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The British Journal of General Practice logoLink to The British Journal of General Practice
. 2010 Oct 1;60(579):e407–e422. doi: 10.3399/bjgp10X532413

Management of epididymo-orchitis in primary care: results from a large UK primary care database

Amanda Nicholson 1,2,3,4,5, Greta Rait 1,2,3,4,5, Tarita Murray-Thomas 1,2,3,4,5, Gwenda Hughes 1,2,3,4,5, Catherine H Mercer 1,2,3,4,5, Jackie Cassell 1,2,3,4,5
PMCID: PMC2944950  PMID: 20883615

Abstract

Background

Epididymo-orchitis is a common urological presentation in men but recent incidence data are lacking. Guidelines for management recommend detailed investigation and treatment for sexually transmitted pathogens, such as Chlamydia trachomatis. Data from secondary care indicate that these guidelines are poorly followed. It is not known how epididymo-orchitis is managed in UK general practice.

Aim

To estimate the incidence of cases of epididymo-orchitis seen in UK general practice, and to describe their management.

Design of study

Cohort study.

Setting

UK general practices contributing to the General Practice Research Database (GPRD).

Method

Men, aged 15–60 years, consulting with a first episode of epididymo-orchitis between 30 June 2003 and 30 June 2008 were identified. All records within 28 days either side of the diagnosis date were analysed to describe the management of these cases (including location) and to compare this management with guidelines.

Results

A total of 12 615 patients with a first episode of epididymo-orchitis were identified. The incidence was highest in 2004–2005 (25/10 000) and declined in the later years of the study. Fifty-seven per cent (6943) of patients were managed entirely within general practice. Of these, over 92% received an antibiotic, with ciprofloxacin being the most common one prescribed. Only 18% received a prescription for doxycycline. Most men, including those under 35 years, had no investigation recorded and fewer than 3% had a test for chlamydia.

Conclusion

These results indicate low rates of specific testing and treatment for sexually transmitted infections in males who attend general practice with symptoms of epididymo-orchitis. There is a need for further research to understand the pattern of care delivered in general practice.

Keywords: chlamydia, electronic health records, epididymitis, incidence, primary health care

INTRODUCTION

Acute epididymitis, without or with testicular involvement (here described as epididymo-orchitis), is a common urological condition in men, presenting with unilateral testicular pain and swelling. Recent epidemiological data are lacking, but a previous estimate from UK general practice suggested incidence rates of 40/10 000 person-years,1 and outpatient data from the US report epididymo-orchitis as the fifth most common urological diagnosis between the ages of 18 and 50 years.2

Existing guidelines are based on a clinical consensus that in men under 35 years, epididymo-orchitis is most commonly caused by a sexually transmitted pathogen such as Chlamydia trachomatis or Neisseria gonorrhoeae.37 In older men, the infection is more likely to be due to non-sexually transmitted enteric Gram-negative organisms.8 The extent of idiopathic or sterile cases is unclear, as some of the literature predates the identification of C. trachomatis, but no infection is identified in a sizeable proportion (46%) of cases.9 Novel organisms, such as Mycoplasma genitalium, which are not included in testing regimes, may be involved in such cases. The data underlying this conventional divide at 35 years may, however, be questioned, as they are based on small studies in selected populations.37 Guidelines from the US and UK suggest a detailed testing schedule, involving C. trachomatis, N. gonorrhoeae, urethral swabs or first-void urine culture, and midstream urinalysis (MSU), followed by antibiotics as indicated by history, with doxycycline for likely C. trachomatis infections, ceftriaxone/ciprofloxacin followed by doxycycline for N. gonorrhoeae infections, and ofloxacin/ciprofloxacin for enteric organisms.8,10

How this fits in

Epididymo-orchitis is a common urological presentation in general practice, which is often related to sexually transmitted infection in younger men. Guidelines for management exist but it is not known how these are followed by GPs. The results of this study, from an anonymised database of primary care electronic records, indicate investigation and treatment that does not address sexually transmitted infection in the majority of men. Further research is required to understand why GPs are not following recommended practice.

Effective treatment and management of epididymo-orchitis is important for clinical and public health reasons. There are clinical concerns about long-term sequelae including infertility, prostatitis, and strictures.1114 Cases related to sexually transmitted infection (STI) present opportunities to screen for infection and to offer treatment, and for partner notification, which should not be missed. The National Strategy for Sexual Health and HIV has, since 2001, recommended a greater role for primary care providers in the care of STIs.15

The sparse literature on the management of epididymo-orchitis raises concerns. A survey of UK urologists indicated low compliance with guidelines,16 whereas a survey of genitourinary medicine (GUM) departments reported near-complete adherence.9 Data from a US university hospital also suggest low rates of testing for STIs.17 Although some cases of epididymo-orchitis may present to GUM clinics or direct to an emergency department, most men will attend their GP first. Simms et al reported high attendance rates for epididymo-orchitis in UK primary care.1 No studies describing GP management of epididymo-orchitis were identified. There is a need for updated descriptive data using real-time patient records to record the incidence of the disorder and to describe management and hence to inform continuing education.

The current study aimed to estimate the incidence of epididymo-orchitis in primary care between 2003 and 2008. It also aimed to describe the management of patients with this condition, within the practice and beyond, and to assess its adequacy in relation to existing guidelines, including associations between management and various patient and practice factors.

