Lecture 29: Urethritis and Cervicitis Flashcards Preview

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Flashcards in Lecture 29: Urethritis and Cervicitis Deck (22):
1

Define Urethritis

Urethritis is an inflammation of urethra, and is not the same as a urinary tract infection (UTI). Criteria vary in different centres.

  • Urethritis is defined as that condition occurring in symptomatic males with >5 PMNL (peripheral blood monocytes and polymorphonuclear leukocytes) per HPF (high-power field) on microscopy of a urethral smear.

Symptoms are of an anterior urethritis, i.e. discharge/dysuria

2

Describe the physiological discharges in males

Littre's glands

  • Urethral glands
    • Produce a colloid secretion containing glycosaminoglycans (protect against urine)
    • Protects the epithelium against urine.

3

What are the causes of vaginal discharge? (5)

 

  • Physiological
    • Cyclical variation
    • Cervical mucus
  • Cervicitis:
    • Endocervical infection (and inflammation involving TZ)
      • Mucoprulent cervicitis e.g. gonorrhoea, or chlamydia
      • “Strawberry cervix” (colpitis macularis: inflammatory punctate haemorrhage) due to trichomonas
    • Other
  • Genital candidiasis
    • (inflammation of vagina)
  • Bacterial vaginosis (BVAB)
  • Others include atrophic vaginitis (and post-partum); desquamative inflammatory vaginitis; ‘cytolytic vaginitis’; foreign body such as retained tampon

4

Describe the characteristics of Chlamydia

Introduction

Chlamydia is a hallmark of the serially monogamous rather than promiscuous

  • Most common bacterial STI in NZ
  • Rarely fatal. Commonly asymptomatic

 

Characteristics

Obligate intracellular bacterium (‘energy parasite’) with complex biphasic lifecycle (cycle 24-48 hours)

  • Deficient in endogenous ATP production
  • Can’t grow on artificial media

Outer membrane similar to that of other gram-negative bacteria

Serovars (distinct variation within a species of bacteria of different individuals, classified based on surface antigens) include:

  • A, B, Ba, C cause endemic trachoma
  • D-K cause genitourinary disease (infect squamocolumnar cells)
  • L1, L2, L3 cause lymphogranuloma venereum (LGV) (infect lymphatic tissue)

5

Describe the Pathophysiology of Chlamydia


Initial infection is mild and self-limited

Antibodies against major outer membrane protein (MOMP) can neutralize organisms.

  • Latent infection is induced

Short term serovar-specific immunity develops

Recurrent infection produces severe inflammation (resulting in tissue damage and scarring)

  • Due to exaggerated host CMI response
  • Cross-reacting heat shock protein aggravated by persisting intracellular chlamydia antigen (chlamydial heat shock protein 60 (Chsp60))

6

Describe how you would diganose Chlamydia

Diagnostic Advances: NAAT (Nucleic Acid Amplification Testing)

  • NAAT is DNA amplification (nucleic acid amplification).
  • NAAT has increased sensitivity over EIA, which detect < log 1 organisms per sample (NAAT > Culture > EIA).
    • Enzyme immunoassay (EIA) detects log 5-7
    • Culture detects log 1-2
  • Obviates most of the problems with false positives. PPV and NPV better than other tests
  • Fewer storage and handling problems compared swabs for culture. Can be automated.

 

Diagnosis of CT (Chlamydia)

  • NAAT> Culture > EIA
  • Modern NAATs are similar in sensitivity & specificity
    • (SDA, PCR, TMA)
  • Can be performed on self-collected samples, which remain stable at room temperature for many days, thus opening up the situation for novel screening strategies
  • Rapid tests allowing point of care (PoC) testing are also well advanced

7

How do you take specimen collection and transport?

Specimen Collection and Transport

  • In males, first-void urine (FVU) in both symptomatic and asymptomatic men
  • In females, vulvovaginalal swab for NAAT; speculum examination is still recommended in symptomatic female patients

8

How would you treat Uncomplicated Chylmydial infection?

Uncomplicated/Complicated Infection

Uncomplicated infection needs presence of effective antimicrobial therapy for at least 2 reproductive cycles (i.e. about 5 days) to treat (azithromycin 1g stat or doxycycline 100mg 2x/d 7d)

  • Doxycycline 100mg bid 7 days (efficacy 97-100%)
  • Azithromycin 1 gm stat (equally efficacious to doxycycline)
    • High level of patient adherence
    • Pregnancy category B1 (limited, no harm)

Complicated disease requires longer Rx (e.g. course of doxycycline).

Fortunately, little in way of antibiotic resistance reported

9

Describe Azithromycin

-how it works

Azithromycin is azalide (a macrolide subclass). It inhibits translation of bacterial mRNA (binding to 50S subunit of bacterial ribosome)

 

  • 3-5% patients experience GI side-effects
  • Tissue levels >50X plasma levels (long tissue half life
  • Risk factor in long QT syndrome
  • In chlamydia, resistance is rare

10

How would you treat a pregnant woman who has Chylamydia?

