Sexually transmitted infections like chlamydia, mycoplasma, trichomoniasis, and candidiasis can cause various genital symptoms in both males and females. Chlamydia and mycoplasma are major causes of non-gonococcal urethritis and cervicitis, and can lead to serious complications if left untreated. These infections are commonly diagnosed using nucleic acid amplification tests of genital specimens and treated with antibiotics like azithromycin or doxycycline. Screening and treatment of partners is also important to prevent reinfection and transmission.

1. NGU-Chlamydia,
Mycoplasma

2. Differentiating Common Sexually Transmitted Genital Lesions
*Other causes of ulcers include mucous patches of secondary syphilis, erosive balanitis,
gummatous ulceration of tertiary syphilis, Behçet syndrome, epithelioma, and trauma.

3. • Several organisms can cause nongonococcal sexually transmitted cervicitis in women
and urethritis, proctitis, and pharyngitis in both sexes. These organisms include:
• Chlamydia trachomatis (causes lymphogranuloma venereum [rare], about 50% of
nongonococcal urethritis cases, and most cases of mucopurulent cervicitis)
• Mycoplasma genitalium and M. hominis (causes urogenital infections in women but
not men)
• “Nonspecific urethritis”  if tests for chlamydiae and gonococci are negative and no
other pathogen is identified.
• Chlamydiae and mycoplasmas also cause infections that are not sexually transmitted,
including trachoma and neonatal conjunctivitis (chlamydiae) and pneumonia
(chlamydiae and mycoplasmas).

4. • Sexually transmitted urethritis, cervicitis, proctitis, and pharyngitis
that are not due to gonorrhea, are caused predominantly by
chlamydiae and less frequently by mycoplasmas.
• Chlamydiae may also cause salpingitis, epididymitis, perihepatitis,
neonatal conjunctivitis, and infant pneumonia.
• Untreated chlamydial salpingitis can become chronic, causing minimal
symptoms but having serious consequences.

6. • In Males---
• Symptomatic urethritis after a 7- to 28-day incubation period, usually
beginning with mild dysuria, discomfort in the urethra, and a clear to
mucopurulent discharge
• Discharge may be slight, symptoms may be mild, frequently more marked
early in the morning
• Urethral meatus is often red and blocked with dried secretions (may also stain
underclothes)
• Occasionally, onset is more acute and severe, with severe dysuria, frequency,
and a copious, purulent discharge that simulates gonococcal urethritis.
• Infection may progress to epididymitis.
• After rectal or orogenital contact with an infected person, proctitis or
pharyngitis may develop.

7. • In Females—
• Usually asymptomatic, although vaginal discharge, dysuria, increased urinary
frequency and urgency, pelvic pain, dyspareunia, and symptoms of urethritis
may occur.
• Cervicitis with yellow, mucopurulent exudate and cervical ectopy (expansion
of the red endocervical epithelium onto the vaginal surfaces of the cervix) are
characteristic.
• Pelvic inflammatory disease (PID; salpingitis and pelvic peritonitis) may cause
lower abdominal discomfort (typically bilateral) and marked tenderness when
the abdomen, adnexa, and cervix are palpated.
• Long-term consequences of PID include ectopic pregnancy and infertility.
• Fitz-Hugh-Curtis syndrome (perihepatitis) may cause right upper quadrant
pain, fever, and vomiting.

8. • Reactive arthritis caused by immunologic reactions to genital and
intestinal infections is an infrequent complication of chlamydial
infections in adults.
• Reactive arthritis sometimes is accompanied by skin lesions
(keratoderma blennorrhagicum), eye lesions (conjunctivitis and
uveitis), non-infectious recurrent urethritis, or balanitis.

