Chlamydial Urethritis and Cervicitis

Essentials

• Diagnose and treat the infection in time to avoid the serious complications of prolonged or recurrent infection (pelvic inflammatory disease, infertility, ectopic pregnancy).
• Prevent the spread of the chlamydial infection by examining and treating the sexual partners of the infected patient.

Investigations in a suspected STD

• The extent of investigations in a suspected sexually transmitted disease (STD) is decided on the basis of the patient interview.
  • Risk factors: unprotected sex with a casual partner; the partner has a diagnosed or suspected STD; infection possibly acquired abroad; sex between men
• The basic tests of a symptomless patient should include at least chlamydia, gonorrhoea and HIV.
• If the patient has symptoms, risk factors or another diagnosed STD, the tests include chlamydia and gonorrhoea from the anatomical sites possibly involved (urethra, cervix, throat or anus), as well as HIV and syphilis, and tests for hepatitis if considered necessary.
• If gonorrhoea is suspected on clinical grounds or a nucleic acid detection test for gonorrhoea is positive, a culture sample is obtained before starting treatment in order to assess antimicrobial sensitivity.
• When taking samples, the incubation periods of the different diseases should be borne in mind: chlamydia and gonorrhoea 1-2 weeks, syphilis 1-2 months and HIV 1-3 months.

Epidemiology

• Sexually transmitted diseases caused by chlamydia (Chlamydia trachomatis) are a significant public health issue.
• Chlamydial infections are diagnosed especially in young adults.
• Worldwide, there were about 127 million new cases of chlamydia in 2016 http://apps.who.int/iris/bitstream/handle/10665/277258/9789241565691-eng.pdf and the worldwide prevalence is estimated at 2.9% http://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-020-05307-w. The disease is more common in women than in men (worldwide prevalence 3.1% vs 2.6%). Regional and country-specific variation exists.
• Asymptomatic infections promote the spread of the disease. The time from infection to diagnosis is on average 4 weeks but may be up to several months. By the time of diagnosis, every third patient has already infected a new partner, which presents a challenge for tracing the infection.

Early symptoms

• The incubation period from chlamydial infection to the possible emergence of symptoms is 1-3 weeks, i.e. longer than in gonorrhoea. The majority of those infected are asymptomatic.
• In men, urethritis is marked by scant, watery (later mucous) discharge from the urethra and dysuria. In women, there is dysuria, pollakiuria and mild leucorrhoea. Cervicitis is a relatively common finding. It is manifested as mucopurulent discharge and oedema or bleeding tendency of the orifice of the uterus.

Late symptoms and complications

• In women, prolonged chlamydial infection may result in endometritis and salpingitis. These conditions are not always associated with severe symptoms; the patient may have just slight fever or mild lower abdominal pain. Endometritis may also cause irregular uterine bleeding.
• Pelvic inflammatory disease (PID Pelvic Inflammatory Disease (Pid)) is a late complication generally requiring inpatient treatment. Perihepatitis is a rare complication of chlamydial infection.
• Late complications of extensive and, especially, recurrent chlamydial infection also include tubal damage which in turn causes infertility and ectopic pregnancies.
• In men, chlamydial infection is an important cause of epididymitis Testis Pain, whereas the etiological significance of chlamydia in prostatitis is considered small.
• Chlamydial infection can trigger the development of reactive arthritis (uroarthritis, Reiter's disease Reactive Arthritis) in both men and women.

Diagnostics

Treatment

• Chlamydia trachomatis is sensitive to macrolides and tetracyclines. Clindamycin is also relatively effective against this species, fluoroquinolones less so Ciprofloxacin Versus Doxycycline for Uncomplicated Genital Chlamydial Infection.
• The treatment of choice is azithromycin 1 g as a single doseAzithromycin and Doxycycline for Uncomplicated Genital Chlamydial Infection or doxycycline 100 mg twice daily for 7 daysDoxycycline for Uncomplicated Genital Chlamydial Infection. Also lymecycline 300 mg twice daily for 7 days may be used Doxycycline for Uncomplicated Genital Chlamydial Infection.
• Azithromycin may be used also during pregnancyInterventions for Treating Genital Chlamydia Trachomatis Infection in Pregnancy.
• Some 10% of patients get mild gastric adverse effects from azithromycin and tetracyclines. Controlled studies have shown similar therapeutic outcomes for these drugs, with 95-97% of patients being cured.
• Chlamydial infections of the throat, anus or eyes are treated with doxycycline for 7 days. For mild complications, patients are given tetracycline or doxycycline for two to three weeks, for reactive arthritis triggered by chlamydial infection even longer. In pelvic infections Pelvic Inflammatory Disease (Pid), combinations of antimicrobials are used, as other bacteria, such as anaerobes, may be involved.
• The patient should abstain from sex for one week and then use condoms until a negative follow-up result.

Post-treatment follow-up and tracing of contacts

• A follow-up specimen should only be collected after 4 weeks because re-testing too early may produce a false positive result.
• A permanent sexual partner should be simultaneously treated. Treatment can be started immediately after obtaining the sample. At the same time, other possible STDs should be tested for and contact tracing performed.
• The treating physician is required to trace the sexual contacts of their patients. During the follow-up visit, the physician should enquire the index patient whether the person who is the source of the infection and any persons potentially infected have been tested for chlamydia and received treatment as needed. If desired, the attending physician may delegate the screening of sexual partners to a physician responsible for communicable diseases.
• Tracing the contacts of the patient is the most effective way of combating the STDs.

Screening for asymptomatic infections Screening for Genital Chlamydia Infection

• In association with an induced abortion
• In a patient less than 25 years of age seeking contraception, either on the first visit or on the follow-up visit after 3 months and again after 12 months
• On a follow-up visit related to contraception if there is a new sexual partner or the patient has a history of previous chlamydial infection