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Chlamydial Urethritis

Chlamydial urethritis is a term denoting an infection by Chlamydia trachomatis, the second-most common cause of urethritis after Neisseria gonorrhoeae. Up to 50-80% of patients may be asymptomatic, whereas urethral discharge, urinating difficulties, and pruritus are main complaints in symptomatic cases. Gram stain of urethral swabs and urinalysis are two crucial steps for the diagnosis, but several other tests can be employed to solidify clinical suspicion.


Presentation

C. trachomatis is a causative agent of a number of infections, including lymphogranuloma venereum (LGV), epididymitis, cervicitis, endometritis, salpingitis, and urethritis [1]. Chlamydia is the primary cause of non-gonococcal urethritis, constituting between 12-40% of all the remaining pathogens [1] [2] [3] [4]. Chlamydial urethritis (CU) poses a great risk for both males and females, as it may lead to numerous complications in the absence of proper therapy, such as pelvic inflammatory disease (PID), infertility, and sterility [2] [5]. Unfortunately, up to 50% of men and 70-80% of women have an asymptomatic course, which significantly delays the diagnosis [1] [6]. In symptomatic patients, main complaints are the presence of a urethral discharge, irritation of the urethra, pruritus, and dysuria [1] [7]. The urethral discharge in CU is described as clear-to-white (but it also may be mucopurulent), and most frequently appears before early morning voiding [6] [7]. Dysuria is not typically accompanied by other related signs such as increased frequency or urgency to urinate [6]. In rare cases, CU can be complicated by a form of reactive arthritis accompanied by conjunctivitis and painless mucopurulent lesions on the palms and soles, known as Reiter's syndrome [6].

