Dysuria: Urethritis, Cervicitis, and testicular pain Flashcards
Urethritis
criteria vary per country
A condition occurring in symptomatic males with >5 PMNL (polymorphonuclear leukocytes) on microscopy of a urethral smear
symptoms = discharge / dysuria
Causes of vaginal discharge
Physiological - cyclical variation - cervical mucus Cervicitis - endocervical infection (and inflammation involving the TZ) --> mucopurulent cervicitis e.g. gonorrhoea or chlamydia, or straw berry cervix due to trychomonas - Genital candidiasis - Bacterial vaginosis -
Epidemiology of chlamydia
hallmark of the serially monogamous rather than the promiscuous
Most common bacterial STI in NZ
Rarely fatal
Commonly asymptomatic
Chlamydia characteristics
Obligate intracellular bacterium with biphasic lifecycle (24-48hours) so have to treat with antibiotics for at least a few days
- deficit in endogenous ATP production
- cant grow on altricial media
How does Clamydia present in the male compared to the female?
Male: discharge the consistency of egg white
Females: cervix has enlarged follicles
The grouping of chlamydial strains
A-C cause endemic trachoma = eye disease
D- K cause genitourinary disease (infect squamocolumnar cells)
L1-L3 infect lymphatic tissue = lymphogranuloma venereum
Spectrum of disease, D-K males,
Urethritis
Epididymitis
Proctitis
Reuter’s Syndrome
Spectrum of disease D-K, females
Cervicitis Sterile pyuria PID and ectopic pregnancy Perihepatitis Infertility
Neonatal and paediatric
Conjunctivitis
Pneumonia
Otitis media
Chlamydia pathophysiology
Initial infection mild and self limiting
Antibodies against major outer membrane protein can neutralised organisms –> latent infection of induced
Short term server specific immunity develops
Recurrent infection produces severe inflammation (resulting in tissue damage and scaring)
- due to exaggerated host CMI response
- Cros reacting heat shock protein aggravated by persisting intracellular chlamydia infection ( human heat shock protein very similar to that of chlamydia - get mimicry response)
Chlamydia testing
Can be performed on self collected samples now, which remain stable at room temp for many days
- PCR based techniques
Specimen collection
Males: FVU (first void urine) in both symptomatic and asymptomatic men
Females: Vulvovaginal swab for NAAT, speculum examination still recommended in symptomatic female patients
Treatment of uncomplicated chlamydial infection
Azithromycin = equally efficacious to doxycycline, but other organisms becoming resistant to this so we try not to use now.
Doxycycline unless pregnant or allergic
then use azithromycin and amoxycillin
uncomplicated disease needs 5 days treatment, complicated may require longer
Azithromycin
Alzalide (macrolide subclass) organisms like gonorrhoea develop resistance to this very quickly.
Inhibits translation of bacterial mRNA, binding to the 50s subunit of the bacterial ribosome
3-5% of patients experience GI side effects
risk factor in long QT syndrome
Chlamydia resistance rare.