METHOD

Target population

The General Practice Research Database (GPRD) is an electronic database of anonymised longitudinal patient records from general practice.18 Established in 1987, it is a UK-wide dataset covering 5.5% of the population, with data from 460 practices, and is broadly representative of the UK population. There are 3.5 million currently active patients. Records are derived from the GP computer system (VISION) and contain complete prescribing and coded diagnostic and clinical information held in different record tables (Figure 1).

Figure 1.

Figure 1

Structure of GPRD database.

Many laboratory results are now imported directly into the system, and letters received from hospitals will be logged with either full text included or the diagnoses coded. Patient-level data include age and sex and, in 200 of 460 practices (approximately 40%), a Townsend deprivation index score based on the postcode of the patient. Practice-level data include a deprivation index score based on the postcode of the practice and the NHS region in which the practice is based.

Study population

The study period was from 30 June 2003 to 30 June 2008 and the source population was all permanently registered male patients in practices meeting GPRD quality standards. The study population consisted of all men with a first coded diagnosis of epididymo-orchitis within the study period, who were aged 15-60 years at the time of diagnosis. Code lists used for the definition of cases are listed in Appendix 1. Men with a coded diagnosis relating to vasectomy, sterilisation, or instrumentation of the urinary tract 60 days before to 28 days after the date of the epididymo-orchitis code were excluded, as they might have an obvious precipitating cause and hence their management might reasonably not folow guidelines. Men over 60 years were excluded because previous work has found a large proportion of catheter-associated infections in this age group.19 Similarly, the vast majority of boys under 15 years will not be sexually active and hence will have low C. trachomatis positivity. Appropriate management for these cases could reasonably not follow recommended guidelines and so they were not included in the study.

If multiple diagnostic codes for epididymo-orchitis were recorded for an individual, the date of the first diagnostic code was used as the index date. Analyses were restricted to records in the period 28 days before and after the index date. Cases where the index date was within 28 days of the start or end of the registration at the practice were excluded from descriptions of management.

Description of management

Testing. A specific chlamydia test was considered to have been carried out if the record contained either a code for a test (for example, ‘chlamydia antigen test’) or a diagnosis of genital C. trachomatis infection (for example, ‘chlamydial epididymitis’ or ‘chlamydial infection of the lower genitourinary tract’). Codes were identified for tests for N. gonorrhoeae. Non-specific microbial tests were considered to have been carried out if there was a code for either appropriate swab (for example, ‘urethral swab’) or a test such as microscopy, culture and sensitivities with no location given. Codes for bacterial urine testing, including dipstick tests and MSU, were also identified.

Treatment. Variables based on prescription records were created for antibiotic treatments:

  • antibiotics recommended for epididymo-orchitis: ofloxacin, doxycycline, ceftriaxone, ciprofloxacin;8,10 code lists were drawn up using drug substance name, and included all formulations except for inappropriate topical preparations;

  • antibiotics suitable for treatment of urinary tract infections (UTIs); code lists included all cephalosporins (British National Formulary (BNF) chapter heading 050102) and amoxicillin, trimethoprim, and nitrofurantoin; and

  • all antibiotics: based on BNF heading 0501.

Dosage and duration of use were not assessed.

Location of care. It was considered that a patient had received care for epididymo-orchitis in another healthcare setting if either of the following conditions were met:

  • a diagnostic code for the condition or a suggestive symptom code (for example, ‘testicular swelling’) within the referral record; or

  • a code anywhere in the records indicating care elsewhere (for example, ‘referral to emergency department’, ‘seen in GUM clinic’). This category also included less specific terms such as ‘discharge summary’ or ‘letter from specialist’.

If there was no evidence of care elsewhere and there was some evidence of any treatment or testing within the practice, the case was considered to have been managed within the practice only. Men with no evidence of either any management in practice or care elsewhere (that is, where the record had just a diagnostic code) were considered a separate group, due to concerns about completeness of recording, particularly related to care elsewhere. Analyses of management were restricted to males who were managed within the practice only. It did not seem appropriate to assess quality of care if important parts of the care may have been delivered outside the practice and hence not necessarily recorded there.

Statistical analysis

Data were prepared using Stata (version 10; Statacorp LP, Texas). Calendar years were defined as mid-years from 30 June, so that year 2003 covered 30 June 2003 to 29 June 2004, and so on. Incidence rates were calculated in specific age groups and event years by dividing the number of cases by the appropriate denominator. Age-standardised rates for all ages combined were then obtained by applying these rates to the European standard population. Differences in incidence rates over time and age groups were assessed using Poisson regression. Analyses of management calculated the proportion of patients with various management markers across years and age groups. Logistic regression models investigated factors associated with optimal management.

A series of sensitivity analyses were performed, extending the window for analysis of management from 28 to 42, 60, and 90 days either side of the index date, to assess whether relevant data were being missed by using the 28-day window. Men with diagnostic codes for orchitis only, with no mention of epididymal involvement, were also excluded as appropriate management of viral orchitis would differ.

RESULTS

Target population and incidence

Figure 2 summarises the identification and exclusion of cases. A total of 12 615 males with first diagnosis of epididymo-orchitis were included in incidence analyses; median age was 37 years (interquartile range 28–46 years). Age-standardised incidence of epididymo-orchitis was highest in 2004 (28/10 000 male person-years) and then declined progressively to 21/10 000 male person-years in 2007 (P<0.001) (Figure 3). This decline was greatest in younger age groups (P-value for interaction term for age less than 35 years with event year = 0.09). Incidence in males over 45 years was stable during the study period at approximately 20/10 000 person-years.

