Urethritis in women attending an STD clinic

Trichomonas vaginalis genital infections: progress and challenges

Trichomonas vaginalis (TV) infection is the most prevalent curable sexually transmitted infection in the United States and worldwide. Most TV infections are asymptomatic, and the accurate diagnosis of this infection has been limited by lack of sufficiently sensitive and specific diagnostic tests, particularly for men. To provide updates for the 2010 Centers for Disease Control and Prevention's Sexually Transmitted Diseases Treatment Guidelines, a PubMed search was conducted of all TV literature published from 9 January 2004 through 24 September 2008. Approximately 175 pertinent abstracts and articles were reviewed and discussed with national experts. This article describes advances in TV diagnostics which have led to an improved understanding of the epidemiology of this pathogen, as well as potential biologic and epidemiological interactions between TV and human immunodeficiency virus (HIV). New data on treatment outcomes, metronidazole-resistant TV, management of nitroimidazole-allergic patients, frequency of recurrent TV infection following treatment, and screening considerations for TV in certain populations are also presented.

Management of Chlamydia trachomatis genital tract infection: screening and treatment challenges

Chlamydia trachomatis is a prevalent sexually transmitted infection that can lead to serious reproductive morbidity. Management and control of C. trachomatis is a challenge, largely due to its asymptomatic nature and our incomplete understanding of its natural history. Although chlamydia screening programs have been implemented worldwide, several countries have observed increasing rates of reported chlamydia cases. We reviewed the literature relating to the long-term complications of C. trachomatis, as well as screening strategies, treatment, and prevention strategies for reducing chlamydia in the population. Articles from 1950-2010 were identified through a Medline search using the keyword "Chlamydia trachomatis" combined with "screening", "pelvic inflammatory disease", "endometritis", "salpingitis", "infertility", "ectopic pregnancy", "urethritis", "epididymitis", "proctitis", "prostatitis", "reinfection", "cost-effectiveness", "treatment", "vaccines", or "prevention". Progression of C. trachomatis varies, and recurrent infections are common. Currently, there is limited evidence on the effectiveness of chlamydia screening. Higher quality studies are needed to determine the efficacy of more frequent screening, on a broader range of sequelae, including infertility and ectopic pregnancy, in addition to pelvic inflammatory disease. Studies should focus on delineating the natural history of recurrent infections, paying particular attention to treatment failures. Furthermore, alternatives to screening, such as vaccines, should continue to be explored.

Should we consider alternatives to combined cervical and urethral swabs for detection of Chlamydia trachomatis in females?

BACKGROUND

The optimum approach for detecting Chlamydia trachomatis (CT) is considered to be combined cervical and urethral testing.

OBJECTIVE

To assess the contribution of female urethral swabs in CT diagnosis and to examine alternatives.

METHOD

Urethral and endocervical samples for CT were performed on 757 sexually active female patients, >16 years, attending the genitourinary medicine clinic at Macclesfield District General Hospital from October 2005 to November 2006. Swabs were collected and transported to the laboratory in separate AC2 sample collection tubes and were tested by AC2 assay.

RESULTS

Of the 757 patients tested simultaneously by both endocervical and urethral swab, a total of 90 had CT identified by either method giving a positivity rate of 11.9%. Results for urethral and endocervical swabs were concordant in 77 patients (85.6%). Eighty two infections (91.1%) would have been diagnosed by swabbing the cervix only but an additional 8 (8.9%) were picked up by urethral swab. Urethral symptoms had been mentioned by 1 of these 8 women.

CONCLUSION

8.9% infected women were positive only on urethral swab. One of these would have been picked up owing to presenting symptoms, hence reducing the extra yield to 7.8% and leaving only 7 positives on 757 urethral swabs with a detection rate of 1% of all urethral swabs. Considering the low yield and the discomfort of urethral swabbing, an additional urethral swab appears unwarranted on grounds of both cost and patient care. As a small number of cases were detected at the urethra but not the cervix, it may be worthwhile investigating the performance of AC2 when placing an endocervical swab in first catch urine. An effective and simpler approach may be a switch to testing vaginal swabs by AC2.

Pelvic inflammatory disease. Current approaches

Pelvic inflammatory disease is an important cause of acute and chronic morbidity among women of reproductive age, and PID rates are rising. Clinical diagnosis of PID is often inaccurate, but can be improved by knowledge of risk factors and use of simple investigations. Early diagnosis and the institution of appropriate treatment regimens, including evaluation and prompt treatment of sexual partners, are essential to prevent PID's devastating sequelae.

