Dysuria: Urethritis, Cervicitis and Testicular Pain Flashcards
How do you define Urethritis?
- Urethritis is an inflammation of the urethra, and is not the same as a urinary tract infection (UTI).
- In symptomatic males you will see increased PolyMorphicNuclearLymphocytes per HPF on microscopy of a urethral smear
- Symptoms are of an anterior urethritis;
- Discharge, dysuria
- Criteria varies
- Can be misleading, eg you may see this post-ejaculation
Where does the discharge come from in Urethritis in men?
- From Litres Glands that line the urethra
- A colloid secretion contains GAGs that protect the epithelium against urine.
What are the potential causes of Discharge in women?
-
Physiological: usually this!
- M. Cyclical variation
- Cervical Mucus: as the urethra is too short to contribute much
- Cervicitis
- endocervical infection (and inflamm. invovling TZ)
- mucoprulent cervicitis eg; gonorrhoea or chlamydia
- Strawberry cervix* rare, infection
- endocervical infection (and inflamm. invovling TZ)
- Genital Candidiasis
- Bacterial Vaginosis (BVAB)
- Other Atrophic vaginitis, foreign body
Chlamydia: who gets it, is it symptomatic and can they generate energy?
- Most common STI
- Usually in the Serially monogamous rather then promiscuous
- Rarely Fatal, commonly asymptomatic
-
Obligate intracellular bacterium (‘energy parasite’) with complex biphasic lifecycle (24-48hrs): no ability to generate enrgey, instead take over host cell ATP production
- can only take over once inside host cells
What are the Reproductive cycle of the Chlamydia bacterium
- have a ‘bimorphic lifestyle’
- Elementary body that is an extremely infectious particle that can attatch to cells and be phagocytosed into
- once inside, it can now use the cell to generate energy and turn into a much larger ‘Reticular Body”
- Reticular Body can then produce/release lots more elementary bodies
- This reproductive occurs over 24-48hrs; In order for antibiotics to be effective (need to cover 2 RC’s to work)
- treatment is therefore 4-5 days
Outer membrane of CHlamydia?
What are the serovars and what do they cause?
Similar to that of other gram negative bacteria
- Serovars: that cause distinct infections
- A-C infect squamous (endemic trachoma)
- D-K: genitourinary disease
- L1,L2,L3 cause lymphogranuloma venereum (lymphatic damage)
What’s the spectrum of disease that can be caused in both males and femals from D-K Serovar Chlamydia? (genitourinary diseases)
Males:
- Urethritis
- Epididimytis
- Proctitis
- Reiter’s syndrome
Female:
- Cervicitis
- Sterile pyuria
- PID (&ectopic pregnancy)
- Perihepatitis
- infertility
Neonatal and Paediatric
- Conjunctivitis
- pneumonia
- otitis media
Pathophysiology of Chlamydia?
- Initial infection is mild and self Limiting!
- Antibodies against the major outer membrane (MOMP) can neutralise organisms
- latent infection is induced, cause problems later
- Short term serovar-specific imunity developing
- Recurrent infection produces severe inflammation (resulting in tissue damage and scarring)
- dueto exaggerated host CMI response
- Cross-reacting heat shock protein aggravated by persisting intracellular chlamydia antigen (Chsp60) that looks like Human HSP!!
How do you diagnose Chlamydia
- DNA amplificaation (nucleic acid amplification)
- Have increased sensitivity : detect
- EIA ehich detects log 5-7 (not v sensitive)
- culture which detects log 1-2
- Have increased specificity over EIA
- Obviates most of the problems with false positives
- PPV and NPV better then other tests
- Fewer storage and handling problems compared swabs for culture
- Can be automated
How do you do specimen collection in males and females?
Males:
- FVU in both symptomatic and asymptomatic men
Females:
- vulvovaginal swab for NAAT
- Speculum examination is still recommended in symptomatic female patients
Treatment of uncomplicated Chlamydial infection
- Azithromycin (1gm stat)
- equally efficacious to doxycycline
- high level of patient adherence
- pregnancy category B1
- Doxycycline 100mg bid 7 days more pop.
- efficacy 97-100%
- Pregnany or breastfeeding women se
- Azithromycin 1 g stat
- Amoxycillin 500mg tid for 7 days
- if you use you need to test 3-4 wks after to make sure
- Uncomplicated infection needs the presence of effective Antimicrobial therapies for at least 2 reproduc. cycles.
Azithromycin as a treatment?
- Azalide (macrolibe subclass)
- Inhibits translation of bacterial mRNA
- binding to 50S subunit of the bacterial ribosome
- 3-5% patients: GI side-effects
- Tissue levels >50x plasma levels (long tissue t1/2)
- Risk factor for long QT syndrome
- Chlamydia: resistance rare
How do you approach the patients partner in terms of treatment?
- Partner Notification
- all partners within the last 60-90 days
- or last partner if >60 days ago
- Test of cure NOT required ( may get false + )
- Treat partner(s) even if test negative
- Expedited partner treatment
- PDPT a possibility in some jurisdictions
- Advise to practise protected sex during treatment
Complications arising from Chlamydia in Males…
- Epididymitis (1-2%) and Infertility
- Reiters Syndrome
- sexually acquired reactive arthritis
- articular disease
- often with ocular involvement (conjunctivitis, uveitis)
- Females can get to as Erosive volvitis
- 20% have increased PMNL in prostatic secretion but prostatitis rare
- Conjunctivitis 1-2%
Gonorrhoea rates in NZ
- not uncommon in auckland
- sits in late adolescant-young adult range
- But older in males
Neisseria gonorrhoea
- Gram negative diplococcus
- Humans only natural host
- Infect non-cornified epithelial cells
- intracellular replication
- Oxidase +
- Fastidious growth
- Chromosomal or plasmid mediated AB resistance
- quick adaptive and good at dodging host defences
Pathogenic and Defence mechanisms!