Inguinal Lymphadenopathy
  • Men with HSV urethritis were significantly more likely to have meatitis (62% vs 23%, P 0.01), genital ulceration (37% vs 0%, P 0.01), or inguinal lymphadenopathy (30% vs 0%, P 0.01) but less likely to have urethral discharge (32% vs 69%, P 0.01).[ncbi.nlm.nih.gov]
Reiter's Syndrome
  • The treatment had no effect on the complications of urethritis like prostatitis and Reiter's syndrome.[ncbi.nlm.nih.gov]
  • In rare cases, CU can be complicated by a form of reactive arthritis accompanied by conjunctivitis and painless mucopurulent lesions on the palms and soles, known as Reiter's syndrome.[symptoma.com]
  • Due to a mixed infection, the Reiter's syndrome is also possible due to gonorrhea. fig. Keratoma blennorrhagicum: Reiter's syndrome (e.g. after urethritis) may result in excessive cornification of the palms or soles. Figure from Dr. M. F.[urology-textbook.com]
  • Reiter’s syndrome (arthritis) Conjunctivitis Skin lesions Discharge Women Pelvic Inflammatory Disease (PID) which can result in ectopic (tubal) pregnancy. Recurrent PID may lead to infertility.[ashasexualhealth.org]
  • Reactive arthritis (formerly known as Reiter's syndrome) is an inflammatory disorder that usually has three features: Painful and swollen joints, one or many Conjunctivitis Sterile urethritis Symptoms The main symptoms of urethritis are pain or burning[drugs.com]
Malaise
  • Fever and malaise commonly accompany local symptoms. The primary genital ulcer often resolves before or during this stage, but proctitis is likely to persist.[ecdc.europa.eu]
Constitutional Symptom
  • Compared with chlamydial urethritis, men with HSV urethritis were significantly more likely to report severe dysuria (20% vs 0%, P 0.01) or constitutional symptoms (15% vs 0%, P 0.01).[ncbi.nlm.nih.gov]
Hutchinson's Triad
  • triad in the congenital form is due to a gram-negative diplococcus produces an ulcer that has ragged edges and soft borders produces symptoms extremely similar to gonorrhea symptoms exhibits antibiotic resistance in PPNG strains is endemic in undeveloped[quizlet.com]
Rigor
  • URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services.[lutheranhealthcare.org]
Urethral Discharge
  • In symptomatic patients, main complaints are the presence of a urethral discharge, irritation of the urethra, pruritus, and dysuria.[symptoma.com]
  • Men with HSV urethritis were significantly more likely to have meatitis (62% vs 23%, P 0.01), genital ulceration (37% vs 0%, P 0.01), or inguinal lymphadenopathy (30% vs 0%, P 0.01) but less likely to have urethral discharge (32% vs 69%, P 0.01).[ncbi.nlm.nih.gov]
  • Signs and tests Taking a sample of secretions from the penis and sending it to a lab for a culture or a test called polymerase chain reaction (PCR) Urethral discharge culture or genital fluid testing for gonorrhea Urine test Treatment Chlamydia can be[coordinatedhealth.com]
  • Symptoms Difficlty urinating Painful urination Burning sensation during urination Discharge from the penis Testicular tenderness Redness, swelling of the opening of the urethra at tip of the penis Signs and tests Urethral discharge culture or seminal[medical-dictionary-search-engines.com]
Vaginal Discharge
  • Symptoms in women include Abnormal vaginal discharge, which may have a strong smell A burning sensation when urinating Pain during intercourse If the infection spreads, you might get lower abdominal pain, pain during sex, nausea, or fever.[icdlist.com]
  • discharge abnormal vaginal bleeding dyspareunia cervicitis fever (in pelvic inflammatory disease) asymptomatic in 80% of patients in males dysuria yellow mucopurulent discharge from the urethra unilateral pain and swelling of the scrotum fever asymptomatic[medbullets.com]
  • There may be a slight vaginal discharge and pelvic pain.[britannica.com]
  • If you have trichomonas, it definitely can be transmitted to a female partner -- where it causes vaginal discharge (if it causes symptoms at all) but in general is not a serious health threat. Cranberry juice etc won't make any difference.[medhelp.org]
  • Women complain of vaginal discharge, dysuria or abdominal pain (sign of progression to pelvic inflammatory disease). The extent of the symptoms is very variable, men and women may be asymptomatic.[urology-textbook.com]
Dysuria
  • Dysuria is not typically accompanied by other related signs such as increased frequency or urgency to urinate.[symptoma.com]
  • Compared with chlamydial urethritis, men with HSV urethritis were significantly more likely to report severe dysuria (20% vs 0%, P 0.01) or constitutional symptoms (15% vs 0%, P 0.01).[ncbi.nlm.nih.gov]
  • Snapshot A 22-year-old man presents to the clinic with a complaint of a dysuria and itching with urination. He admits that he has been engaging in unprotected sexual intercourse with several females.[medbullets.com]
  • Overview Urethral discharge and/or dysuria are typical symptoms of male urethritis. Make a clinical diagnosis of gonorrhoea or non-gonococcal urethritis (NGU) and treat accordingly.[sti.guidelines.org.au]
  • Men complain of glassy or purulent discharge from the urethra, Dysuria and burning in the urethra. Women complain of vaginal discharge, dysuria or abdominal pain (sign of progression to pelvic inflammatory disease).[urology-textbook.com]
Burning Micturition
  • Case Report A 33-year-old man presented to the sexually transmitted disease clinic at All India Institute of Medical Sciences, New Delhi, with a mucopurulent urethral discharge and burning micturition for 20 days.[ijdvl.com]
Epididymal Tenderness
  • For urethritis: Check for penile discharge, meatal crusts, no costovertebral angle tenderness, no epididymal tenderness or prostatic tenderness on exam.[clinicaladvisor.com]

Workup

Because of the common asymptomatic nature of the ailment, CU may be particularly hard to diagnose. For this reason, the physician must obtain a detailed patient history and conduct a proper physical examination. During the interview, the presence of symptoms, their duration, as well as severity should be assessed, whereas a history of sexual activity could identify a recent contact with partners who are already suffering from sexually transmitted infections (STIs). A urethral examination can be crucial for a presumptive diagnosis, as serial palpation of the urethra might result in the release of urethral discharge [8], which should be then collected for microbiological investigation. Swabs of the urethra and the urethral discharge must be obtained and stored very delicately, as Chlamydia rapidly dies in the external environment [5]. Several laboratory procedures are used to confirm the medical entity [5] [6] [8] [9]:

