hematuria, chills, fever, frequency, hesitancy, nocturia, urgency, perineal pain, scrotal masses, postvoid dribbling, genital pain other than dysuria.
NAAT- to identify CH and GN. Tryptophan synthetase coding gene id and responcible NA amplified to detect the organism.Eg. RT-PCR,LCR,Trascrption mediated amplification.ETC
1. MY REFERENCES:
1. King homes
INTRODUCTION AND HISTORY
CHLAMEDIA AND PGU
SYMPTOMS AND SIGNS IN MALE,FEMALE
TREATMENT AND FOLLOW UP
COMPLICATIONS IN MALE AND FEMALE
TREATMENT OF COMPLICATIONS
1800, even prior to the discovery of N. gonorrhoea, the
existence of several types of urethritis was already suspected.
Gonorrhoea is known since Greek-roman period.
Galen coined the word gonorrhoea
1880s◦ The isolation of N. gonorrhoea
◦ introduction of Gram stain
◦ differentiation of gonococcal from Non Gonococcal Urethritis.
Early part of the twentieth century◦ Intra cytoplasmic inclusions were seen in urethral smears of some men
with urethritis suggesting Non gonococcal aetiology.
Insight into the etiology of NGU
◦ Discovery of Ureaplasma urealyticum in 1954.
1965-the cell culture isolation techniques for C. trachomatis were
1990-Nucleic acid amplification tests (NAATs) for sexually
transmitted diseases (STDs).
◦ Characterised by urethral discharge, dysuria, or itching at the end
of the urethra, in the response of the urethra to inflammation, of
Non gonococcal urethritis (NGU) :
◦ Urethritis caused by any aetiology other than N. gonorrhoea or
wherein N.gonorhea is not detected.
◦ It is NGU occurring after curative therapy for gonorrhoea, is called
postgonococcal urethritis (PGU).
Ch. trachomatis (15-40%)
Mycoplasma genitalium (15-25%)
◦ T Vaginalis
◦ U Urealiticum
◦ HSV (In absence of skin lesions)
◦ Adeno Virus
7. ◦ Miscellaneousin association with urinary tract infection,
 secondary to instrumentation of the urethra,
13 mycoplasma species known to infect humans
four are found in the genital tract:
◦ Mycoplasma hominis,
◦ M. genitalium,
◦ Ureaplasma parvum, and
◦ U. urealyticum.
◦ M. genitalium - 21.1% in men with chlamydia-negative
◦ U. urealyticum 18%
◦ U. parvum 9.9%
C. trachomatis first visualized -1907 by
Halberstaedter and von Prowazek
◦ 25-60% (usually 30-40%) NGU,
◦ 4-35% (usually 15-25%) gonorrhea,
◦ 0-7% men without obvious urethritis
Chlamydia pneumoniae -respiratory
pathogen of humans, possible cause of CAD.
C.TRACHOMATIS L1, L2, L3
A, B, Ba, C
Hyperendemic blinding trachoma
B, D, E, F, G,
H, I, J, K
Inclusion conjunctivitis (adult and
newborn), nongonococcal urethritis,
cervicitis, salpingitis, proctitis,
epididymitis, pneumonia of newborns
C. trachomatis 15-40% of NGU.
◦ Gonorrhea has a shorter incubation period 2-6days
◦ chlamydial IP 1-5 weeks
◦ so men with both infections can present with gonorrhea
while the chlamydial infection is still incubating.
When gonorrhea is treated and do not eradicate
Hence, concurrently Chlamedial/NGU/PGU
develops who have concurrent C. trachomatis
Hence PGU - provides assessment of the ability of
C. trachomatis to produce urethritis.
meatitis, inguinal lymphadenitis.
The symptoms and signs of GU and NGU are
similar but differ significantly in severity.
Both may cause urethral discharge, dysuria, or
Discharges - profuse and purulent in
men with gonorrhoea, but are
generally scanty and mucoid in men
Discharge may be detected only in
the morning or noted as crusting at
the meatus or as staining on
Gonorrhoea usually develops 2-6
days after exposure, whereas NGU
generally develops between 1 and 5
weeks after the acquisition of
In urethritis caused by HSV and adenovirus,
dysuria is severe.
viral urethritis presents with meatitis, but
is seen in a minority of cases caused by bacteria.
Adenovirus cases tend to occur in the winter and
often associated with conjunctivitis.
Following are seen with primary HSV urethritis.
pain in groin/leg/buttock,
blood stained discharge
Asymptomatic urethritis common in chlamydial
infections. Constitutes a large reservoir of infection.