Figure 2.

Figure 2

Flow chart of study: patient identification and exclusions.

Figure 3.

Figure 3

Incidence of first episode of epididymo-orchitis in primary care: 2003–2007.

Management of cases

Analyses of management included 12 270 males, of which 4955 were aged under 35 years (Table 1); 57% of men (6943) were managed entirely within the practice, and 26% (3141) had evidence of receiving care elsewhere; 18% of cases (2186) had no evidence either of management within practice or care elsewhere. Of the 6943 cases managed by primary care (Table 2), 92% received an antibiotic prescription; 56% received an antibiotic recommended for epididymo-orchitis, 18% received doxycycline, and 29% received an antibiotic indicated for a UTI but not for epididymo-orchitis. Recorded investigations were uncommon, with fewer than 3% of men having a C. trachomatis test recorded and only 12% having had any microbial investigation for urethritis. Testing for N. gonorrhoeae was extremely unusual. Urinalysis, including MSU, was the most common form of testing (22%) but the majority of men had no test or result coded.

Table 1.

Location of management of epididymo-orchitis cases seen in primary care.

Aged <35 years, n (%) Aged ≥35 years, n (%)


n Evidence of care elsewhere Managed only in practice No evidence of management n Evidence of care elsewhere Managed only in practice No evidence of management
2003 973 203 (20.9) 551 (56.6) 219(22.5) 1484 291 (19.6) 889 (59.9) 304 (20.5)

2004 1232 321 (26.1) 642 (52.1) 269 (21.8) 1609 356 (22.1) 954 (59.3) 299(18.6)

2005 1060 276 (26.0) 584 (55.1) 200(18.9) 1533 431 (28.1) 852 (55.6) 250(16.3)

2006 871 230 (26.4) 495 (56.8) 146(16.8) 1416 388 (27.4) 800 (56.5) 228(16.1)

2007 819 244 (29.8) 454 (55.4) 121 (14.8) 1273 401 (31.5) 722 (56.7) 150(11.8)

P-value for trend <0.001 0.60 <0.001 <0.001 0.02 < 0.001

Total 4955 1274 (25.7) 2726 (55.0) 955(19.3) 7315 1867 (25.5) 4217 (57.7) 1231 (16.8)

Table 2.

Treatment and investigation of cases managed within practice only.

n(%

All, n = 6943 Aged <35 years, n = 2726 Aged ≥35 years, n = 4217 P-value for difference between age groups
Treatment

Antibiotic recommended for Chlamydia trachomatis
 Doxycycline 1270 (18.3) 541 (19.9) 729 (17.3) 0.007
 Ciprofloxacin 2511 (36.2) 941 (34.5) 1570 (37.2) 0.022
 Ofloxacin 224 (3.2) 88 (3.2) 136 (3.2) 0.990
 Ceftriaxone 0 0 0
 Any one of the abovea 3859 (55.6) 1514 (55.5) 2345 (55.6) 0.980

Other UTI antibioticb 2045 (29.4) 796 (28.9) 1249 (29.6) 0.720

Any other antibioticb 508 (7.3) 212 (7.8) 296 (7.0) 0.230

Any antibiotica 6412 (92.4) 2522 (92.5) 3890 (92.3) 0.640

Investigation

 Chlamydia test 180 (2.6) 120 (4.4) 60 (1.4) <0.001
Neisseria gonorrhoeae test 4 (0.06) 3 (0.1) 1 (0.02) 0.146
 Any microbial test 649 (9.4) 284 (10.4) 365 (8.7) 0.014
 Urine testc 1507 (21.7) 547 (20.1) 960 (22.7) 0.008
a

Total of rows above.

b

Excludes all antibiotics in preceding rows of tables.

c

Bacterial urine testing, including dipstick tests and midstream urinalysis. UTI = urinary tract infection.

There was some evidence that men under 35 years were managed differently from older men, although the differences were small. Younger men were more likely to have no evidence of any management (19.2% versus 16.8%, P<0.001) and, correspondingly, were less likely to be managed only within the GP practice (55.2% versus 57.7%, P = 0.003). Of those managed by GPs, younger men were more likely to be prescribed doxycycline and have a C. trachomatis or microbial test than older men, and less likely to be treated or investigated for a UTI.

The proportion of patients managed within general practice was stable across the study period but there was a fall in the proportion of cases with no evidence of management in both age bands, and this was matched by an increase in the proportion with evidence of care elsewhere (Table 1). When trends in treatment and investigation over the study period were examined (not shown in tables), the use of ciprofloxacin increased over time, rising from 31% to 44% in both age bands (P<0.001), but there was no evidence of an increase in doxycycline prescriptions or C. trachomatis testing in either age group during the study period.

Factors associated with optimal management

Table 3 summarises patient and practice factors associated with receiving a prescription for doxycycline, the preferred treatment for chlamydia. This multivariate analysis indicates that patients over 35 years were 20% less likely to receive doxycycline, and confirms no increase in the use of doxycycline over the study period. Practices in the most and least deprived areas were less likely to prescribe doxycycline. Patterns were similar when analyses were restricted to younger men. In the subsample (54%) for whom an individual deprivation index was available, patients from the least deprived quintile were least likely to receive doxycycline. The odds ratio (adjusted for age group and event year) for the least deprived quintile compared to all others was 0.9 (95% CI = 0.7 to 1.2) for all men (n = 3498) and 1.0 (95% CI = 0.7 to 0.8) for men aged under 35 years (n = 1350).

