Downloaded from https://journals.lww.com/pages by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3eAp+OykKvQ1bASEz/oPc5PTYEmIm5CBURDrrW9Xn9+c48FMAH2y+aQ== on 09/15/2020 New Approach to Microscopy of Gram-Stained Urethral Smear: The Kissing Slide Method Mehmet Sarier, MD,* Meltem Demir, MD,† Hasan Turgut, MD,‡ Aydan Hizel, PhD,§ Mestan Emek, MD,¶ Erdal Kukul, MD,|| and Nevgun Sepin, MD** Background: The effectiveness of microscopy of Gram-stained smear (GSS) for the detection of male urethral infection is debatable, especially in cases with low inflammation and no visible urethral discharge. This clin- ical study compared GSS samples collected with the conventional swab method and our new technique, the kissing slide method, together with po- lymerase chain reaction results to demonstrate the effectiveness of this new method in men with acute urethritis. Methods: The study included 64 men who presented to the urology out- patient clinic with complaints of acute urethritis between October 2019 and January 2020. Two GSS samples were collected from each patient, first using the kissing slide method (applying the slide directly to the urethral mucosa), followed by the conventional method. The results were compared with polymerase chain reaction findings. Results: The patients' mean age was 37.4 ± 7.8 years, and 68.7% had no visible urethral discharge on physical examination. At a GSS threshold of ≥5 polymorphonuclear leukocytes/high-power field, sensitivity values were 60% (95% confidence interval [CI], 42.32%–75.41%) for the kissing slide method and 23.33% (95% CI, 11.79%–40.93%) for the conventional method. At a threshold of ≥2 polymorphonuclear leukocytes/high-power field, sensitivity values with the kissing slide and conventional methods were 80% (95% CI, 62.69%–90.5%) and 50% (95% CI, 33.15%–66.85%) in all patients, and 66.67% (95% CI, 41.71%–84.82%) and 20% (95% CI, 7.047%–45.19%) in cases without visible urethral discharge, respectively. Conclusion: The new kissing slide method is a noninvasive alternative method that may have better sensitivity than the conventional GSS sam- pling method in the diagnosis of male acute urethritis. Randomized studies are needed to verify these findings. U rethritis is an inflammation of the urethra and is often caused by sexually transmitted pathogens. 1 At present, urethritis im- poses a substantial global socioeconomic burden because of its transmissible nature. Therefore, diagnosis of acute urethritis is im- portant because undiagnosed patients not only spread disease but also increase the global burden of antibiotic use. Urethritis in men is traditionally diagnosed upon detection of an average of ≥5 poly- morphonuclear leukocytes (PMNLs) in 5 high-power fields (HPFs) on microscopic examination of Gram-stained smear (GSS) of a ure- thral discharge sample. 2 Gram-stained smear is an inexpensive, quick, and easily applied method that not only establishes urethri- tis diagnosis but also allows for the differentiation of gonococcal urethritis (GU) and nongonococcal urethritis (NGU) based on presence or absence of gram-negative diplococci. 3 However, the effectiveness of GSS has long been a subject of debate. The most common symptoms of urethritis in men are urethral discharge, burning, and itching. Urethral discharge is the main sign of ure- thral inflammation. 4 Although GSS is sensitive enough in cases of pyogenic urethritis such as GU, its sensitivity is much lower in cases without visible urethral discharge or with low inflamma- tion associated with NGU pathogens. 5,6 For this reason, in its 2015 sexually transmitted disease treatment guidelines, the US Centers for Disease Control and Prevention reduced the positivity threshold value to be used in GSS from ≥5 to ≥2 PMNL/HPF to prevent the underdiagnosis of these cases. 7 Nevertheless, it can be seen from the literature that an alternative method to conven- tional GSS is still being sought for the diagnosis of urethritis. The ideal method should be inexpensive, be easy to implement, and have high sensitivity in the diagnosis of male urethritis. The aim of this clinical study was to compare the results obtained with GSS samples collected from acute urethritis patients using the conventional method and our new technique, the kissing slide (KS) method, together with polymerase chain reaction (PCR) re- sults to demonstrate the effectiveness of this new method. MATERIALS AND METHODS The study included men who presented to the urology out- patient clinic of the Medical Park Antalya Hospital Complex be- tween October 1, 2019, and January 31, 2020, with complaints of burning while urinating, itching, and/or urethral discharge that had started after sexual intercourse. Patients who had received an- tibiotic therapy because of any infection within the past 4 weeks were excluded from the study. The presence or absence of visible urethral discharge was noted during physical examination. From each of the 64 consecutive patients included in the study, 2 sam- ples were collected for GSS. The penis was not “milked” or other- wise manipulated to express discharge before GSS sampling. Specimens were first obtained with the KS method, then with the conventional method. We ensured that the patients had not uri- nated within 2 hours before GSS sampling. Immediately after GSS sampling, we first collected urethral samples using a cotton-tipped swab, then first-void urine samples (15 mL) for real-time PCR analysis. All samples were stored at -80°C before analysis. KS Method If the patient is uncircumcised, the prepuce is first retracted. With the external urethral meatus exposed, the penis is held in one hand, slightly pulling the glans back from the sides with the first and second fingers to open the external urethral meatus. When the urethral mucosa is clearly visible, the sample is obtained by pressing the slide directly onto the urethral mucosa with the other hand (Fig. 1). We called this method “kissing slide” because of the direct contact between the external urethral mucosa and the slide, From the *Department of Urology, Istinye University, Istanbul; †Depart- ment of Clinical Biochemistry, Medical Park Hospital, Antalya; ‡Faculty of Health Science, Avrasya University, Trabzon; §Department of Clinical Microbiology, Medical Park Hospital; ¶Department of Public Health, AkdenizUniversity; ||Department of Urology, Medical Park Hospital; and **Department of Clinical Microbiology and Infectious Disease, Training and Research Hospital, Antalya, Turkey Conflict of Interest and Sources of Funding: None declared. Correspondence: Mehmet Sarier, MD, Department of Urology, Medical Park Hospital, Muratpaşa 07110, Antalya, Turkey. E‐mail: drsarier@gmail.com. Received for publication April 25, 2020, and accepted June 17, 2020. DOI: 10.1097/OLQ.0000000000001228 Copyright © 2020 American Sexually Transmitted Diseases Association. All rights reserved. ORIGINAL STUDY 712 Sexually Transmitted Diseases • Volume 47, Number 10, October 2020 Copyright © 2020 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.