Atypical presentations of NGU
a) Meatitis with urethral inflamation
c) Periurethral abscess
d) Associated disease manifestations
◦ classic urinary tract infection,
◦ acute prostatitis/flare-up of chronic prostatitis,
◦ acute epididymitis or orchitis
hematuria, chills, fever, frequency, hesitancy, nocturia,
urgency, perineal pain, scrotal masses, postvoid dribbling,
genital pain other than dysuria.
Gram staining of discharge or sediment of First Voided Urine:
◦ Absence of Gonnorheal Diplococci
◦ Presence of leukocytosis
◦ i.e.more than 5 PMNs per high power field.(in Minimum of 5 fields
20. AND / OR
Leukocyte esterase testing on FVU or
gram stained specimen of centrifuged sediment of FVU with
>10 PMNL/x1000 microscopic field.
In pts who are symptomatic without evidence of urethritis
(i.e., discharge on examination or the presence of PMNL in
the stained urethral smear),
non sexually transmitted
causes of urethritis considered.(-like urinary tract infection)
22. S.NO Disease
Chlamedial Dysuria, urethral
Gram Stain, 5 or
pyuria on FVU
Diagnostic tests for U. ureaplasma, M. genitalium, and T.
vaginalis either lack sensitivity or specificity.
Clinical circumstances, identification of C. trachomatis as
the cause of NGU is not necessary, as recommended
antibiotic therapy currently is the same for both chlamydiapositive and chlamydia negative NGU. (King Homes)
Disease may be asymptomatic (40%)
• Minimal cervical mucoid/mucopurulent discharge
(IUD in situ)
• Cervical erosion/cervicitis(OCP users)
• Microfollicles in cervical mucosa are diagnostic of
Salpingitis is imp complication.
◦ B/L low abdominal pain, involving both adnexae
◦ Often with uterine bleeding,
◦ Constitutional symptoms: fever, headache, vomiting
◦ can lead to ectopic pregnency, Infertility
Gram stain of Cx smear is of little
significance. As pus cells in Cx may even be
Numerous pus cells in absence of Gonococci,
may be due to NGU.
Male partner should be investigated for NGU.
STD treatment guidelines from the CDC 2010 and the World
Health Organization currently recommends
◦ doxycycline 100 mg twice daily for 7 days. OR
• Azithromycin 1G orally
◦ Erythromycin base 500mg four times for 7days OR
◦ Ofloxacin 300mg twice daily for 7 days OR
◦ Levofloxacin 500 mg once daily for 7days
29. All Sex Partners In Last 60 Days Should Be Evaluated And
Sexual abstinence till completion of treatment.
Pts with NGU reviewed 2-3 weeks after treatment to confirm
resolution of symptoms and treatment of sexual contacts.
Should be checked for other STIs including Syphilis and
HIV,Results of tests checked during review.
30.  Abstinence
Self examination, squeezing urethra
from alcohol during treatment
partner treatment, and follow up.
urine at least for 4 hours before next
1 Week- repeat 2 glass test, repeat staining,
check test reports.
2/3 week- check 2 glass test and stain
4/6weeks-Symptomatic for urethritis
3 months- check for syphilis
33. 1. Symptoms of urethritis+ O/E: supportive signs of
The following should be checked:
 Abstinence- chance of re-infection
 Compliance/drug interaction eg: milk/liver enzyme
 Self examination: Repeated/habitual milking of urethra
by patient or H/O masturbation.
34.  Wrong diagnosis:
b. Trichomonal urethritis
 Stricture: suspect in all chronic cases until
 Neurosis: often seen in patients with
habitual self examination.
35. 2. Iatrogenic:
over enthusiastic treatment of pus cells during
follow up in asymptomatic patients.
◦ reinfection/ relapse suspected◦ 2 glass test -abnormal in both glass
prostatitis as seat of infection
Culture from Mid Stream Urine
(On three successive days)
Urethroscopy and IVU-
higher seated source of infection
 anterior urethroscopy
 1. stricture
 2. reassurance of neurotic patient
 3. VUR/hydronephrosis/pyelonephritis
UTI: C&S followed by antibiotics
Trichomoniasis: secnidazole 2g stat
Stricture: urology for opinion and Rx
Symptoms disproportionate to signs:
◦ Strong reassurance
◦ Test and Strong reassurance
Reported by Hans Reiter 1916.
Described by sir benjamin brodie.
“Reiter’s Syn. is an infectious induced systemic
illness characterized by an aseptic inflammatory
joint involvement occurring in a genetically
predisposed patient with a bacterial infection
localized in a distant organ/system”.
Incidence varies widely (1% to 20%).
Consists of :
◦ Asceptic arthritis
Post dysenteric and urethritis
◦ Yersinia enterocolitica