Table 3.

Factors associated with receiving doxycycline prescription for epididymo-orchitis

Adjusted odds ratio for receiving doxycycline (95% CIs) for those managed within practice only

All ages (n = 6928) ≤35 years (n = 2476)
Age group, years
 15–24 1.0 (0.8 to 1.2)
 24–35 1
 35–44 0.8(0.7 to 1.0)
 45–60 0.8(0.7 to 1.0)

Event year
 2003 1 1
 2004 1.1 (0.9 to 1.3) 1.1 (0.8 to 1.4)
 2005 1.1 (0.9 to 1.3) 1.1 (0.8 to 1.4)
 2006 1.1 (0.9 to 1.3) 1.1 (0.8 to 1.5)
 2007 1.2 (1.0 to 1.4) 1.1 (0.8 to 1.5)

Practice quintile of deprivation
 1 (least deprived) 1 1
 2 1.5 (1.3 to 1.9) 1.2 (0.9 to 1.7)
 3 1.4(1.1 to 1.7) 1.3 (0.9 to 1.7)
 4 1.3(1.1 to 1.6) 1.4 (1.0 to 1.8)
 5 (most deprived) 1.0 (0.8 to 1.2) 1.0(0.7 to 1.3)

Excluding 1575 men with diagnostic codes for orchitis did not alter the results. Sensitivity analyses showed that the proportion of cases with evidence of care elsewhere increased as the time window for management was widened for patients managed within practice, but the pattern of care was similar (Appendix 2).

DISCUSSION

Summary of main findings

A substantial caseload of epididymo-orchitis is seen in primary care and the condition is not restricted to younger men. Incidence fell between 2003 and 2008, with the greatest decline in younger age groups and a relatively stable incidence in older men. Fifty-seven per cent of all cases were managed entirely within primary care and of these, 56% received recommended antibiotics but very few had appropriate testing.

Strengths and limitations of the study

This research examined an unselected population of men with epididymo-orchitis seen in primary care. To the authors' knowledge this is the first study that has considered management by GPs rather than GUM clinics or in secondary care. By using real-time patient records, the study avoided the response bias that affects self-report questionnaire data completed by doctors. As electronic patient record databases are designed primarily for patient care, caution is required. Only coded data were used (based on Read Codes) and information entered as free text in the record was not accessed. This means that there may be some errors both in the classification of men as cases and in the assessment of their management. As epididymo-orchitis is not included in any Quality and Outcomes Framework targets, there is little incentive for GPs to code all elements of the consultation beyond diagnosis and prescribing accurately. Relevant management information, such as advice to attend a GUM clinic, may be present in text only.

Definition as a case requires the GP both to make a diagnosis and record it as a code. The study may have excluded cases diagnosed by the GP but coded using non-specific symptoms rather than a diagnostic code. Equally, some cases with a diagnostic code may not truly reflect a confirmed diagnosis, although sensitivity analyses suggest that the inclusion of cases of possible viral orchitis has not affected results.

The classification of the location of management was complex. The referral (rather than clinical) record was used in the study as evidence of care elsewhere, but this record file may not be used consistently by GPs. Some Read Codes taken as evidence of care elsewhere were non-specific and may not have been actually related to the epididymo-orchitis diagnosis. As expected, as the management window was widened, the proportion with evidence of care elsewhere increased but more unrelated referrals may have been included. The proportion with evidence of care elsewhere increased during the study period, which may be due to better recording of referrals. It was assumed that a prescription was for epididymo-orchitis based on the interval between date of prescription and date of diagnostic code, with similar potential for an overestimate of antibiotic use. However, sensitivity analyses did not indicate that the estimates of treatment were dependent on the length of the management window.

Comparison with existing literature

Incidence estimates for epididymo-orchitis for 1994–2001, based on the Royal College of General Practitioners Weekly Returns Service,1 are higher than those in the present study (38/10 000 person-years in 2001). The difference is probably because this study counted first episode only, whereas the previous estimate counted repeat episodes and relied on the GP classification of new/follow-up consultation.

The decline in incidence may be due to a true fall in incidence of the condition, or may reflect more cases being seen outside general practice, or changes in coding practice. There are consistent data, including from the GPRD, that pelvic inflammatory disease, an associated infection in women, is declining.2022 It is unclear how this is related to increasing rates of testing for chlamydia in England.23 Literature reviews of the impact of C. trachomatis screening on health outcomes have found little evidence that pelvic inflammatory disease in women is reduced, and the effect on male health outcomes such as epididymo-orchitis has not been studied.24,25 It is possible that the National Chlamydia Screening Programme in England has contributed to the decline in incidence observed, though it is estimated that coverage rates of 30% are required to reduce C. trachomatis prevalence by 29%.26 The greater decline in younger age groups is consistent with a role for the screening programme.

Given the assumed contribution of STIs to epididymo-orchitis, it was surprising to find that incidence was relatively consistent across all age groups of men up to the age of 45 years. This was also reported in a survey of cases in US hospitals, where patients over 35 years accounted for more than 50% of cases, although this study relied only on the number of cases.27 The present data confirm that the disease is not restricted to younger men. It was also surprising to find that there was some evidence that men from more affluent areas were less likely to receive doxycycline. This should be explored in other studies.

