MUDS — Key Facts & Diagnosis

Clinical description

• Main symptoms: putrid discharge from meatus penis, spontaneous or after 'urethral milking'. ± painful/frequent urination, ± testicular/epididymal tenderness or swelling.
• Most common causes in Malawi: Neisseria gonorrhoeae, Chlamydia trachomatis.
• Rare: Trichomonas vaginalis, Mycoplasma genitalium. Consider Schistosoma haematobium if haematuria/painful/frequent urination.
• The infections causing MUDS in men are mostly asymptomatic in women. Treatment of all sex partners is needed.
• Routine syphilis screening (treponemal rapid test) is useful in men with MUDS to diagnose asymptomatic syphilis.

Treatment

Treat if putrid discharge from the meatus is confirmed. 'Milk' the urethra if no spontaneous discharge. Add empirical genital schistosomiasis treatment if compatible symptoms. Collect urethral swab for culture and sensitivity if discharge persists despite initial treatment (N. gonorrhoea rapidly develops resistance).

Standard syndromic treatment for MUDS

• Ceftriaxone 500 mg IM stat.
• Azithromycin 1 g oral single dose stat.

Return if symptoms not resolved after 5 days.

5-day review

• Compliance confirmed: ceftriaxone 500 mg IM stat (repeat) + metronidazole 2 g oral stat + praziquantel 40 mg/kg oral stat. Swab for culture + sensitivity. Ensure partner treatment.
• Compliance doubtful: ceftriaxone 500 mg IM stat + azithromycin 1 g oral stat. Ensure partner treatment.

Partner treatment

Partner treatment (asymptomatic)

• Uncomplicated MUDS: ceftriaxone 500 mg IM stat + azithromycin 1000 mg oral stat.
• Persistent/recurrent MUDS: ceftriaxone 500 mg IM stat + metronidazole 2000 mg oral stat.

At every visit

HIV & ART status

• Ascertain HIV + ART status from health passport or self-report.
• Offer new HIV test for all unless previously diagnosed. Do not use coercion.
• New positive: active referral for ART initiation.
• New negative: refer/offer PrEP, VMMC, consistent condom use.
• Known positive: reinforce ART adherence or refer for re-initiation.

Hepatitis B

• Offer HBV rapid test for all patients born before 2002.
• HBsAg negative: refer for HBV vaccination unless previously completed 3 doses.
• HBsAg positive: refer for clinical and treatment assessment.

Syphilis screening

• Offer syphilis rapid test for concurrent asymptomatic syphilis (except in GUD/ARI where it does not influence treatment decisions).

Risk reduction & condoms

• Risk reduction counselling. Promote and dispense condoms.
• Promote VMMC for all non-circumcised men. Schedule appointment in 2 weeks.