Dysuria: Urethritis, Cervicitis, and testicular pain Flashcards Preview

Blood and Immune > Dysuria: Urethritis, Cervicitis, and testicular pain > Flashcards

Flashcards in Dysuria: Urethritis, Cervicitis, and testicular pain Deck (35):
1

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

2

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
-

3

Epidemiology of chlamydia

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

4

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

5

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

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

6

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

7

Spectrum of disease, D-K males,

Urethritis
Epididymitis
Proctitis
Reuter's Syndrome

8

Spectrum of disease D-K, females

Cervicitis
Sterile pyuria
PID and ectopic pregnancy
Perihepatitis
Infertility

9

Neonatal and paediatric

Conjunctivitis
Pneumonia
Otitis media

10

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)

11

Chlamydia testing

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

12

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

13

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

14

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.

15

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

16

Reiter's syndrome

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

17

Neisseria Gonorrhoea

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

18

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

19

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

20

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

21

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

22

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

23

Gonorrhoea, complications in males

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

24

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

25

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

26

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

27

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

28

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

29

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

30

PID symptoms and signs

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

31

PID microbial causes

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

32

PID treatment

must include activity against
- gonococcus
- chlamydia
- anaerobes

33

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

34

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

35

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