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STDs: Urethritis, Cervicitis and
PID
Shahbaz Hasan
Infectious Care
OUTLINE
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Management of male patients with urethritis
Management of cervicitis
Chlamydial infections
Gonococcal infections
Diseases causing vaginal discharge: BV and
Trichomonas
• Pelvic Inflammatory Diseases
Urethritis in male patients
• Can be infectious or noninfectious
• Asymptomatic infections are common
• Symptoms: discharge of purulent or
mucopurulent material; dysuria; itching
• In absence of clinic-based diagnostic tools,
treat empirically for GC and Chlamydia
• Diagnosis is recommended: partner
notification, reportable diseases, improved
treatment and compliance
Etiology of urethritis in males
• GNID (Gram Negative Intracellular Diplococci)
• NGU (Nongonococcal urethritis)
1. Chlamydia trachomatis: 15-55%. Varies by STD
risk factors
2. Ureaplasma urealyticum
3. Mycoplasma genitalium
4. Trichomonas vaginalis
5. HSV, adenovirus
6. Enteric bacteria: insertive anal sex
Confirming a diagnosis
• Presence of purulent or mucopurulent
discharge. OR
• Gram stain of urethral secretion with >5
WBC/hpf. High Sen/Sp. OR
• First-void urine specimen with pyuria, either
microscopic or dipstick test
• In the absence of above, test specifically for
GC/Chlamydia before treatment. An exception
can be made for high risk individuals.
Followup after treatment
• Abstain from sex for 7d after treatment
initiation and partner is adequately treated
• Recurrent symptoms alone should not be
treated without objective evidence of urethral
inflammation
• True persistence: consider reinfection, chronic
prostatitis, Trichomonas, drug resistant
microorganisms
Management of Cervicitis: Diagnosis
• Often asymptomatic
• Abnormal vaginal discharge or intermenstrual
bleeding
• Purulent or mucopurulent endocervical exudate
• Easily inducible endocervical bleeding
• Leukorrhea (>10 WBC/hpf)
• All cases of cervicitis should be assessed for PID
Etiology of cervicitis
• Majority of cases will not have a clear etiology:
persistent abnormal vaginal flora, douching,
exposure to chemical irritants
• Chlamydia
• GC
• Trichomonas
• HSV2
• BV
• Mycoplasma genitalium, ureaplasma
Followup after treatment
• Abstain from sex for 7d after treatment
initiation and partner is adequately treated
• Recurrent symptoms need exclusion of
reinfection. Exclude BV and trich and drug
resistant microorganisms
• Persistent symptoms in absence of infection:
ablative therapy?
Chlamydial infections
• Commonest STD in the US. Highest prevalence
in <25yr age group
• Asymptomatic infection is common in both
sexes
• Serious sequelae: PID, ectopic pregnancy,
infertility
• Annual screening is recommended in all high
risk women and is suggested in high risk men
Chlamydia: Diagnosis
• Specimens: Urine; Swabs (urethra, endocervix,
vagina, rectum)
• Culture, direct immunofluorescence, EIA,
nucleic acid hybridization tests, NAAT
• NAATs are the most sensitive and FDAapproved for all source specimens EXCEPT
Rectal
Chlamydia: diagnosis, PHD
• BD Probetec (SDA-Strand Displacement
Amplification) a form of NAAT
• For urethral, endocervical and urine only
• Blue cap for male urethral specimens
• Pink cap for female specimens
Chlamydia: Treatment
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Azithromycin: 1gm oral in a single dose
Doxycycline: 100mg bid for 7d
Erythromycin base: 500mg qid for 7d
Levofloxacin: 500mg once daily for 7d
Chlamydia: followup after treatment
• Abstain from sex for 7d after single-dose
treatment or until completion of the 7d course
and partner is adequately treated
• Test of cure, at 3-4 weeks, is recommended for
1. Pregnant women
2. Concern for noncompliance
3. Concern for reinfection
• Consider retesting all women at 3 months
Chlamydia: Pregnancy
• Azithromycin and erythromycin (except
estolate which carries risk of hepatotoxicity)
are safe
• Amoxicillin 500mg tid for 7d is an alternative
• Test of cure at 3-4 weeks is necessary to
prevent risk of infant infections (ophthalmia
neonatorum and pneumonia)
Gonococcal infections
• Second most commonly reported bacterial
STD. 600,000 new cases each year in US
• Majority of men are symptomatic. Women can
be asymptomatic
• USPSTF recommends screening all high risk
women for GC: prior h/o GC, other STDs, new
or multiple sex partners, inconsistent condom
use, commercial sex workers, drug users,
pregnant women
GC: diagnosis
• Gram stain of male uretheral specimen in
symptomatic patients has high Sen (>95%)/Sp
(>99%)
• Gram stain not sensitive in asymptomatic men or
for endocervical, pharyngeal or rectal specimen
• Specific diagnosis (culture, nucleic acid
hybridization tests and NAAT) are indicated
• NAAT is FDA-cleared for urine and genital sites
• Culture is indicated for non-genital sites: pharynx,
rectum, joints, blood.
