Lecture 29: Dysuria- Dysuria-urethritis, cervicitis and testicular pain Flashcards
Definition and symptoms of urethritis in males?
Criteria can vary in different centres but
- A condition occurring in symptomatic males with >5PMNL (polymorphonuclear leucocytes) per HPF on microscopy of a urethral smear
- Symptoms are of an anterior urethritis (ie. discharge/dysuria)
- Urethritis in women often presents as urinary issues
Littre’s glands = Urethral glands produce a colloid secretion containing GAGS that protect the epithelium against urine.
Causes of Vaginal Discharge?
Physiological
- Cyclical variation
- cervical mucus
Cervicitis
- Endocervical infection (mucorulent cervicitis eg. gonorrhoea or chlamydia)
- “strawberry cervix” (colpitis macularis: inflammatory punctate haemorrhage) due to trichomonas
Genital Candidiasis (vaginal inflammation)
Bacterial Vaginosis (not inflammation)
Other
Chlamydia epidemiology, infection?
- A hallmark of serially monogamous and is the most common STI in NZ and is rarely fatal
- Bacterium (gram negative) that infects cells forming reticulate body that eventually ruptures the cell releasing elementary bodies into the tissue.
- Many subtypes that infect different cell types (D-K infect squamocoloumnar cells)
pathophysiology of chlamydia? Diagnosis?
- Initial infection is mild and self-limiting
- Antibodies against the major outer membrane protein can neutralise organism
- Short term serovar-specific immunity develops
- Recurrent infection produces severe inflammation resulting in tissue damage and scarring
DNA amplification tests have improved and are becoming more specific and accurate. They use PCR in most private labs for testing upto even 3 weeks after collection.
Specimen collection?
Males
- FVU in both symptomatic and asymptomatic
Females
- Vulvovaginal swab for NAAT
- Speculum examination is still recommended in symptomatic females
Treatment of uncomplicated chlamydia infection?
- Doxycycline 100mg bid 7 days - 97-100% efficacy
- Azithromycin 1gm stat - equally efficacious in genital sites (good for women breastfeeding or pregnant) - 3-5% experience GI side-effects and can cause QT prolongation (rare to see resistance)
- Need to have effective antimicrobial therapy for at least 2 reproductive cycles (about 5 days - azithromycin has a very long half life)
Complications of chlamydia in males?
- Epididymitis (1-2%) and infertility
- Reiter’s syndrome - a sexually aquired reactive arthritis
- 20% have increased PMNL in prostatic secretion but prostatitis is rare
- Conjunctivitis 1-2%
Gonorrhoea is a?
Neisseria gonorrhoea is a gram negative diplococcus that has humans as its only host. Has fastidious growth and expresses chromosomal or plasmid mediated antibiotic resistance.
Urethral infection of gonorrhoea in males?
Most are symptomatic with an incubation period of 1-14 days (2-5 is most common)
Inflammation of the anterior urethra presenting with discharge and dysuria as well as erythema of meatus being variable (meatitis)
Untreated men - 95% asymptomatic after 6 months
Treatment of gonorrhoea?
If sensitivities are unknown, or if pregnant and/or breastfeeding then 500mg IMI stat of Ceftriaxone as well as azithromycin 1g po stat.
If sensitivities are known then we give 500mg p.o. stat of ciprofloxacin with 1g po azythromycin stat (but 50% of isolates are resistant to ciprofloxacin) - is a 2nd generation fluoroquinolone with a broad action, can’t be used in pregnancy or breastfeeding and there are some resisitant organisms
Complications of gonorrhoea in males?
Epididymitis
- Most frequent
- presents with unilateral testicular swelling and pain
Lymphangitis
- generalised penile oedema
Urethral stricture
- now rare
Rectal infection
- May be symptomatic/asymptomatic
- due to direct inoculation
- common anorectal coinfection in women
Pharyngeal infection
- Aquired through oral sex and usually asymptomatic (can have sore throat) but very uncommon as sole site of infection.
Complications of gonorrhoea in Women?
Endocervical infection
- Urethral infection also common but this is main site of infection
- Local symptoms (if they develop) usually within 10 days
- Asymptomatic ususally but can have vaginal discharge, dysuria, intermenstrual bleeding.
PID (pelvic inflammatory disease)
- occurs in 10-20% of women with acute infections
- perihepatitis can be a further complication leading to Right Upper quadrant pain
Pathogenesis of PID? Clinical findings?
Primary cervicitis (endocervix)
- Infection may spread
- Longterm: chronic pain, infertility, ectopic/tubal pregnancy
- Vaginal discharge and bleeding each in 50% of patients respectively.
- Dysuria in 25% of patients
- Abdominal or adnexal tenderness, cervical motion tenderness
PID Treatment?
Must include activity against: gonococcus, chlamydia and anaerobes
Ceftriaxone 500mg IMI stat + doxycycline 100mg bid 14d, with/without metronidazole 400mg bid 14d