Ciprofloxacin was the most commonly prescribed antibiotic, which is consistent with reports from secondary care where quinolones were the treatment of choice for epididymo-orchitis,16,17 whereas doxycycline treatment was the norm in GUM clinics.9 The extremely low rates of C. trachomatis testing reported in the present study are consistent with reports of 3% in a US hospital.17 Cassell et al, using data from a British national probability survey, reported that few men received a C. trachomatis diagnosis in general practice,28 and that rates of non-specific urethritis (often a clinical diagnosis) were disproportionately high in comparison with chlamydia in primary care.19 The rates of investigation for urethritis found in the present study are even lower than the 18% reported by UK urologists.16

Implications clinical practice and future research

The management of epididymo-orchitis in primary care fails to recognise the need to test for a STI, even in younger men. Syndromic treatment is often given with no apparent investigation. This is consistent with what has been seen in urology but is of greater concern due to the large numbers of patients seen in general practice and the potential public health impact. Potential reasons for this syndromic treatment include reluctance of the doctor or patient to undertake invasive and potentially embarrassing tests. There is a need for further research to understand the pattern of care delivered in general practice. Surprisingly high rates of epididymo-orchitis were found in men over 35 years in this study. Work is needed to understand the aetiology, particularly in older men, so that guidelines are evidence based. The accuracy of coded information in primary care databases needs to be confirmed, and the authors plan to consult anonymised free text in a selection of patients to investigate whether textual data alter the estimates of management.

Acknowledgments

This study is based in part on data from the Full Feature General Practice Research Database obtained under license from the UK Medicines and Healthcare products Regulatory Agency. However, the interpretation and contained in this study are those of the authors alone.

Appendix 1. Code lists: A. Diagnostic codes for epididymo-orchitis

GPRD Medical Code Read/OXMISTerm Read/OXM IS Code
205990 A981311 Acute gonococcal orchitis

207436 K242300 Epididymo-orchitis in diseases EC

216427 K241200 Epididymitis unspecified

216428 K242000 Epididymo-orchitis with abscess

220371 604 AT ABSCESS TESTIS/TESTICLE

237903 0980F ORCHITIS GONOCOCCAL*

238377 6075TT INFECTION TESTIS

243662 K241100 Epididymitis with no abscess

243664 K241z00 Epididymitis NOS

252783 K241.00 Epididymitis

252784 K241000 Epididymitis with abscess

252785 K241300 Epididymitis in diseases EC

252786 K24z.00 Orchitis and epididymitis NOS

256799 604 BA ORCHITIS ACUTE*

266026 604 AE ABSCESS EPIDIDYMIS

266027 604 C ORCHITIS NOT MUMPS

271289 K242200 Epididymo-orchitis unspecified

280340 K241600 Chlamydial epididymitis

280341 K242.00 Epididymo-orchitis

280342 K242100 Epididymo-orchitis with no abscess

289462 K241400 Acute epididymitis

298729 K242z00 Epididymo-orchitis NOS

304349 604 A EPIDIDYMITIS

304350 604 B ORCHITIS

304351 604 D EPIDIDYMO-ORCHITIS

207435 K240z00 Orchitis NOS

234647 K240200 Orchitis unspecified

252780 K24..00 Orchitis and epididymitis

252781 K240000 Orchitis with abscess

252782 K240300 Orchitis in diseases EC

280339 K240100 Orchitis with no abscess

298728 K240.00 Orchitis

265494 0980E GONOCOCCAL EPIDIDYMITIS

265495 0980EF GONOCOCCAL EPIDIDYMO-ORCHITIS

278873 A981300 Acute gonococcal epididymo-orchitis

220376 6075AD ABSCESS VAS DEFERENS

Appendix 1.

Code lists: B. Code lists for chlamydia test.

GPRD Medical Code Read/OXMIS Term Read/OXMIS Code
205965 Chlamydial infection, unspecified A78AW00

