Microbiology and Epidemiology

Most cases are caused by either Neisseria gonorrhoeae or Chlamydia trachomatis. Other causative organisms include Mycoplasma genitalium, Ureaplasma urealyticum, Trichomonas vaginalis, HSV, and occasionally anaerobes (especially Leptotrichia/Sneathia species) involved in bacterial vaginitis. Chlamydia causes 30-40% of nongonococcal urethritis (NGU) cases. M. genitalium is the probable cause in many Chlamydia-negative cases of NGU.

Clinical Manifestations

Urethritis in men produces urethral discharge, dysuria, or both, usually without frequency of urination.

Diagnosis

Pts present with a mucopurulent urethral discharge that can usually be expressed by milking of the urethra; alternatively, a Gram's-stained smear of an anterior urethral specimen containing ≥2 PMNs/1000× field confirms the diagnosis.

• Centrifuged sediment of the day's first 20-30 mL of voided urine can be examined for inflammatory cells instead.
• N. gonorrhoeae can be presumptively identified if intracellular gram-negative diplococci are present in Gram's-stained samples.
• Early-morning, first-voided urine should be used in “multiplex” nucleic acid amplification tests (NAATs) for N. gonorrhoeae and C. trachomatis.

Microbiology

In sexually active men <35 years old, epididymitis is caused most frequently by C. trachomatis and less commonly by N. gonorrhoeae.

• In older men or after urinary tract instrumentation, urinary pathogens are most common.
• In men who practice insertive rectal intercourse, Enterobacteriaceae may be responsible.

Clinical Manifestations

Acute epididymitis-almost always unilateral-produces pain, swelling, and tenderness of the epididymis, with or without symptoms or signs of urethritis. Epididymitis must be differentiated from testicular torsion, tumor, and trauma. If symptoms persist after treatment, a testicular tumor or a chronic granulomatous disease (e.g., tuberculosis) should be considered.

Microbiology and Clinical Manifestations

C. trachomatis, N. gonorrhoeae, and occasionally HSV cause symptomatic urethritis-known as the urethral syndrome in women-that is characterized by “internal” dysuria (usually without urinary urgency or frequency), pyuria, and an absence of Escherichia coli and other uropathogens at counts ≥10² /mL in urine.

Diagnosis

Specific tests (e.g., NAATs of vaginal secretions collected with a swab) are used to evaluate for infection with N. gonorrhoeae or C. trachomatis.

Microbiology

A variety of organisms are associated with vulvovaginal infections, including N. gonorrhoeae and C. trachomatis (particularly when they cause cervicitis), T. vaginalis, Candida albicans, Gardnerella vaginalis, and HSV.

Clinical Manifestations

Vulvovaginal infections encompass a wide array of specific conditions, each of which has different presenting symptoms.

• Unsolicited reporting of abnormal vaginal discharge suggests trichomoniasis or bacterial vaginosis (BV).
  • Trichomoniasis is characterized by vulvar irritation and a profuse white or yellow homogeneous vaginal discharge with a pH that is typically ≥5.
  • - BV is characterized by vaginal malodor and a slight to moderate increase in white or gray homogeneous vaginal discharge that uniformly coats the vaginal walls and typically has a pH >4.5.
  • Vaginal trichomoniasis and BV early in pregnancy are associated with premature onset of labor.
• Vulvar conditions such as genital herpes or vulvovaginal candidiasis can cause vulvar pruritus, burning, irritation, or lesions as well as external dysuria (as urine passes over the inflamed vulva or areas of epithelial disruption) or vulvar dyspareunia.

Diagnosis

Evaluation of vulvovaginal symptoms includes a pelvic examination (with a speculum examination) and diagnostic testing.

• Abnormal vaginal discharge is assessed for pH, a fishy odor after mixing with 10% KOH (BV), evidence on microscopy of motile trichomonads and/or clue cells of BV (vaginal epithelial cells coated with coccobacillary organisms) when the specimen is mixed with saline, or hyphae or pseudohyphae on microscopy when 10% KOH is added (vaginal candidiasis).
• A NAAT for T. vaginalis is available.