- Pilin
- adherence
- resistance to neutrophils
- antigenic variation
- Opa proteins
- adherence
- phase variation
- LOS
- tissue toxin
- antigenic variation
- Serum resistance
- sialylation of LOS
- IgA1 protease
Where/how do you collect and transport gonnorhea samples?
- ALways away from the site with symptoms/signs and also from other areas identified in sexual history at risk
- IF symptomatic take a sample for culture
- Specimen for culture can be left at room temp for up to 5 h without loss of viability
- Amies or stuarts only for transport where inoculation of growth medium will occur within 4-8h
- not overnight
You can grow gonnorrhea on __________ either with a _______ or ______ medium
You can grow gonnorrhea on selective artificial media either with a New York City or Thayer Martin medium
SAMs: contain blood, other growth promoters, antibiotics. Some fastidious strains may be sensitive to vancomycin
NY medium: done when you can expect a clean ‘culture’ eg from urethra
THayer Martin: when you can expect a lot of other bacteria, other things in there to suppress the other stuff
Once N. gonnorrhea is cultured, you can confirm it via a _______ and then speciate it by….
Once N. gonnorrhea is cultured, you can confirm it via a oxidase test and then speciate it by …..
- carbohydrate degredation testing
- enzyme substrate tests
- combination
- Sensitivity testing
Urethral infection in males…
- Most are symptomatic
- incubation period 1-14 days (2-5 common)
- Anterior Urethritis
- discharge (pussy, thick) and dysuria
- erythema of meatus is variable (meatitis)
- Untreated men (95% asymptomatic after 6 months)
Although gram staining is really only good from the urethra, culturing is good…?
NAAT??
really anywhere
NAAT: high sensitivity but specificity depends on brand and method
eg: 2 targets for GU and 3 targets for extra-genital
Treatment of Gonorrhoea is?
Uncomplicated: very easy to treat if you use
- high dose Ceftiraxone
- and concomitant azithromycin
If sensitivities known and sensitive
- ciprofloxacin with azithromycin
- Directly observed treatment (DOT)
- (but 50% isolates are resistaant to ciprofloxacin)
DO NOT USE Aziithromycin as sole first line therapy to minimise risk of resistance developing, instead do concurrent anti-chlamydial therapy as co-infection with chlamydia is common
Contact trace all individuals in last 30-90 days
Describe Ciprofloxain as a gonorrhea treatment and what are it’s issues?
- 2nd generation fluoroquinolone
- Broad spectrum of action; excellent tissue penetration
- Inhibits DNA gyrase
- bacterial DNA Seperation is impede and cell division inhibited
- Resistant organisms have mutated topoisomerases; so the drug can’t bind :(
Complications of Gonorrhea in males?
- Epididymitis
- most frequent
- presents with unilateral tetiular pain and swelling
- Lymphangitis
- generalised penile oedma
- Urethral Stricture
- now rare
Describe Rectal gonorrhea Infections
- May be symptomatic or asymptomatic
- if symptomatic, may vary from painless discharge to overt proctitis with tenesmus and pain
- If men not a reliable indicator of occurrence of unsafe anal sex, but due to direct inoculation
- In women anorectal con-infection is common; generally asymptomatic and usually due to contiguous spread from the genital area
Describe Pharyngeal Gonnorrheal infection
- Acquired through oral sex
- usually peno-oral
- Usually asymptomatic but can have a sore throat
- very uncommon as sole site of infection
- Important to treat with ceftriaxone and azithromycin
- under-treatment in pharyngeal infection probably sigificantly contributes to the emergence of resistance (eg other antibiotics)
Describe Endocervical gonnorrheal infection
- Primary site of infection
- urethral infection also common
- incubation period
- less certain than in men
- if local syptoms develop this is usually within 10 days
- infections usually asymptomatic
- if symptomatic, commonly have vaginal discharge, dysuria, intermenstrual bleeding or menorrhagia
- only ~40% gram stain
COmplicaions of Gonnorrhea in women?
- PID occurs in an estimated 10-20% of women with acute infection
- GOnococcal PID is often more severe than non-gonococcal PID but rates of tubal involvement are similar
- Bartholins abscess, Skene’s abscess are less common complications
Learn about PID
- Treatment has to be high dose for a long time (>2weeks)
- REpeated infection leads to increased inflammation → infertility
- 10-15%
- 25-35%
- 50-75%
- Lots of PID is Silent
Disseminated Gonococci infection?
- Occurs in 0.5-3% cases
- Most commonly as dermatitis-arthritis syndrome
- Risks for DGI are female gender, post-menstruation, pharyngeal or asymptomatic infection, complement deficiency
- Proving infection microbiologically can be hard
- can occur in males
Non-Specific Urethritis (when we don’t know what’s causing it)
- Diagnosis (really just a label) of NSU depends on
- presence of symptoms or signs
- microscopy of a urethral smear looking for PMNL (note that false + do occur)
- rule out infection w chlamydia and gonorrhea
- Other pathogens can cause ‘NSU’
- trichomonas vaginalis (more likely to be symptomatic as a cause of VDx in women but can be transiently symptomatic in men but is inhibited by the Zn present in prostatic secretions)
- Mycopplasmuc genitalium : gives similar pictue as chlamydia with mild urethritis
- candida
- other ciruses or bacteria
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