  • Non-specific tests - The leukocyte esterase (LE) test, designed to detect products secreted by polymorphonuclear (PMN) cells, provides a qualitative result of an ongoing disease within 30 minutes, while enzyme immunoassay (EIA) testing for C. trachomatis may be performed [5] [6]. Although possessing a low sensitivity and specificity rate [5] [6], they are of great use in the initial diagnostic workup. The early-morning urine sample should be evaluated with non-specific tests [8]. Detection of >10 white blood cells in the urine sediment is another indication of a genitourinary disorder [5] [6] [8].
  • Specific tests - Gram staining, although now being replaced by novel methods, is a highly useful and rapid procedure that excludes gram-negative diplococci on microscopic examination [4] [7], which then points to other pathogens, primarily C. trachomatis. For a definite diagnosis to be made, cultivation, direct fluorescent antibody test (DFA), cytology, enzyme-linked immunosorbent assay (ELISA), and polymerase chain reaction (PCR) exam need to be done [5] [6] [8].
Pyuria
  • The majority of patients with cystitis will have pyuria ( 10 WBCs per mm3) on microscopy; however, pyuria without symptoms and signs is not sufficient to make the diagnosis.[clinicaladvisor.com]
Chlamydia Trachomatis
  • Abstract Trospectomycin is an aminocyclitol analog of spectinomycin with significant in vitro activity against Chlamydia trachomatis.[ncbi.nlm.nih.gov]
  • Abstract Conjunctival Chlamydia trachomatis was studied in 50 males with chlamydial urethritis. Conjunctival samples from 49 patients were negative for chlamydial antigen by enzyme immunoassay.[ncbi.nlm.nih.gov]
  • Abstract First-void urine (FVU) sediments of 240 men were tested for Chlamydia trachomatis antigens by two enzyme immunoassays, TestPack Chlamydia (15 min) and Chlamydiazyme (3.5 h), and the results were compared with urethral swab culture results.[ncbi.nlm.nih.gov]
  • On admission, Chlamydia trachomatis DNA was not detected in the urine sediment by PCR method, however, he was diagnosed to have reactive arthritis based on the clinical findings of asymmetric dactylitis, circinate balanitis, stomatitis and positivity[ncbi.nlm.nih.gov]
  • Abstract Chlamydia trachomatis was isolated from 47% of asymptomatic, sexually active men whose urethral smears contained four or more polymorphonuclear leukocytes (PMN) per high-power field (hpf) one week after their sexual activity was restricted.[ncbi.nlm.nih.gov]

Treatment

  • Both treatments lasted for 9 days. Follow-up examinations were carried out 2 weeks (14-16 days) and 4 weeks (26-30 days) after the start of treatment.[ncbi.nlm.nih.gov]
  • BACKGROUND: Currently, there is no single-dose therapy that is effective in the treatment of urethral or endocervical infections with Chlamydia trachomatis.[ncbi.nlm.nih.gov]
  • Treatment-related discontinuations were comparable between the drug groups.[ncbi.nlm.nih.gov]
  • OBJECTIVE: To compare the efficacy and safety of azithromycin and doxycycline in the treatment of males with uncomplicated urethritis caused by chlamydia trachomatis. DESIGN: A multicentre, double-blind, randomised treatment study.[ncbi.nlm.nih.gov]
  • Trospectomycin was well tolerated but failed to eradicate chlamydial infection, as determined by cultures obtained approximately 1 week after treatment.[ncbi.nlm.nih.gov]

Prognosis

  • Expectations (prognosis) Antibiotic treatment is usually successful. Complications Narrowing (strictures) of the urethra may occur. This may require surgery to correct.[coordinatedhealth.com]
  • Expectations (prognosis) Antibiotic treatment is usually successful. Complications Strictures (narrowing) of the urethra may occur. This may require surgical intervention to correct.[medical-dictionary-search-engines.com]

Etiology

  • In humans, chlamydiae are known to cause trachoma (which is still one of the major blinding diseases in the world) and are also one of the most common etiological agents of sexually transmitted diseases and the sequelae thereof, such as infertility.[books.google.com]
  • License: Public Domain Definition of Urethritis Urethritis is a term that means inflammation of the urethra which is usually infectious in etiology.[lecturio.com]
  • Trichomonas vaginalis: an anaerobic, parasitic flagellated protozoan, rare cause of urethritis ( Uncertain etiology: in 20–30%. Signs and Symptoms Urethritis: Incubation period 1–5 weeks.[urology-textbook.com]
  • Chlamydia (STD) by Lance Rosenquest Chlamydia (STD); Etiological agent- Chlamydia trachomatis (4). Transmission : Transmitted through sexual contact with an infected individual (vaginal, anal, or oral sex).[austincc.edu]
  • Etiologies of nongonococcal urethritis: bacteria, viruses, and the association with orogenital exposure”. J Infect Dis. vol. 193. 2006. pp. 336-45. Foxman, B.[clinicaladvisor.com]

