primary care for mostly male patients. From January to August 1999, consecutive men with signs or symptoms of urethritis were enrolled in the study. All the patients had reported dysuria or urethral pruritus, or they had a Gram-stained urethral smear yielding more than 4 polymorphonuclear leukocytes per oil immersion field. Patients were excluded if they had received antibiotic therapy within 3 weeks of their clinic visit.

All the patients were screened for chlamydia and questioned on their recent (within 1 month) sexual contact with a CSW. The clinicians also asked whether they used condoms during previous sexual exposures. For men who denied contact with a CSW (n = 192), two urethral swabs were collected for gonorrhea culture and for ligase chain reaction (LCR) (C trachomatis and N gonorrhoeae amplification). The sequence of specimen collection was randomized. A type 1 Dacron swab was inserted approximately 2 cm into the urethra, withdrawn, and placed into the LCR transport media or swabbed onto a Thayer-Martin plate without antibiotic supplementation. For men who had contact with a CSW, a urethral swab was collected for chlamydia LCR. A first-void urine specimen was collected from men who refused a urethral swab.

For culture of N gonorrhoeae, plates were incubated for 48 hours at 36 °C under carbon dioxide. 12 Typical colonies contained oxidase-positive gram-negative diplococci. Suspected organisms with poor growth were subcultured onto chocolate agar. Isolates were confirmed by the GonoGen Colorimetric Test II (Becton-Dickinson, Sparks, MD). Urethral swabs and first-void urine were collected and processed according to the LCR manufacturer’s instructions (Abbott Laboratories, Abbott Park, IL).

Patients were treated after laboratory results were obtained. Men with C trachomatis were given a single oral dose of azithromycin (1 g). Men with N gonorrhoeae were given a single dose of ceftriaxone (2 g).


There were 813 symptomatic men enrolled in the study. The overall prevalence of C trachomatis, as determined by LCR, was 15.7% (128/813). Table 1 shows the breakdown of chlamydia by age range. The average age was 35.2 ± 6.5. Most chlamydia was found in the lower age range. Chlamydia prevalence was 15.3% (95/621) for the men who had contact with CSWs, as compared with 17.2% (33/192) for the men who had no contact with CSWs (P = 0.53). A total of 600 men had sexual contact with East European CSWs, and 21 men had sexual contact with registered Turkish CSWs. All the men with positive test results had contacts with East European CSWs. This was a significant difference (P = 0.029).

Table 1
Table 1:
Prevalence of Chlamydia trachomatis (CT) by LCR in Turkish Men With Urethritis (n = 813)

Of the 813 men enrolled in the study, only 192 were screened for both organisms. In this group, STD infection was detected in 24% (46/192) of the men. As determined by LCR and culture, N gonorrhoeae prevalence was 9.4% (18/192). Among the men with gonorrhea, 28% had concomitant chlamydial infections (5/18).


This study shows that chlamydia and gonorrhea are commonly found in Turkish men with urethritis. In two previous studies, we also found comparable chlamydia rates in men with urethritis of 19.5% and 12.1%. 13,14 The latter study was performed by cell culture, which is less sensitive, accounting for the lower chlamydia rate, whereas the former was performed by a combination of three tests: polymerase chain reaction (PCR) (Amplicor; Roche Molecular Systems, Branchburg, NJ), EIA (Dako Diagnostics, Cambridge, UK), and tissue culture isolation. Although, our findings (16% of men with nongonococcal urethritis [NGU] had chlamydia) are similar to those from a study by Stamm et al, 15 whose results showed that 15% of the men with NGU had chlamydia, we suspect that the infection rates could be somewhat low. This may be the result of widespread antibiotic use among our patients. In Turkey, the population can freely purchase over-the-counter medications (antibiotics). The patients’ use of antibiotics before clinical evaluation may have resulted in a falsely low estimation of gonorrhea and chlamydial prevalence.

We did not find significantly higher chlamydia prevalence in men who had contact with CSWs. In contrast, prevalence was slightly lower (15.3% versus 17.2%). Our chlamydia results are similar to those from an earlier study 16 that used Syva MicroTrak direct fluorescent antibody (DFA) (Behring Diagnostics, Inc., Cupertino, CA) on clients with urethritis who had been exposed to sex workers. Chlamydia prevalence was 12%.

Legal sex workers in Turkey are required to register with municipal authorities and attend clinics for regular periodic STD examinations including chlamydia testing, whereas unregistered sex workers do not have access to routine STD monitoring. 8 Therefore, a higher incidence of STD infections would be expected in the latter. Legal CSWs work in brothels, but illegal CSWs work the streets. Studies of STD prevalence in CSWs have reported conflicting results about whether unregistered foreign CSWs were more frequently infected with STDs. A study of 158 registered Turkish CSWs and 90 unregistered East European CSWs found rates of C trachomatis to be comparable: 12% and 14.4%, respectively, as determined by DFA. 17 Ertem et al 18 detected chlamydia at a rate of 25.4% in registered CSWs in Izmir, Turkey. Clearly, registered and unregistered Turkish CSWs are high-risk groups. By comparison, Stary et al 19 found a significant difference in chlamydia prevalence between registered CSWs (2%) and unregistered CSWs (10%) in Vienna. Although our number of contacts with legal prostitutes was quite small (n = 21), all the men with positive test results for chlamydia were clients of unregistered East European CSWs.

In conclusion, we have shown that C trachomatis and N gonorrhoeae can be detected in men with urethritis. Clearly, the lack of condom use among these men is a risk behavior for STDs. These men represent a significant source of STD/HIV and its transmission to CSWs and other non-CSW partners. Identification, treatment of infections, and education regarding condom use in this group and among CSWs could help in the overall reduction of chlamydia and other STDs. With the introduction of LCR and the use of first-catch urine as a noninvasive test, more screening studies are needed to determine the prevalence of chlamydia and gonorrhea in asymptomatic male populations in Turkey.


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