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BII > L30: Dysuria > Flashcards

L30: Dysuria Flashcards

1
Q

Urethritis in males

A
  • Condition occurring in symptomatic males with >5 PMNL (polymorphic nucleotides) per HPF (high power field) on microscopy of urethral smear
  • May see some PMNLs on normal slide (e.g. if male ejaculated and not urinated 2-3hrs before sample)
  • Symptoms of anterior urethritis (e.g. dysuria, discharge)
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2
Q

Physiological discharge in males

A

Littre’s glands (urethral glands) produce colloid secretion containing glycosaminoglycans, protects epithelium against urine

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3
Q

Vaginal discharge

A
  1. Physiological: cyclical variation, some cervical mucus
  2. Cervicitis: endocervical infection (and inflammation involving transformation zone)
    - Mucopurulent cervicitis e.g. gonorrhoea, chlamydia
    - “Strawberry cervix” (Colpitis macularis - inflmmatory punctate haemmorhage) due to trichomonas
  3. Genital candidiasis
  4. Bacterial vaginosis
  5. Other e.g. atrophic vaginitis (post-partum), foreign body
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4
Q

Chlamydia

A
  • Most common bacterial STI in NZ (mainly young adults)
  • Commonly asymptomatic, rarely fatal
  • Outer membrane similar to other gram-neg bacteria (does not show on typical gram stain)
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5
Q

Chlamydia lifecycle

A
  • Obligate intracellular bacterium (energy parasite) with biphasic lifecycle (24-48hrs - need antibiotics for 2 cycles)
  • Deficient in endogenous ATP production (use host cell ATP)
  • Cannot grow on artificial media
  • Elementary body (small,compact) phagocytosed by cells, takes over ATP production machinery and turns into larger reticulate body
  • Reticulate body multiples producing elementary bodies (cell ruptures and release of elementary bodies)
  • Serovars D-K cause GU disease (infect squamocolumnar cells)
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6
Q

Chlamydia - spectrum of disease

A

Males: urethritis, epididymitis, proctitis, Reiter’s syndrome
Female: cervicitis, pyuria, PID (+ectopic pregnancy), perihepatitis, infertility
Neonatal and paediatric: conjunctivitis (follicular), pneumonia, otitis media

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7
Q

Chlamydia pathophysiology

A
  • Initial infection mild and self-limited
  • Short term serogroup-specific immunity (few months)
  • Recurrent infection causes severe inflammation (tissue damage and scarring): due to exaggerated cell-mediated immune response by cross-reacting heat shock protein (chlamydia heat shock protein similar to human heat shock protein)
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8
Q

Diagnosis of chlamydia

A
  • Sample collected: first void urine in men, vulvo-vaginal swab in women (+ speculum exam in symptomatic women)
  • Enzyme immune assay (ELISA): not very sensitive, need high amount of organisms in sample
  • DNA amplification (NAAT - nucleic acid amplification test): detects very low amounts of material, but be careful of established infection or just contamination, fewer storage/handling problems than swabs for culture
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9
Q

Which tests are better for diagnosis of chlamydia?

A

NAAT > culture > EIA

  • Modern NAATs similar in sensitivity and specificity
  • SDA used currently but also PCR
  • Can be performed on self-collected sample which remain stable at room temp for many days
  • Some advancement in rapid point of care testing
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10
Q

Treatment of uncomplicated chlamydial infection

A
  • Preferred treatment is doxycycline for 7 days: efficacy 97-100%
  • Azithromycin 1gm stat: similar efficacy in doxy in genital sites, can be given in clinic, concern about rising resistance
  • In preg/breastfeeding: azithromycin 1gm stat or amoxicillin for 7 days (test of cure 3-4wks after finishing treatment)
  • Uncomplicated infection needs effective antimicrobial treatment for at least 2 reproductive cycles (5 days)
  • Complicated disease requires longer course
  • Treat partners in last 60-90 days even if negative test + protected sex in treatment
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11
Q

Azithromycin action

A
  • Azalide (macrolide subclass)
  • Inhibits translation of bacterial mRNA (binds to 50s subunit of ribosome)
  • Long tissue half life: tissue levels > 50x plasma levels
  • 3-5% have GI side effects (do not take on empty stomach)
  • Risk factor for long QT syndrome
  • Chlamydia resistance rare
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12
Q

Complications in of chlamydia in males

A
  • Epididymitis (1-2%) and infertility
  • Reiter’s syndrome: reactive arthritis + ocular involvement (conjunctivitis, uveitis) or mucocutaneous involvement (note: Reiters can occur in females = erosive vulvitis)
  • 20% have increased PMNL in prostatic secretion but prostatitis is rare
  • Conjunctivitis 1-2%
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13
Q

Neisseria gonorrhoea

A
  • Gram neg diplococcus
  • Humans are only natural host
  • Infect non-cornified epithelial cells
  • Oxidase positive
  • Fastidious growth
  • Chromsomal or plasmid mediated antibiotic resistance
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14
Q

N. gonorrhoea defence mechanisms

A
  1. Pilin: adherence, resistance to neutrophils, antigenic variation
  2. Opa proteins: adherence, phase variation
  3. LOS: tissue toxin, antigenic variation
  4. Serum resistance
  5. IgA protease
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15
Q