205969 Other viral or chlamydial disease NOS A7z..00

206063 [X]Other chlamydial diseases Ayu6100

207468 Female chlamydial pelvic inflammatory disease K40y100

214967 Chlamydial inf of pelviperitoneum oth genitourinary organs A78A300

215059 [X]Chlamydial infection, unspecified Ayu6200

225563 Chlamydia cervicitis K420900

242170 Chlamydial infection of genitourinary tract, unspecified A78AX00

242258 [X]Chlamydial infection of genitourinary tract, unspecified Ayu4K00

251351 Chlamydial infection of lower genitourinary tract A78A000

258276 Chlamydia antigen by ELISA 43U0.00

267536 Chlamydia antigen test 43U..00

278838 Other viral and chlamydial diseases A7...00

278847 Other viral or chlamydial diseases A78..00

278852 Chlamydial infection A78A.00

280340 Chlamydial epididymitis K241600

285745 Chlamydia antigen ELISA positive 43U1.00

285746 Chlamydia antigen ELISA negative 43U2.00

287974 Other specified viral and chlamydial diseases A78y.00

289351 Chlamydial peritonitis J550400

297184 Chlamydial infection of anus and rectum A78A200

297190 Other specified viral or chlamydial diseases A7y..00

297288 [X]Other diseases caused by chlamydiae Ayu6.00

302966 INFECTION CHLAMYDIAL 0399C

302967 CHLAMYDIA TRACHOMATIS 0399CT

307938 Chlamydia trachomatis IgG level 43eJ.00

308079 Chlamydia trachomatis L2 antibody level 43eC.00

308199 Chlamydia group complement fixation test 43eF.00

308461 Chlamydia antibody level 43eE.00

308950 Chlamydia trachomatis polymerase chain reaction 43h0.00

309472 Chlamydia group antibody level 43WM.00

309613 Chlamydia trachomatis IgM level 43ez.00

309766 Endocervical chlamydia swab 4JK9.00

309829 Urethral chlamydia swab 4JKA.00

332003 Chlamydia trachomatis IgA level 43n9.00

342066 Chlamydia trachomatis antigen test 43U3.00

342214 Chlamydia deoxyribonucleic acid detection 43jK.00

342310 Chlamydia serology 4JDM.00

343726 Urine screen for chlamydia 68K7.00

343949 Chlamydia PCR positive 43U4.00

343968 Chlamydia PCR negative 43U5.00

344624 Urine Chlamydia trachomatis test positive 46H6.00

344736 Urine Chlamydia trachomatis test negative 46H7.00

345942 Chlamydia screening declined 8I3T.00

346998 Chlamydia screening counselling 677L.00

347186 Chlamydia trachomatis contact 65PJ.00

347227 Low vaginal swab for chlamydia taken by patient 4JKD.00

347301 Chlamydial infection of genital organs NEC A78A500

347315 Chlamydia test offered 9Oq0.00

347970 Chlamydia test positive 43U8.00

348085 Chlamydia test negative 43U6.00

348329 Chlamydia test equivocal 43U7.00

Appendix 1.

Code lists: C. Tests for Neisseria gonorrhoea.

GPRD Medical Code Read/OXMIS Term Read/OXMIS Code
249090 Gonorrhoea infect. titre test 43E6.00

309228 Neisseria gonorrhoeae polymerase chain reaction 43h6.00

309635 Neisseria gonorrhoeae nucleic acid detection 43jA.00

340376 Gonococcal swab 4JLA.00

342356 Gonococcal cervical swab 4JKB.00

343558 Gonococcal urethral swab 4JKC.00

348093 Gonorrhoea test positive 4JQA.00

348168 Gonorrhoea test negative 4JQ8.00

348381 Gonorrhoea screening counselling 677M.00

Appendix 1.

Code lists: D. Other microbial tests.

GPRD Medical Code Read/OXMIS Term Read/ OXMIS Code
203712 Infectious titres NOS 43E..00

