Dysuria: Urethritis, Cervicitis, and testicular pain

Question 1

Urethritis

Answer 1

criteria vary per country
A condition occurring in symptomatic males with >5 PMNL (polymorphonuclear leukocytes) on microscopy of a urethral smear
symptoms = discharge / dysuria

Question 2

Causes of vaginal discharge

Answer 2

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 
-

Question 3

Epidemiology of chlamydia

Answer 3

hallmark of the serially monogamous rather than the promiscuous
Most common bacterial STI in NZ
Rarely fatal
Commonly asymptomatic

Question 4

Chlamydia characteristics

Answer 4

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

Question 5

How does Clamydia present in the male compared to the female?

Answer 5

Male: discharge the consistency of egg white
Females: cervix has enlarged follicles

Question 6

The grouping of chlamydial strains

Answer 6

A-C cause endemic trachoma = eye disease
D- K cause genitourinary disease (infect squamocolumnar cells)
L1-L3 infect lymphatic tissue = lymphogranuloma venereum

Question 7

Spectrum of disease, D-K males,

Answer 7

Urethritis
Epididymitis
Proctitis
Reuter’s Syndrome

Question 8

Spectrum of disease D-K, females

Answer 8

Cervicitis 
Sterile pyuria 
PID and ectopic pregnancy 
Perihepatitis 
Infertility

Question 9

Neonatal and paediatric

Answer 9

Conjunctivitis
Pneumonia
Otitis media

Question 10

Chlamydia pathophysiology

Answer 10

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)

Question 11

Chlamydia testing

Answer 11

Can be performed on self collected samples now, which remain stable at room temp for many days
- PCR based techniques

Question 12

Specimen collection

Answer 12

Males: FVU (first void urine) in both symptomatic and asymptomatic men
Females: Vulvovaginal swab for NAAT, speculum examination still recommended in symptomatic female patients

Question 13

Treatment of uncomplicated chlamydial infection

Answer 13

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

Question 14

Azithromycin

Answer 14

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.

Question 15

Chlamydia notification

Answer 15

All partners within the last 60-90 days, last partner if grater than 60 days ago. Treat partner even if their test is negative

Question 16

Reiter’s syndrome

Answer 16

a sexually acquired reactive arthritis 
articular disease / enthesopathy 
often with ocular involvement (conjunctivitis, uveitis) 
or 
mucocutaneous involvement 
can occur in females

Question 17

Neisseria Gonorrhoea

Answer 17

Humans only natural host
Infect non-cornified epithelial cells - intracellular replication
Oxidase positive
Fastidious growth
Chromosomal or plasmid mediated antibiotic resistance

Question 18

Pathogenic and defence mechanisms G

Answer 18

Pillin: adherence and resistance to neutrophils
Opa Proteins: Adherence, phase variation
LOS: Tissue toxin, antigenic variation
Serum resistance: sialylation of LOS
IGA protease

Question 19

Specimen collection and transport

Answer 19

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

Question 20

Urethral infection in men

Answer 20

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

Question 21

Treatment of uncomplicated gonorrhoea

Answer 21

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

Question 22

Ciproflaxacin

Answer 22

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

Question 23

Gonorrhoea, complications in males

Answer 23

Epididymitis 
- most frequent, presents with unilateral testicular pain and swelling 
Lymphangitis 
- generalised penile oedema 
Urethral stricture 
- now rare

Question 24

Gonorrhoea rectal infection

Answer 24

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

Question 25

Pharyngeal infection

Answer 25

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

Question 26

Endocervical infection

Answer 26

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

Question 27

PID and G complications in females

Answer 27

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

Question 28

PID complications

Answer 28

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

Question 29

Pathogenesis of PID

Answer 29

``` Primary cervicitis (endocervix) Infection may spread - endometrial infection - cervical mucous - retrograde menstruation - uterine instrumentation Long term - chronic pain - infertility - ectopic / tubal pregnancy ```

Question 30

PID symptoms and signs

Answer 30

``` Symptoms - LAP - Vaginal discarge - Vaginal bleeding - Dysuria - Other Signs - Abdominal or adnexal tenderness - Cervial motion tenderness - Anexal mass - Fever ```

Question 31

PID microbial causes

Answer 31

``` Poly microbial primary - Chlamydia - Gonorrhoea Secondary - BV organisms - others ```

Question 32

PID treatment

Answer 32

must include activity against - gonococcus - chlamydia - anaerobes

Question 33

DGI

Answer 33

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

Question 34

Non-specific urethritis

Answer 34

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

Question 35

Trichomoniasis

Answer 35

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