N. gonorrhoea specimen collection and transport

A
  • From site with signs/symptoms + other at risk areas from sexual history
  • If symptomatic take sample for culture
  • Specimen can be left at room temp for 5hrs (but do not tolerate drying out)
  • Amies’ or Stuart’s for transport where inoculation of growth medium will occur within 4-8hrs (not overnight)
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16
Q

N. gonorrhoea growth and identification

A
  • 35-37 degrees, 5% CO2, pH 6.5-7.5, needs iron
  • New York City medium (GU sites)
  • Thayer Martin medium (more antibiotics, sites with other bacteria e.g. rectum, throat)
  • Neisseria confirmed by positive oxidase test
  • Species identified by carbohydrate degradation testing or enzyme substrate testing
  • Sensitivity test: E test strip (MIC can be read directly)
17
Q

N. gonorrhoea - urethral infection in males

A
  • Mostly symptomatic: incubation period 1-14 days (2-5 common)
  • Anterior urethritis: discharge and dysuria, erythema of urethra variable (meatitis)
  • Untreated men - 95% asymptomatic after 6months
18
Q

Diagnostic techniques for N. gonorrhoea

A

Gram stain:

  • High accuracy from male urethra
  • Cervix and rectum less sensitive/specific

Culture from site: relatively accurate from any site (with adjusting culture medium)

NAAT (nucleic acid amplification test):

  • High sensitivity and specificity depends on brand, method and site (2 targets positive from GU samples, 3 from non-genital samples)
  • High patient acceptability (can be self-collected)
  • Still need culture for antibiotic resistance
  • Chlamydia NAAT typically combined with gonorrhoea
  • Molecular typing to confirm gonococcal strain
19
Q

Treatment of uncomplicated gonorrhoea

A
  • If sensitivities unknown or breastfeeding/pregnant = ceftriaxone IMI stat, concomitant treatment with azithromycin 1g stat
  • If sensitivities known and sensitive = ciprofloxacin 500g stat + azithromycin 1g stat (but 50% of isolates resistant to cipro)
  • Do not use azithromycin as sole first-line (minimise risk of resistance increase)
  • Concurrent anti-chlamydial therapy as co-infection common (ceftriaxone and azithro + doxy if known chlamydia)
  • Contact trace 30-90 days
20
Q

Ciprofloxacin action

A
  • 2nd generation fluoroquinolone
  • Broad spectrum, excellent tissue penetration
  • Inhibits DNA gyrase: inhibited cell division
  • Resistant organisms have mutated topoisomerases so drug cannot bind
  • Contraindicated in pregnancy, breastfeeding
21
Q

Gonorrhoea - complications in males

A
  • Epididymitis (most common, unilateral testicular pain and swelling)
  • Lymphangitis: generalised penile oedema
  • Urethral stricture: rare
22
Q

Rectal gonorrhoea infection

A
  • Symptomatic or asymptomatic
  • Pain/painless discharge, or proctitis, tenesmus (sense of needing to defecate)
  • In men not reliable indicator of unsafe anal sex (can be contaminated finger, transfer from genitalia)
  • In women anorectal co-infection common (usually asymptomatic, spread from genitalia)
23
Q

Pharyngeal gonorrhoea infection

A
  • Oral sex
  • Usually asymptomatic, sometimes mild sore throat
  • V. uncommon as only site of infection
  • Important to treat with ceftriaxone and azithromycin (site of increasing resistance)
24
Q

Endocervical gonorrhoea infection

A
  • Primary site of infection
  • Urethral infection also common
  • Usually asymptomatic
  • Can have vaginal discharge, dysuria, inter-menstrual bleeding, menorrhagia
  • Gram stain not effective so require lab based isolation
25
Q

Gonorrhoea - complications in females

A
  • PID in 10-20% of women with acute infection
  • Gonococcal PID more severe than non-gonococcal
  • Bartholin’s abscess, Skene’s abscess are less common complications
26
Q

PID

A

= Pelvic inflammatory disease (complication of gonorrhoea)

  • If mild high chance of asymptomatic urethritis in male partner
  • If moderate/severe often due to mixed infection e.g. with chlamydia
  • Fitz-Hugh-Curtis syndrome = peri-hepatic pain and formation of adhesions (usually chlamydia)

Microbial causes: polymicrobial, primary (chlamydia, gonorrhoea), secondary (BV organisms, others e.g. anaerobes)

27
Q

Treatment and complications of PID

A

Treatment: ceftriaxone + doxycycline with/without metronidazole

Complications:

  • Chronic pain, subsequent PIC, infertility, ectopic pregnancy
  • Silent PID: 50-60% of women with infertility have serological evidence of previous chlamydia or gonorrhoea
28
Q

Non-specific urethritis

A
  • Diagnosis largely depends on symptoms/signs + urethral smear for PMNL
  • Typically chlamydia and gonorrhoea
  • Trichomonas vaginalis
  • Mycoplasma genitalium = mild urethritis or asymptomatic, responds to azithromycin or moxifloxacin, only tested for in NZ with persistent NSU
  • Also herpes simplex virus, adenoviruses, N. meningitidis
29
Q

Trichomonas vaginalis

A
  • Common cause of STIs esp. females
  • Protozoa with flagella (large, seen under light microscopy with no stain)
  • Infection may facilitate HIV transmission

Males:
- Transient in male tract, inhibited by high zinc in prostate secretions, infection usually symptomatic

BII (41 decks)

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