Chlamydia notification
All partners within the last 60-90 days, last partner if grater than 60 days ago. Treat partner even if their test is negative
Reiter’s syndrome
a sexually acquired reactive arthritis articular disease / enthesopathy often with ocular involvement (conjunctivitis, uveitis) or mucocutaneous involvement can occur in females
Neisseria Gonorrhoea
Humans only natural host
Infect non-cornified epithelial cells - intracellular replication
Oxidase positive
Fastidious growth
Chromosomal or plasmid mediated antibiotic resistance
Pathogenic and defence mechanisms G
Pillin: adherence and resistance to neutrophils
Opa Proteins: Adherence, phase variation
LOS: Tissue toxin, antigenic variation
Serum resistance: sialylation of LOS
IGA protease
Specimen collection and transport
always from the sight with symptoms and signs and 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 unto 5 hours without loss of viability
Urethral infection in men
Most are symptomatic: incubation prepaid 1-14 days
Anterior urethritis
- discharge and dysuria
- erythema of meatus is variable
Untreated men, 95% asymptomatic after 6 months
Treatment of uncomplicated gonorrhoea
if sensitivities unknown or if pregnant or breast feeding
Ceftriaxone
concomninant treatment with azithromycin
If other sensitivities known and sensitive
- ciproflaxin, directly observed treatment (DOT)
DO NOT USE AZITHROMYCIN AS SOLE FIRST LINE THERAPY (minimise risk development developing)
concurrent antichlamydia therapy as co infection
Ciproflaxacin
2nd generation fluroqinoline
broad spectrum action; excellent tissue penetration
Resistant organisms have mutated topisomerases so the drug cant bind
Not effective first lie therapy for gonorrhoea when antibiotic sensitivity result not available
Gonorrhoea, complications in males
Epididymitis - most frequent, presents with unilateral testicular pain and swelling Lymphangitis - generalised penile oedema Urethral stricture - now rare
Gonorrhoea rectal infection
symptomatic (painless discharge to overt proctitis with tenesmus and pain) or asymptomatic
In men not reliable indicator of occurrence of unsafe anal sex, but due to direct inoculation
In women anorectal confection common; generally asymptomatic and usually due to contagious spread from genital area
Pharyngeal infection
Acquired through oral sex
Usually asymptomatic but can have sore throat
Very uncommon as sole sight of infection
Treat pharyngeal gonorrhoea with ceftriaxone and azithromycin
Endocervical infection
primary site of infection
Urethral infection also common
Incubation period
- less certain than in men
- If local symptoms develop this is usually within 10 days
Infections usually asymptomatic
If symptomatic: commonly vaginal discharge, dysuria, intermnestural bleeding or menorrhagia
PID and G complications in females
PID occurs in ~ 10-20% of women with acute infection Gonoccal PID often more severe than non-gonococcal PID but rate of tubal involvement similar
PID complications
If mild
- 2/3 have male partners with unsymptomatic urethritis
- may present with secondary dysmenorrhoea, intermenstural or post coital bleeding, vaginal discharge
- signs of cervical motion tenderness, uterine tenderness
Moderate
- often due to mixed microbial infection of which chlamyida is part
PID with perihepatic pain in women
- Fitz-Hugh Curtis syndrome
Pathogenesis of PID
Primary cervicitis (endocervix) Infection may spread - endometrial infection - cervical mucous - retrograde menstruation - uterine instrumentation Long term - chronic pain - infertility - ectopic / tubal pregnancy
PID symptoms and signs
Symptoms - LAP - Vaginal discarge - Vaginal bleeding - Dysuria - Other Signs - Abdominal or adnexal tenderness - Cervial motion tenderness - Anexal mass - Fever
PID microbial causes
Poly microbial primary - Chlamydia - Gonorrhoea Secondary - BV organisms - others
PID treatment
must include activity against
- gonococcus
- chlamydia
- anaerobes
DGI
disseminated gonococci infection
- occurrence in 0.5-3% of all cases
- most common form is dermatitis arthritis syndrome
- Risks for DGI are female gender, post menstruation, pharyngeal or asymptomatic genital infection complement deficiency
Non-specific urethritis
The diagnosis of NSU largely depends on
- the presence of symptoms or signs
- microscopy of a urethral smear
- rule out infection with chlamydia or gonorrhoea
Other pathogens cause NSU
- Trichinas vaginalis
men often eliminate it quickly and women often left with low grade infection in the vagina
Trichomoniasis
A protozoan - flagellated (the only protozoan that is an STI)
Site specific - lower urogenital tract
Incubation period about 3-21 days
Diagnosis: wet film
Culture
pap smear - poor sensitivity and specificity
PCR - highly sensitive and specific
- Has demonstrated that rates of infection higher than previously thought