9. Infants born to women with chlamydial
cervicitis may develop chlamydial pneumonia
or ophthalmia neonatorum (neonatal
conjunctivitis)

11. Diagnosis of Chlamydia
• Urethritis--- clinically,
• Mucoid, mucopurulent, or purulent discharge observed during examination
• ≥ 10 white blood cells per high-power field in spun first-void urine
• A positive leukocyte esterase test on first-void urine
• ≥ 2 white blood cells per oil immersion field in Gram-stained urethral secretions
• Samples of cervical or vaginal specimens or male urethral or rectal
exudates are obtained for chlamydiae.
• Urine samples can be used as an alternative to cervical or urethral
specimens.
• Throat and rectal swabs are needed to test for infection at those sites.

12. • Because other STIs (particularly gonococcal infection) often coexist
with NGU, patients who have symptomatic urethritis should also be
tested for gonorrhea.
• All patients who receive a diagnosis of gonorrhea or chlamydia should
be tested for other STIs, including syphilis and HIV.
• Contact Tracing
• Screening esp.females during pregnancy (1st and 3rd trimesters)
• Commercially available nucleic acid amplification tests (NAATs) are
highly sensitive and specific for chlamydia & mycoplasmas

13. Treatment of Chlamydia
• Azithromycin 1 g orally, single dose
• Doxycycline 100 mg orally twice a day for 7 days
• Levofloxacin 500 mg orally once a day for 7 days
• For pregnant women, Azithromycin 1 g orally, once (Amoxicillin 500
mg orally 3 times a day for 7 days is an alternative therapy )
• For Mycoplasma, preferred treatment is doxycycline 100 mg orally
twice a day for 7 days, followed by
• azithromycin 1g orally initial dose followed by 500 mg orally once a day for 3
additional days OR
• moxifloxacin 400 mg orally once a day for 7 days

14. • Chlamydial infections can have serious long-term consequences for
women, even when symptoms are mild or absent--- chronic
endometritis, salpingitis, or pelvic peritonitis and their sequelae
 pelvic pain, infertility, and increased risk of ectopic pregnancy
• Hence, detecting the infection in women and treating them and their
sex partners is crucial
• Single dose of ceftriaxone 500 mg IM (1 g IM for patients weighing ≥
150 kg) if gonorrhea has not been excluded
• In areas where trichomoniasis is prevalent, empiric treatment with
metronidazole is recommended

15. Vaginal Candidiasis
• Candidal vaginitis is vaginal infection with Candida species, usually
C. albicans.
• Symptoms are usually a thick, white vaginal discharge and
vulvovaginal pruritus that is often moderate to severe; Erythema,
edema, and excoriation are common Infection in sex partners is rare
• Risk factors for candidal vaginitis include the following:
• Diabetes
• Use of a broad-spectrum antibiotic or corticosteroids
• Pregnancy
• Constrictive nonporous undergarments
• Immunocompromised

16. Diagnosis of Candidal Vaginitis
• Criteria for diagnosing candidal vaginitis include
• Typical discharge (a thick, white, curd-like vaginal discharge)
• Vaginal pH is < 4.5
• Budding yeast, pseudohyphae, or mycelia visible on a wet mount with
potassium hydroxide (KOH)

17. Treatment of Candidal Vaginitis
• Antifungal medications (fluconazole in a single oral dose 150 mg)
• Avoidance of excess moisture accumulation
• Keeping the vulva dry and wearing loose, absorbent cotton clothing
• Topical butoconazole, clotrimazole, miconazole, and tioconazole are
available over the counter.

18. Trichomoniasis
• Trichomoniasis is infection of the vagina or male genital tract with
Trichomonas vaginalis.
• It can be asymptomatic or cause urethritis, vaginitis, or occasionally
cystitis, epididymitis, or prostatitis.
• Diagnosis is by direct microscopic examination, dipstick tests, or
nucleic acid amplification tests of vaginal secretions or by urine or
urethral culture.
• Patients and sex partners are treated with metronidazole or
tinidazole.
• Coinfection with gonorrhea and other sexually transmitted infections
(STIs) is common