Pregnancy

In pregnant or breastfeeding women use:

  • Azithromycin 1g stat
  • Aoxycillin 500mg tid for 7 days (test of cure should be performed 3-4 weeks after completing amoxicillin therapy)

11

What would happen with the partner of of an individual who was diagnosed with Chylamydia?

Partner Treatment

Partner notification include all partners within last 60-90 days, or last partner if > 60 days ago

  • Test of cure of required not required (also, if using NAAT may get false positive)

Treat partner(s) (even if their test is negative)

  • Expedited partner treatment (patient-delivered partner therapy (PDPT) is a possibility in some jurisdictions)
  • Advise to practice protected sex during treatment

12

Describe the bacteria that causes gonorrhoea

Neisseria gonorrhoea is Gram-negative diplococcus.

Humans are only natural host. It infects non-cornified epithelial cells (intracellular replication).

  • Oxidase positive
  • Fastidious growth
  • Chromosomal or plasmid mediated antibiotic resistance

13

Describe Specimen Collection and Transport for suspected Gonorrhoea

Always from the site with symptoms/signs, and also 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 up to 5 hours without loss of viability (but don’t tolerate drying)
  • Amies’ or Stuart’s only for transport where inoculation of growth medium will occur within 4-8 hours (not overnight)

14

What can gonorrhoea cause in males?

Urethral Infection In Males

  • Most are symptomatic (incubation period 1-14 days (2-5 is common))
  • Anterior urethritis (discharge and dysuria, erythema of meatus is variable (meatitis))
  • Untreated men are 95% asymptomatic after 6 months

15

What is a method of Diagnosing Gonorrhoea?

1) Gram stain : Presumptive diagnosis

2) Culture by site

3) NAAT

 

Diagnostic: NAAT (Nucleic Acid Amplification Testing)

NAAT has high sensitivity. Specificity varies by brand and specific method.

  • Should be confirmed by supplemental testing
  • 2 targets for GU samples
  • 3 targets for extra-genital (non-genital) samples

NAAT has high patient acceptability, can be done on self-collected samples

No antibiotic sensitivities (still a need for culture to enable surveillance of antimicrobial resistance)

Chlamydia NAAT typically combined on modern versions [CT/NG NAATs]

16

How do you treat uncomplicated gonorrhoea?

Uncomplicated Gonorrhoea

If sensitivities are unknown, or if pregnant or breastfeeding:

  • Ceftriaxone 500 mg IMI stat
  • Concomitant treatment with azithromycin 1g p.o. stat

 

If sensitivities are known and sensitive:

  • Ciprofloxacin 500mg p.o. stat with azithromycin 1g p.o. stat (but ~50% isolates are resistant to ciprofloxacin)
  • Directly observed treatment (DOT)

 

Do not use Azithromycin as sole first-line therapy (to minimise risk of resistance developing)

Concurrent anti-chlamydial therapy as co-infection with chlamydia is common

Contact trace include all contacts within last 30-90 days

17

Describe Ciprofloxacin

Has become a problem in treating gonorrhoea

 

Ciprofloxacin

Ciprofloxacin is 2nd generation fluoroquinolone. It has broad spectrum of action, excellent tissue penetration.

  • Inhibits DNA gyrase
  • Bacterial DNA separation is impeded (thus cell division inhibited)

Resistant organisms have mutated topoisomerases, so the drug can’t bind

18

What are the complications of Gonorrhoea in males?

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

19

Define PID

Pelvic inflammatory disease (PID) is an infection of the female reproductive organs. It usually occurs when sexually transmitted bacteria spread from your vagina to your uterus, fallopian tubes or ovaries.

20

What are the complications associated with PID?

Pelvic Inflammatory Disease

 

If mild (subclinical/subacute):

  • 2/3 have male partners with asymptomatic urethritis
  • It may present with secondary dysmenorrhoea, intermenstrual or postcoital bleeding, vaginal discharge
  • Signs of cervical motion tenderness, uterine tenderness

If moderate/severe, often due to mixed microbial infection of which chlamydia is a part.

PID with perihepatic pain in women is Fitz-Hugh Curtis Syndrome.

21

What are the pathogenisis of PID?

Pelvic Inflammatory Disease

 

  • Primary cervicitis (endocervix)
  • Infection may spread (endometrial infection, cervical mucus, retrograde menstruation, uterine instrumentation)
  • In long-term, there would be chronic pain, infertility, ectopic/tubal pregnancy

22

How do you diganose non-specific urethritis?

The diagnosis of NSU largely depends on

  • The presence of symptoms or signs
  • Microscopy of a urethral smear looking for PMNL (false positive results occur (e.g. samples taken soon after ejaculation))
  • Rule out infection with chlamydia and gonorrhoea

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