Rectal occurrence of Mobiluncus species

The simultaneous occurrence of Mobiluncus spp in the vagina and rectum was studied in women attending a sexually transmitted diseases (STD) department. Of 43 women with bacterial vaginosis (BV), 32 had Mobiluncus spp in the vagina and 23 in the rectum. In 20 women the same Mobiluncus species was found concomitantly in the vagina and the rectum. Mobiluncus spp were found in the rectum only in two women with BV, one with candidal vaginitis, and one healthy woman. In a treatment study of 23 women, BV was cured in nine out of 10 treated with metronidazole and six out of 13 treated with tetracycline. After treatment Mobiluncus spp persisted in the vaginas of two out of 19 women and in the rectums of two out of 10.

Bacterial vaginosis in women attending STD clinic: diagnostic criteria and prevalence of Mobiluncus spp

The diagnostic criteria of bacterial vaginosis (BV) and the prevalence of Mobiluncus spp as detected by monoclonal antibodies were investigated in all new women patients attending the sexually transmitted disease (STD) clinic in Uppsala during a four month period. Of 455 patients, 164 fulfilled the generally accepted criteria for BV, but in 57 of them simultaneous infection with a recognised pathogen was diagnosed. BV was thus the only clinical diagnosis in 107 (24%) of the women. The sniff test and clue cells in the wet smear were the two criteria most relevant for the diagnosis of BV. The sniff test was positive in 95% (156) of the 164 patients with BV and negative in all other cases. The corresponding figure for the clue cells was 98% (160 of 164), but clue cells were also detected in 19 patients without BV. Though 99% (162) of women with BV had a vaginal pH of more than 4.5, so did 83 women without BV. Only 59% (96) of women fulfilling the criteria of BV had a characteristic discharge. Mobiluncus spp were present in 20% (90) of the 455 women and in 50% (53) of the 107 women with BV only. Of the 90 Mobiluncus spp isolates, M curtisii comprised 44% (40), M mulieris 34% (31), and both strains together 21% (19). Mobiluncus spp were detected with monoclonal antibodies in 35 women who had no motile curved rods on wet smear microscopy. Furthermore, Mobiluncus spp were often detected in women infected with recognised pathogens, as well as in a few women without signs of genital infection.

Effect of blind passage and multiple sampling on recovery of Chlamydia trachomatis from urogenital specimens

Detection of chlamydial infections depends on the sensitivity of the techniques used. Variables include the number of body sites sampled, the number of samples obtained, and the number of passages in tissue culture. To assess these factors, microdilution plate cultures with a single blind passage were performed on specimens from 10,291 men and women attending a sexually transmitted disease clinic. Overall, 21% of the men and 30% of the women were culture positive. However, 18% of endocervical, 28% of female urethral, and 29% of male urethral cultures that were positive became so only after a single passage. Of culture-positive women, 23% were positive at the urethra only. Pooled urethral and endocervical specimens were positive more often than an endocervical specimen alone but less often than separately cultured endocervical and urethral specimens. A total of 221 specimens from 92 men and 66 women were subjected to five serial blind passages. Of 83 positive specimens, 29 (35%) were positive only after two or more passages. A total of 37 (46%) women were culture-positive, but only 12 (33%) of those who were positive and had an endocervical culture would have been detected by a single endocervical culture that was not passaged. The sensitivity of chlamydial culture is substantially less than 100% but can be improved by culturing samples from both the urethra and endocervix in women and by serial passage in tissue culture.

Chlamydial infections of the urethra in women

Cervical and endourethral swabs from 360 untreated women attending a sexually transmitted disease (STD) clinic were cultured for Chlamydia trachomatis and other genitourinary pathogens. The patients included contacts of men with non-gonococcal urethritis, women with gonorrhoea, and those in whom symptoms suggestive of urinary tract infection were the main reasons for their attendance. Chlamydial infection of the urethra was less common than, and seldom occurred in the absence of, cervical chlamydial infection; it was frequently silent, producing no signs or symptoms of urethritis. Only 33/96 women with evidence of urethritis gave chlamydia positive urethral swabs, and 14 of them had other concurrent infections of the genitourinary tract. Chlamydia trachomatis thus does not appear to be a major cause of the signs and symptoms of urethritis commonly found in women attending STD clinics, and there seems to be no indication for taking routine urethral swabs to aid in the diagnosis of chlamydial infection in women.

Chlamydial infection: a common sexually transmitted disease

Chlamydia trachomatis infection is more prevalent than gonorrhea and causes a similar clinical picture. It is the prime cause of non-gonococcal urethritis in men and pelvic inflammatory disease in women. Its sequelae in women are ectopic pregnancy and infertility. It can be transmitted from an infected mother to her newborn child, leading to inclusion conjunctivitis and pneumonia. Tetracycline and erythromycin are effective in eradicating chlamydial infections, but the penicillins are not. Screening of high risk groups and special diagnostic facilities would help control this common sexually transmitted disease.