203917 Sample microscopy 4I15.00

203918 White cells seen on microscopy 4I15100

203919 RBCs seen on microscopy 4I15200

203947 High vaginal swab culture negative 4JK2100

203948 HVS culture – Trichomonas vaginalis 4JK2200

205666 Refer for microbiological test 8HP2.00

210464 PENILE SWAB CULTURE NEGATIVE L167DN

210515 HVS TRICHOMONAS VAGINALIS L1670FT

212942 Sample culture 4J17.00

212962 Semen sent for C/S 4JL8.00

219515 SWAB CERVICAL ABNORMAL L167FC

219570 HVS LACTOBACILLI L1670FL

221698 Direct microscopy 31B1.00

222017 Sample: no organism isolated 4J11.00

222018 Sample: organism isolated 4J12.00

222020 Sample: bacteriology – general 4J2..00

222022 Sensitivity-bacteriology 4J2..13

222038 Microbiology NOS 4JZ..00

228578 MICROBIOLOGY REPORT ABNORMAL L2MA

228611 HVS CULTURE NEGATIVE L167FN

228613 SWAB CULTURE BACTERIAL GROWTH L167XE

230862 Blood sent – infectious titres 43E1.00

231003 Parasite in urine 46H..15

231090 Microbiology 4J...00

231091 Sample – microbiological exam 4J1..00

231094 Sample: dir.micr.:no organism 4J71.00

231095 Bacteria on microscopy 4J72.11

231108 Urethral swab culture positive 4JK1000

231109 High vaginal swab: white cells seen 4JK2500

231110 Vaginal swab culture negative 4JK6.00

237538 MICROBIOLOGY REPORT L2MR

237571 VAGINAL SWAB CULTURE POSITIVE L167FZ

237574 SWAB CULTURE FUNGAL GROWTH L167XC

237587 VIRAL TITRES L189D

237617 HVS GARDNERELLA VAGINALIS L1670FG

237618 HVS YEAST L1670FY

240066 Sample: direct micr. organism 4J7..00

240075 High vaginal swab culture positive 4JK2000

240076 HVS culture – Gardnerella vaginalis 4JK2300

240077 Low vaginal swab taken 4JK3.00

240078 Misc. sample for organism 4JL..00

246733 SWAB CERVICAL L167FA

246735 URETHRAL SWAB CULTURE NEGATIVE L167IN

249028 Swab sent to Lab 4147.00

249310 Culture – general 4J...11

249324 Cervical swab culture positive 4JK5000

258486 Sample: microbiology NOS 4J1Z.00

258503 Urethral swab culture negative 4JK1100

258504 Vaginal swab culture positive 4JK7.00

258505 Penile swab culture positive 4JK8000

258506 Penile swab culture negative 4JK8100

265145 PENILE SWAB L167D

265146 PENILE SWAB CULTURE POSITIVE L167DP

265197 HVS WBC L1670FW

267662 Urine microscopy: orgs/FBs 46H..00

267735 Sensitivity-microbiol. 4J...12

267736 Sample: organism sensitivity 4J15.00

267739 O/E: stained micr.: organism 4J8..00

267754 Vaginal swab taken 4JK..11

267755 Vulval swab taken 4JK4.00

267756 Penile swab taken 4JK8.00

267757 GUT swab NOS 4JKZ.00

274368 HVS EPITHELIAL CELLS L1670FE

276782 Culture – bacteriology 4J2..12

276783 Sample sent for culture/sensit 4J22.00

276800 GUT sample taken for organism 4JK..00

276801 High vaginal swab taken 4JK2.00

276802 Cervical swab taken 4JK5.00

283373 HVS L167F

283374 HVS CULTURE POSITIVE L167FP

283375 VAGINAL SWAB CULTURE NEGATIVE L167FY

285938 Microscopy, culture and sensitivities 4I16.00

285943 Sample: bacteria cultured 4J23.00

285955 Urethral swab taken 4JK1.00

285958 Microbiology test 4JQ..00

292462 MICROBIOLOGY REPORT NORMAL L2MN

292509 SWAB CERVICAL NORMAL L167FB

292511 URETHRAL SWAB CULTURE POSITIVE L167IP

292515 SWAB CULTURE NO GROWTH L167XB

295145 High vaginal swab: fungal organism isolated 4JK2400

295146 Cervical swab culture negative 4JK5100

297019 Microbiology report received 9ND3.00

301878 VAGINAL SWAB L167FX

301879 URETHRAL SWAB L167I

301882 SWAB CULTURE YEAST GROWTH L167XD

308931 Bacterial antibody level 43e..00

309727 Microscopy 4JS..00

331709 Gram stain microscopy 4JS0.00

332043 Anaerobic culture 4J18.00

339918 Concentrate microscopy 4JS2.00

340342 Genital microscopy, culture and sensitivities 4I1C.00

340745 Fluid microscopy, culture and sensitivities 4I1D.00

343815 Semen microscopy 49L..00

343816 Aerobic culture 4J19.00

344353 Additional urine tests 46h..00

345784 Culture for fungi 4J45.00

350883 Low vaginal swab taken by patient 4JKE.00

350959 Self taken low vaginal swab 4JKE.11

203821 Urine exam. – general 461..00

203822 Urine dipstick test 4618.00

203825 Urine protein test = + 4674.00

203826 Urine protein test = ++ 4675.00

203827 Urine ketone test = ++++ 4687

203831 Urine sent for microscopy 46D1.00

203832 Urine microscopy: no casts 46E1.00

203840 Urine culture – no growth 46U1.00

203841 Urine culture – E. coli 46U3.00

203842 Urine culture – Str. faecalis 46U5.00

203843 Urine culture – Staph. albus 46U6.00

203844 Urine culture – Bacteria OS 46U8.00

210442 URINE INVESTIGATIONS L131AA

210443 URINE CASTS PRESENT L 132CP

210520 ABNORMAL URINE TEST NOT YET DIAGNOSED L2590AN

210544 URINE NEGATIVE L7891N

211701 STERILE PYURIA 7891D

212820 Urine examination 46...00

212821 MSU sent to lab. 4615.00

212822 Urine inspection 462..00

212823 Urine: cloudy 4627

212827 Urine protein test = ++++ 4677

212830 Urine: trace non-haemol. blood 4693.00

212840 Urine Microscopy: white cells 46G8.00

212959 Urine for culture 4JJ..13

212960 Early morning urine 4JJ..14

212961 Urine sample for organism NOS 4JJZ.00

219490 MSU NORMAL L133MN

219573 URINE ALBUMIN+++ L2400CC

219576 CASTS IN URINE POSITIVE L2591PV

221916 MSU = no abnormality 4616.00

221921 Urine blood test 469..00

221922 Urine bacteria test NOS 46BZ.00

221923 Urine microscopy: no crystals 46F1.00

221924 Sterile pyuria 46G4.12

221925 Urine micr.: bacteria present 46H4.00

221955 Urine culture – Escherich. coli 46U3.11

222034 MSU sent for bacteriology 4JJ2.00

228591 URINE CULTURE POSITIVE GROWTH L133P

228673 URINE ALBUMIN+ L2400AA

230985 Urinalysis requested 4612.00