GC: diagnosis at PHD
• For culture: use the Duo blue top swabs with
gel (anaerobic transport swabs). Walk
specimen down to lab
• Chocolate agar and Thayer-Martin are
available. Jembec plates are available if you
want to plate at the bedside
• Most genital specimens are run with the BD
Probetec. (Blue cap for male and Pink cap for
female specimens)
GC: Treatment: uncomplicated Genital
and Rectal infections
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Ceftriaxone 125mg IM single dose
Cefixime 400mg po single dose
Spectinomycin 2gm IM single dose
Azithromycin 2gm po single dose
Fluoroquinolones no longer acceptable
Other cephalosporins: ?
GC: Treatment: Uncomplicated
Pharyngeal infections
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Eradication is more difficult.
Use Rocephin 125mg IM single dose
Use other cephalosporins with caution
Spectinomycin is unreliable. Perform test of
cure 3-5d after administration
GC: Treatment: Conjunctivitis
• Ceftriaxone 1gm IM single dose
• Local care
Disseminated Gonococcal Infection
(DGI)
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Results from gonococcal bacteremia
Petechial or pustular acral skin lesions
Asymmetric arthralgias
Tenosynovitis
Septic arthritis
Endocarditis
Meningitis
DGI: Treatment
• Ceftriaxone 1gm IV daily for 7d
• Spectinomycin 2gm IM bid for 7d
• Meningitis and endocarditis need higher
doses and longer courses
GC: Followup
• Uncomplicated cases do not need tests of cure
• May consider tests of cure in subjects being
treated with alternative regimens or
pharyngeal infections
• Persistent symptoms should be evaluated by
culture for antimicrobial susceptibility testing.
• Avoid sex till 7d after completion of therapy
and partner is adequately treated
Bacterial Vaginosis
• Polymicrobial clinical syndrome resulting from the
replacement of normal H2O2 producing lactobacillus in
the vagina with anaerobic bacteria (prevotella,
gardnerella, mycoplasma hominis)
• Associations: multiple sex partners, new sex partner,
douching, lack of vaginal lactobacilli
• Most prevalent cause of vaginal discharge and
malodor. More than 50% of women are asymptomatic
• Associated with adverse pregnancy outcomes: preterm
labor, preterm birth, PROM, postpartum endometritis
• Increased risk of infectious complications following
hysterectomy and abortions
BV: Diagnosis
• Any 3 of the following:
1. Homogenous, thin, white discharge
2. ‘clue cells’ on wet prep
3. pH of vaginal fluid >4.5
4. ‘whiff test’: fishy odor with 10% KOH
• Other commercial tests and culture not
recommended
BV: Treatment
• All women with symptomatic disease
• Pregnant women, whether symptomatic or
asymptomatic should be treated
• Metronidazole 500mg po bid for 7d
• Metrogel 0.75%, intravag daily for 5d
• Clindamycin cream 2%, intravag daily for 7d
• Clindamycin 300mg po bid for 7d
• Metronidazole 2gm single dose po is no longer
recommended.
Trichomonas
• Caused by the protozoan Trichomonas
vaginalis.
• May be asymptomatic in both sexes
• Men generally present as NGU, women with
diffuse, malodorous, yellow-green, vaginal
discharge and vulvar irritation
• Association with adverse pregnancy outcomes
Trichomonas: Diagnosis
• Microscopic exam of vaginal secretions has a
sensitivity of only 60-70%
• FDA approved POC tests are more sensitive
and specific
• Culture is the most sensitive and specific
commercially available method of diagnosis
• Wet preps are very insensitive for men.
Culture is required for a confirmed diagnosis
Trichomonas: Treatment
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Metronidazole 2gm po single dose
Tinidazole 2gm po single dose
Metronidazole 500mg po bid for 7d
Avoid alcohol for 24hr after metronidazole and 72h
after tinidazole
• Metronidazole is pregnancy category B, while
tinidazole is category C.
• Lactating women should hold off breast feeding for 24h
after metronidazole and 72h after tinidazole
• Consult CDC in cases of allergies or resistance issues.
Pelvic Inflammatory Disease
• Spectrum of inflammatory disorders of the
upper female genital tract: endometritis,
salpingitis, tubo-ovarian abscess and pelvic
peritonitis
• STDs: GC and chlamydia
• Vaginal flora: anaerobes, enteric GNR,
GBStrep, H influenzae
• Mycoplasma hominis and genitalium,
Ureaplasma
PID: Diagnosis
• Clinical diagnosis is imprecise
• Many episodes of PID go unrecognized
• Due to the potential of damage to the
reproductive health of women and difficulty in
diagnosis, maintain a low threshold for the
diagnosis and treatment of PID.
PID: low threshold of diagnosis
• Woman at risk for STD, experiencing lower
abdominal or pelvic pain, AND has
• Cervical motion tenderness, OR
• Uterine tenderness OR
• Adnexal tenderness
• Presence of lower genital tract inflammation
increases specificity of diagnosis
PID: additional criteria for diagnosis
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Fever
Abnormal vaginal or cervical discharge
Leucorrhea
Elevated markers of inflammation: ESR, crp
Documentation of cervical infection with GC
or chlamydia
PID: specific criteria for diagnosis
• Histopath evidence of endometritis on biopsy
• Imaging: Transvag US or MRI showing fluid
filled, thick tubes; pelvic fluid; tuboovarian
complex; tubal hyperemia
• Laparoscopic evidence of PID
PID: Treatment
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Regimens must cover GC and chlamydia
Anaerobes must be covered
Enteric GNRods must be covered.
Treat for 14 days