Urethritis or inflammation of the urethra, is the most common syndrome in symptomatic male urethritis, accompanied by dysuria, pruritus, and urethral discharge. Most cases of infectious urethritis are caused by Neisseria gonorrhoeae (N. gonorrhoeae) and/or Chlamydia trachomatis (C. trachomatis) [1] . Sexually Transmitted Infections (STI) are the leading cause of infectious urethritis and pose a serious public health concern [2] . The number of sexual partners, prior sexual education, inconsistent condom usage, and prior STI are the most significant factors that have been found to affect the appearance of an STI [3] .

Among the pathogens responsible for urethritis, N. gonorrhoeae is a sexually transmitted pathogen of very deep concern and has been classified by the World Health Organization (WHO) as a priority pathogen due to the worldwide emergence of multidrug-resistant isolates and the rapid increase in antimicrobial resistance rates. To make matters worse, extensively drug-resistant (XDR) strains of N. gonorrhoeae, which is resistant to ceftriaxone and highly resistant to azithromycin have emerged in several countries in recent years. For example, several European countries have been affected by XDR isolates of N. gonorrhoeae since 2022, with 4 cases reported in Austria, France, and the United Kingdom, and 2 more cases in France in 2023 [4] - [6] . Caméléna F 2024, Michaela Day, Clara Maubaret Cambodia also reported 3 cases of XDR isolates of N. gonorrhoeae between 2021 and 2022 [7] . All these strains were genetically related.

In addition to gonococcal urethritis, there is urethritis caused by other pathogens and in almost half of these cases of non-gonococcal urethritis, no specific agent is identified, despite extensive microbiological testing [8] . According to the WHO, surveillance data on gonococcal and chlamydial infections are also very limited in low- and middle-income countries. Most of the information available on STIs in these countries comes either from research studies or population surveys [9] .

Medical laboratory diagnosis of genital infections remains extremely delicate, as it is often difficult or even impossible to find extremely fragile germs that can be cultured, hence the use of molecular techniques [10] . It is estimated that one million people a day contract an STI, of which around 498.91 million STIs are considered curable, namely those due to Treponema pallidum (syphilis), N. gonorrhoeae, C. trachomatis, and T. vaginalis, occur worldwide each year, with the highest rates recorded in sub-Saharan Africa and Latin America and the Caribbean, followed by the Western Pacific Region [9] (ONUSIDA 2012). Since the onset of HIV/AIDS infection, there has been renewed interest in STIs, because on the one hand, they are cofactors of the infection and, on the other, their proper management can reduce the acquisition of HIV/AIDS infection.

In many low- and middle-income countries, there is a problem with accurate diagnosis of STIs. This is due to the lack of appropriate techniques. Clinical laboratories do not perform high-performance tests, the traditional culture method lacks sensitivity (lack of appropriate culture media), and molecular assays are absent from routine testing. This situation leads to inadequate management of STI patients and possible expansion of STI outbreaks as well as outbreaks of XDR strains.

Our study aimed to estimate the prevalence and frequency of the most common STI pathogens involved in male urethritis by an effective diagnostic method, real-time polymerase chain reaction (real-time PCR) or qPCR, and to evaluate the diagnostic performance of the culture method.

Our study aimed to estimate the prevalence and frequencies of common NTD pathogens involved in urethritis in male patients in Burkina Faso using a commercial qPCR assay and to compare the performance of traditional diagnostic methods with qPCR.

Of 83 urethritis patients, n = 55 (66.26%) were positive for at least one of the STI pathogens detected by qPCR. qPCR assay was more sensitive (50/83, positive cases) compared to culture (15/83, positive cases).

The most exposed age group in our study population was the group aged 16 - 30 years (44.58%), representing the youngest patients. Sexual activity must be highest in this age group, which did not frequently use methods of protection against sexual contact.

The most common NTD pathogen detected was N. gonorrhoeae with a high prevalence of 60.24% (50/83) and frequency (within only positive cases of an NTD pathogen) 49/55 (89.01%). In addition to N. gonorrhoeae 4 and 2 positive cases were detected respectively for T. vaginalis and C. trachomatis. One case of co-infection with N. gonorrhoeae and C. trachomatis was found in this study. N. gonorrhoeae with its multidrug resistance and extensive drug resistance emergence is a worldwide concern pathogen and many countries have run N. gonorrhoeae surveillance programmes [4] . For example, Burkina Faso has included N. gonorrhoeae resistance in its antimicrobial resistance (AMR) surveillance of bacterial pathogens of concern [11] [12] . Contrary to the results of our study showing a high prevalence of N. gonorrhoeae in cases of urethritis, the 2022 and 2023 reports of AMR surveillance in Burkina Faso involving 22 sentinel laboratories reported no cases of N. gonorrhoeae isolation in Burkina Faso [11] [12] . This is an alarming situation that calls into question the technical capacity of Burkina Faso’s clinical laboratories, the performance of the public health surveillance programme, and the relevance of the algorithm for the management of N. gonorrhoeae infections in Burkina Faso.

Our results provide evidence that clinical laboratories in Burkina Faso are not able to isolate N. gonorrhoeae from clinical specimens, and certainly not able to isolate C. trachomatis and T. vaginalis found in our study. An additional concern is the multidrug and extensively drug-resistant strains of N. gonorrhoeae, which are on the rise worldwide and for which phenotypic drug susceptibility testing cannot be performed in the absence of the isolate.