230986 Urine = normal on inspection 4621.00

230987 Urine inspection NOS 462Z.00

230993 Urine protein test 467..00

230994 Urine protein test negative 4672.00

230995 Urine dipstick for protein 4679.00

230996 Urine: trace haemolysed blood 4694.00

230997 Urine microscopy: no cells 46G1.00

230998 RBCs – red blood cells in urine 46G2.11

230999 Urine micr.: leucocytes present 46G4.00

231000 Leucocytes in urine 46G4.11

231001 Urine micr.: leucs – % polys 46G5.00

231002 Pus cells in urine 46G7.11

231003 Parasite in urine 46H..15

231031 Urine culture – mixed growth 46U2.00

237549 URINE CULTURE L133

237622 URINE ALBUMIN++ L2400BB

237649 URINE TEST L7890T

239977 Urine protein test = trace 4673.00

239980 Urine microscopy – general NOS 46DZ.00

239981 Urine microscopy – casts 46E..00

239982 Urine microscopy: epith. casts 46E2.00

239986 FB in urine – microscopy 46H..12

239987 Urine microscopy: no orgs/FBs 46H1.00

240073 Mid-stream urine sample 4JJ..12

240074 Urine sent for culture 4JJ3.00

246820 MSU L7891MS

249215 Urine exam. – general NOS 461Z.00

249223 Urine dipstick for blood 4698.00

249224 Urine bacteriuria test 46B..00

249225 Urine bacteria test: positive 46B3.00

249226 Urine microscopy – general 46D..00

249227 Urine micr.: leucs – % lymphs 46G6.00

249228 Urine microscopy: red cells 46G9.00

249229 Bacteria in urine O/E 46H..11

249242 Urine test NOS 46Z..00

249322 Urine sample for organism 4JJ..00

255953 URINE WBC'S ABSENT L132WA

255954 URINE WBC'S PRESENT L132WP

258374 MSU = equivocal 461A.00

258375 Urine: red – blood 4625.00

258376 Urine: looks clear 4626

258381 Proteinuria 4678.00

258384 Urine blood test = ++ 4696.00

258385 Urine blood test = +++ 4697.00

258386 Urine bacteria test: negative 46B2.00

258387 Urine microscopy: casts NOS 46EZ.00

258390 Urine microscopy: cells 46G..00

258391 Urine microscopy: RBCs present 46G2.00

258392 Urine microscopy: pus cells 46G7.00

258398 Urine protein 46N..00

258399 Urine protein abnormal 46N2.00

258414 Urine culture 46U..00

258502 MSU sent for C/S 4JJ1.00

265127 URINE CULTURE NO GROWTH L133N

265202 PROTEINURIA L2020PV

267459 Urine sample sent to Lab 4146.00

267646 Urine tests 46...11

267647 MSU – general 461..11

267648 MSU = no growth 4619.00

267653 Blood in urine test 469..11

267655 Urine blood test = + 4695.00

267656 Urine blood test NOS 469Z.00

267658 Urine microscopy = abnormality 46D3.00

267659 Urine microscopy: crystals 46F..00

267660 Urine micr.: uric acid crystals 46F3.00

267661 Urine microscopy: no white cells 46G1100

267662 Urine microscopy: orgs/FBs 46H..00

274306 URINE EPITHELIAL CELLS PRESENT L132EP

274307 MSU ABNORMAL L 133MA

276691 Urinalysis – general 461..12

276695 Urine blood test = negative 4692.00

276697 Urine microscopy:hyaline casts 46E3.00

276799 Catheter urine -> culture. 4JJ4.00

285852 Urinalysis = no abnormality 4613.00

285853 Urinalysis = abnormal 4614.00

285854 MSU = abnormal 4617.00

285855 Urine: pale 4624

285858 Urine protein test = +++ 4676.00

285859 Urine protein test NOS 467Z.00

285866 Urine micr.: orgs/FBs NOS 46HZ.00

292486 URINE INVESTIGATIONS ABNORMAL L 131 AC

295030 Urine microscopy: no epithelial cells 46G1000

295031 Urine micr.: epithelial cells 46G3.00

301855 URINE INVESTIGATIONS NORMAL L131AB

302605 Urine microalbumin positive 46w0.00

333181 Urine leucocyte test 46f..00

333245 Urine leucocyte test = + 46f2.00

333246 Urine leucocyte test = ++ 46f3.00

333247 Urine leucocyte test = +++ 46f4.00

335402 Urine microscopy 46Z1.00

339791 Urine leucocyte test = negative 46f1.00

340095 Urine microscopy: yeasts 46H5.00

Appendix 2. Results of sensitivity analyses

28-day management window (1575 orchitis-only cases excluded) <35 years, % ≥35 years, %
Management
 Managed in practice 56.0 58.2
 No evidence of management 19.0 16.9
 Evidence of care elsewhere 25.0 24.9

Drug prescribed
 Any recommended drug 56.6 55.7
 Ciprofloxacin 34.9 36.7
 Doxycycline 20.7 18.1

Test carried out
Chlamydia trachomatis test 4.6 1.3
 Microbial test 11.8 11.1
 Urine test 20.1 22.1

42-day management window

Management
 Managed in practice 52.5 55.3
 No evidence of management 17.8 15.2
 Evidence of care elsewhere 29.7 29.6

Drug prescribed
 Any recommended drug 55.4 55.4
 Ciprofloxacin 34.4 37.0
 Doxycycline 20.5 17.5

Test carried out
Chlamydia trachomatis test 4.5 1.5
 Microbial test 13.0 13.0
 Urine test 20.8 23.8

60-day management window

Management
 Managed in practice 50.3 52.4
 No evidence of management 16.7 13.9
 Evidence of care elsewhere 33.1 33.7

Drug prescribed
 Any recommended drug 54.6 55.1
 Ciprofloxacin 34.1 37.0
 Doxycycline 20.0 17.5

Test carried out
Chlamydia trachomatis test 4.5 1.6
 Microbial test 13.5 13.7
 Urine test 22.6 25.0

90-day management window

Management
Managed in practice 46.8 48.7
No evidence of management 15.0 12.3
Evidence of care elsewhere 38.2 38.9

Drug prescribed
Any recommended drug 54.3 43.6
Ciprofloxacin 34.0 36.9
Doxycycline 20.4 17.2

Test carried out
Chlamydia trachomatis test 4.6 1.6
Microbial test 14.2 14.7
Urine test 23.1 27.1

Funding body

Access to the GPRD database was funded through the Medical Research Council's license agreement with the Medicines and Healthcare products Regulatory Agency.

Ethical approval

The study was approved by the GPRD Independent Scientific Advisory Committee (protocol number 08_097).

Competing interests

The authors have stated that there are none.

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