Microbiology

N. gonorrhoeae, C. trachomatis, and M. genitalium are the primary causes of mucopurulent cervicitis. Of note, NAATs for these pathogens, HSV, and T. vaginalis have been negative in nearly half of cases.

Clinical Manifestations

Mucopurulent cervicitis represents the “silent partner” of urethritis in men and results from inflammation of the columnar epithelium and subepithelium of the endocervix.

Diagnosis

Yellow mucopurulent discharge from the cervical os, with ≥20 PMNs/1000× field on Gram's stain of cervical mucus, indicates endocervicitis. The presence of intracellular gram-negative diplococci on Gram's stain of cervical mucus is specific but <50% sensitive for gonorrhea; thus NAATs for N. gonorrhoeae and C. trachomatis are always indicated.

Microbiology

The agents most often implicated in acute PID-infection that ascends from the cervix or vagina to the endometrium and/or fallopian tubes-include the primary causes of endocervicitis (e.g., N. gonorrhoeae, C. trachomatis, M. genitalium) and anaerobes associated with BV; other organisms (e.g., Prevotella spp., peptostreptococci, E. coli, Haemophilus influenzae, and group B streptococci) account for 25-33% of cases.

Epidemiology

In 2014, there were 51,000 visits to physicians' offices for PID in the United States; there are ∼70,000-100,000 hospitalizations related to PID annually.

• Risk factors for PID include cervicitis, BV, a history of salpingitis or recent vaginal douching, menstruation, and recent insertion of an intrauterine contraceptive device (IUD).
• Oral contraceptive pills decrease risk.

Clinical Manifestations

The presenting symptoms depend on the extent to which the infection has spread.

• Endometritis: Pts present with midline abdominal pain and abnormal vaginal bleeding. Lower-quadrant, adnexal, or cervical motion or abdominal rebound tenderness is less severe in women with endometritis alone than in women who also have salpingitis.
• Salpingitis: Symptoms evolve from mucopurulent cervicitis to endometritis and then to bilateral lower abdominal and pelvic pain caused by salpingitis. Nausea, vomiting, and increased abdominal tenderness may occur if peritonitis develops.
• Perihepatitis (Fitz-Hugh-Curtis syndrome): 3-10% of women present with pleuritic upper abdominal pain and tenderness in the RUQ due to perihepatic inflammation. Most cases are due to chlamydial salpingitis.
• Periappendicitis:∼5% of pts can have appendiceal serositis without involvement of the intestinal mucosa as a result of gonococcal or chlamydial salpingitis.

Diagnosis

Speculum examination shows evidence of mucopurulent cervicitis in the majority of pts with gonococcal or chlamydial PID; cervical motion tenderness, uterine fundal tenderness, and/or abnormal adnexal tenderness also is usually present. Vaginal or endocervical swab specimens should be obtained for NAATs for N. gonorrhoeae and C. trachomatis.

Microbiology and Epidemiology

Acquisition of HSV, N. gonorrhoeae, or C. trachomatis (including lymphogranuloma venereum [LGV] strains of C. trachomatis) during receptive anorectal intercourse causes most cases of infectious proctitis in women and in men who have sex with men (MSM). Sexually acquired proctocolitis is most often due to Campylobacter or Shigella spp. In MSM without HIV infection, enteritis is often attributable to Giardia lamblia.

Clinical Manifestations

Anorectal pain and mucopurulent, bloody rectal discharge suggest proctitis or proctocolitis. Proctitis is more likely to cause tenesmus and constipation, whereas proctocolitis and enteritis more often cause diarrhea.

• HSV proctitis and LGV proctocolitis can cause severe pain, fever, and systemic manifestations.
• Sacral nerve root radiculopathy, with urinary retention or anal sphincter dysfunction, is associated with primary HSV infection.

Diagnosis

Pts should undergo anoscopy to examine the rectal mucosa and exudates and to obtain specimens for testing for rectal gonorrhea, chlamydial infection, herpes, and syphilis.