The reasons for the total failure of clinical laboratories in Burkina Faso to isolate N. gonorrhoeae and other STI bacterial pathogens include the use of inappropriate culture media, technical problems in culture with insufficient saturation with 5% CO₂ in the incubator, the time taken from collection to isolation on the appropriate medium and the quality of the enriched medium used. Overall, the low diagnostic performance of STI pathogens based on traditional routine methods in Burkina Faso by clinical laboratories may lead to a very important misdiagnosis of STI. The negative impact on personalized treatment and care for patients, and public health with the possible rapid emergence of multidrug-resistant strains, is considerable.

This study also highlights the urgent need to optimize culture for the diagnosis of STI pathogens in Burkina Faso. As the diagnostic performance of culture is also low compared to qPCR, this study highlights the usefulness and the need for the introduction of molecular diagnostic methods in routine diagnosis for the detection of STI pathogens in the medical laboratories in Burkina Faso. Our study showed that the diagnostic performance of culture even using appropriate culture media was still low, 30% for the detection of N. gonorrhoeae. In our study, we did not use appropriate culture media to isolate C. trachomatis and T. vaginalis, which explains the lack of detection of these pathogens by the culture method.

However, based on qPCR, T. vaginalis was the second STI pathogen isolated in this study and C. trachomatis was the third, each with low prevalence. Dwari et al. (2018) in India found N. gonorrhoeae (61.42%) and C. trachomatis (45.9%) [13] . Rietmeijer et al., 2018 in Zimbabwe, conducted similar studies giving N. gonorrhoeae (73.5%) and C. trachomatis (22.5%) [14] . These literature research data corroborate the high prevalence of N. gonorrhoeae worldwide but show a high prevalence of T. vaginalis and C. trachomatis compared to our results.

These sexually transmitted infections have few symptoms in men, with the most common symptom being acute anterior urethritis, while gonococcal infections in women have no specific symptoms [15] [16] but have important consequences if not detected early and treated successfully (N. gonorrhoeae, C. trachomatis, T. vaginalis). If undetected and untreated, they can lead to chronic pelvic pain, infertility, and ectopic pregnancy, as well as facilitating HIV acquisition and transmission [17] .

Untreated chlamydia can lead to trachoma, a major cause of blindness, and lymphogranuloma venereum, which can cause chronic proctitis, rectal stenosis, and genital lymphoedema in both men and women after anal intercourse [14] . STIs are, therefore, a serious public health problem that affects both men and women. In addition to early diagnosis which is crucial for prompt treatment [15] [17] , public health measures to control these diseases can include a variety of means. These include encouraging men to use condoms correctly and consistently and educating them about the importance of protecting themselves during sexual activity. Accessibility of condoms is an important part of this prevention strategy. It is also important to promote frank and open dialogue to create an atmosphere conducive to informed decision-making and to reduce the stigma associated with STIs [18] . Because STIs can have an impact on mental health and quality of life. Finally, improving the sexual and reproductive health of men and their partners is an important component of all these packages of measures [15] [19] [20] . One strategy is to create an STI control program, similar to Burkina Faso’s existing tuberculosis, malaria, and HIV control programs. A program would allow the country to mobilize internal and external funds and strengthen control methods. This study had limitations including the lack of appropriate media to isolate C. trachomatis, T. vaginalis and other STI pathogens. The qPCR assay kit does not take into account all the pathogens involved in urethral discharge. The antibiogram was not performed due to the lack of an appropriate E-test and the lack of certain information on the patient’s report card.

Despite these limitations, this study provides evidence-based results on the importance of N. gonorrhoeae infection, the inadequate quality (low sensitivity) of results from clinical laboratories isolating STI pathogens in Burkina Faso using the culture method, and the usefulness of molecular methods.

This study also highlights the urgent need to optimize culture for the diagnosis of STI pathogens in Burkina Faso and the need for the introduction of molecular diagnostic methods in routine diagnosis for the detection of STI pathogens in the clinical laboratories in Burkina Faso.

This study shows the high prevalence of N. gonorrhoeae infection in male urethritis in Burkina Faso, but unfortunately poor patient care and public health prevention on all fronts due to the low diagnostic performance of the routine culture method and the lack of antibiotic susceptibility testing. This study also highlights the urgent need to optimize culture for the diagnosis of STI pathogens, the need to introduce molecular diagnostic methods into routine diagnosis for the detection of STI pathogens in clinical laboratories, and the need to strengthen the STI surveillance system in Burkina Faso. These measures are very important and urgent to prevent STI outbreaks (especially N. gonorrhoeae infection outbreaks) in many foci in Burkina Faso, as the vulnerable exposed population has increased dramatically in recent years. Due to the security crisis, there were approximately 2 million internally displaced persons (IDPs) in March 2024, including many sexually active and vulnerable adolescents. Urgent action, including effective screening methods and sexual and reproductive health interventions, is therefore warranted for this specific population.

M.K.G: Writing—original draft, Methodology, Conceptualization; A.D: Conceptualization, Writing—original draft, Methodology; L. R. W. Belem: Writing—original draft; K. G: Methodology; K.R: Statistical analyse; A.Q: Methodology; A. M. S: Review & Editing; S. Sa: Conceptualization, Validation, Writing—original draft; D.K: Conceptualization, Writing—original draft.