Epidemiology

  • The sensitive micro IF test is considered useful in the epidemiologic study of chlamydial infections of genital origin and can provide information about the nature of infecting strains.[jimmunol.org]
  • (HIV) and exacerbate retroviral disease. [17] The identification of this new serovar indicates the need for larger epidemiological and clinical studies in India as characterization of C. trachomatis strains can provide important epidemiological knowledge[ijdvl.com]
  • Describe the epidemiology, spectrum, and clinical manifestations of diseases caused by C pneumoniae . Discuss the limitations of serology in the diagnosis of C pneumoniae infections in children.[pedsinreview.aappublications.org]
  • Chlamydia is under epidemiological surveillance within the EU. The reported national incidence rates vary widely and most of the more than 250 000 cases reported to ECDC for 2007 were notified by only five countries.[ecdc.europa.eu]
  • Epidemiology Increasing incidence, nowadays more frequent than gonorrheal urethritis. Causes (Pathogens) of Non-Gonococcal Urethritis Chlamydia trachomatis: Most often cause of NGU.[urology-textbook.com]
Sex distribution
Age distribution

Pathophysiology

  • Insight into the pathophysiology of chla mydial infections has also increased, and new methods for the diagnosis of chlamydial infections have been introduced.[books.google.com]
  • Review Date: 5/5/2008 Reviewed By: Linda Vorvick, MD, Seattle Site Coordinator, Lecturer, Pathophysiology, MEDEX Northwest Division of Physician Assistant Studies, University of Washington School of Medicine; and David C.[lutheranhealthcare.org]
  • Urethritis can also complicate the picture of lower urinary tract infections and cystitis, Pathophysiology of Urethritis The different identified organisms for urethritis are known to be transmitted by sexual intercourse.[lecturio.com]

Prevention

  • The proper use of condoms during intercourse usually prevents infection. References U.S. Preventive Services Task Force. Screening for chlamydial infection: U.S. Preventive Services Task Force recommendation statement.[indiatoday.intoday.in]
  • Part 7 of 7: Prevention How to Prevent Chlamydial Urethritis in Men Men who are sexually active can prevent STIs with safe sex practices. Male and female condoms can greatly reduce the spread of infection.[en.parsiteb.com]
  • This helps prevent reinfection. Without proper treatment, sexual partners may continue to pass the bacteria back and forth.[healthline.com]
  • The proper use of condoms during intercourse usually prevents infection.[coordinatedhealth.com]

References

Article

  1. Bachmann LH, Manhart LE, Martin DH, et al. Advances in the Understanding and Treatment of Male Urethritis. Clin Infect Dis. 2015;61 Suppl 8: S763-769.
  2. Tait I, Hart C. Chlamydia trachomatis in non-gonococcal urethritis patients and their heterosexual partners: routine testing by polymerase chain reaction. Sex Transm Infect. 2002;78(4):286-288.
  3. Wetmore CM, Manhart LE, Lowens MS, et al. Demographic, behavioral, and clinical characteristics of men with nongonococcal urethritis differ by etiology: a case-comparison study. Sex Transm Dis. 2011;38:180–186.
  4. Falk L, Fredlund H, Jensen JS. Symptomatic urethritis is more prevalent in men infected with Mycoplasma genitalium than with Chlamydia trachomatis. Sex Transm Infect. 2004;80:289–293.
  5. Chernesky MA. The laboratory diagnosis of Chlamydia trachomatis infections. Can J Infect Dis Med Microbiol. 2005;16(1):39-44.
  6. Malhotra M, Sood S, Mukherjee A, Muralidhar S, Bala M. Genital Chlamydia trachomatis: An update. Indian J Med Res. 2013;138(3):303-316.
  7. Moi H, Blee K, Horner PJ. Management of non-gonococcal urethritis. BMC Infect Dis. 2015;15:294.
  8. Brill JR. Diagnosis and treatment of urethritis in men. Am Fam Physician. 2010;81(7):873-878.
  9. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2006: diseases characterized by urethritis and cervicitis. https://www.cdc.gov/std/treatment/2010/urethritis-and-cervicitis.htm

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Last updated: 2019-07-11 21:02