Urogenital Chlamydial Infections

Men develop 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, and symptoms may be mild but are frequently more marked early in the morning; then, the urethral meatus is often red and blocked with dried secretions, which 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.

Women are usually asymptomatic, although urethritis (urethral irritation and discharge, dysuria, urinary frequency) as well as vaginal discharge, pelvic pain, and dyspareunia 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; endometritis, 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 infertility and increased risk of ectopic pregnancy. Fitz-Hugh-Curtis syndrome (perihepatitis) may cause right upper quadrant pain, fever, and vomiting.

After rectal or orogenital sexual contact with an infected person, proctitis or pharyngitis may develop in both sexes.

Chlamydiae may be transferred to the eye (eg, during sexual activity if genital infectious secretions are transferred to the ocular surface via contaminated fingers, or perinatally from pregnant patient to neonate), causing acute conjunctivitis, trachoma, and potential blindness.

Reactive arthritis (formerly known as Reiter syndrome) caused by immunologic reactions to genital and intestinal infections is an infrequent complication of chlamydia in adults. Reactive arthritis sometimes is accompanied by skin lesions (keratoderma blennorrhagicum), eye lesions (conjunctivitis and uveitis), noninfectious recurrent urethritis, or balanitis.

Manifestations of Chlamydial Reactive Arthritis

Keratoderma Blennorrhagicum in Chlamydial Reactive Arthritis

This photo shows keratoderma blennorrhagicum, thickened, scaly, pustular lesions on the feet of a person with chlamydial reactive arthritis (also known as Reiter syndrome).

... read more

Image courtesy of Susan Lindsley via the Public Health Image Library of the Centers for Disease Control and Prevention.

Conjunctivitis in Chlamydial Reactive Arthritis

This photo shows conjunctivitis in a person with chlamydial reactive arthritis (also known as Reiter syndrome).

Image courtesy of Joe Miller via the Public Health Image Library of the Centers for Disease Control and Prevention.

Balanitis in Chlamydial Reactive Arthritis

This photo shows circinate balanitis (superficial, ring-like ulcers) on the penis of a person with chlamydial reactive arthritis (also known as Reiter syndrome).

... read more

Image courtesy of Drs. Weisner and Kaufman via the Public Health Image Library of the Centers for Disease Control and Prevention.

Keratoderma Blennorrhagicum in Chlamydial Reactive Arthritis

This photo shows keratoderma blennorrhagicum, thickened, scaly, pustular lesions on the feet of a person with chlamydial reactive arthritis (also known as Reiter syndrome).

... read more

Image courtesy of Susan Lindsley via the Public Health Image Library of the Centers for Disease Control and Prevention.

Conjunctivitis in Chlamydial Reactive Arthritis

This photo shows conjunctivitis in a person with chlamydial reactive arthritis (also known as Reiter syndrome).

Image courtesy of Joe Miller via the Public Health Image Library of the Centers for Disease Control and Prevention.

Balanitis in Chlamydial Reactive Arthritis

This photo shows circinate balanitis (superficial, ring-like ulcers) on the penis of a person with chlamydial reactive arthritis (also known as Reiter syndrome).

... read more

Image courtesy of Drs. Weisner and Kaufman via the Public Health Image Library of the Centers for Disease Control and Prevention.

Infants born to people with chlamydial cervicitis may develop chlamydial pneumonia or neonatal conjunctivitis.

• Nucleic acid amplification tests (NAATs) of cervical, vaginal, urethral, pharyngeal, or rectal secretions or urine

Chlamydia is suspected in patients with symptoms of urethritis, salpingitis, cervicitis, or unexplained proctitis, but similar symptoms can also result from gonorrhea.

If clinical evidence for urethritis is uncertain, urethritis can be documented by any of the following (1):

• 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 to check 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.

Commercially available NAATs are highly sensitive and specific for chlamydia and can also be performed on self-collected urine or vaginal specimens, eliminating the need for doing an uncomfortable swab of the urethra or cervix. Point-of-care NAAT platforms are available and can provide same-visit results. In general, samples from the throat and rectum should be tested only in laboratories that have verified the use of these tests for those anatomic sites.

Because other STIs (particularly gonorrhea) often coexist, 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 infection.

In the United States, confirmed cases of chlamydia, as well as gonorrhea and syphilis, must be reported to the public health system.

Testing urine or self-collected vaginal swabs using NAAT is especially useful for screening asymptomatic people at high risk of STIs because genital examination is not necessary. Screening recommendations vary by sex, age, sexual practices, and setting (1).

Women are screened annually if they are sexually active and < 25 years of age or if they are ≥ 25 years of age, sexually active, and have one or more of the following risk factors:

• Have a history of a prior STI

• Sexual activity with increased risk of exposure (eg, have a new sex partner or more than 1 sex partner; engage in sex work; or use condoms inconsistently when not in a mutually monogamous relationship)

• Have a partner who has an STI or who has concurrent sex partners

Pregnant patients who are < 25 years or who are ≥ 25 years with one or more of the risk factors are screened during their first prenatal visit and again during their third trimester if risk remains high (1, 2,3).

Men who have sex with men are screened at least annually if they have been sexually active within the previous year (for insertive intercourse, urine screen; for receptive intercourse, rectal swab; and for oral intercourse, pharyngeal swab), regardless of condom use. Those at increased risk (eg, with HIV infection, receive preexposure prophylaxis with antiretrovirals, have multiple sex partners, or whose partner has multiple partners) should be screened more frequently, at 3- to 6-month intervals (1, 4).

Transgender and gender diverse people are screened if they are sexually active on the basis of sexual practices and anatomy (eg, annual screening for all people with a cervix who are < 25 years old; if ≥ 25 years old, people with a cervix should be screened annually if at increased risk; rectal swab based on reported sexual behaviors and exposure) (1).

Men not included in the above categories are not routinely screened except for those in clinical settings with a high prevalence of chlamydia (eg, adolescent clinics, STI clinics, correctional facilities).

• Oral antibiotics

• Empiric treatment for gonorrhea if it has not been excluded

• Treatment of sex partners from past 60 days and/or most recent sex partner

Uncomplicated documented or suspected chlamydia is treated with doxycycline 100 mg orally 2 times a day for 7 days (Uncomplicated documented or suspected chlamydia is treated with doxycycline 100 mg orally 2 times a day for 7 days (1, 2).

Azithromycin as a single 1-gram oral dose or levofloxacin 500 mg orally once/day for 7 days is an alternative medication.Azithromycin as a single 1-gram oral dose or levofloxacin 500 mg orally once/day for 7 days is an alternative medication.

For pregnant patients, azithromycin as a single 1-gram oral dose should be used. Amoxicillin 500 mg orally 3 times a day for 7 days is the alternative therapy to For pregnant patients, azithromycin as a single 1-gram oral dose should be used. Amoxicillin 500 mg orally 3 times a day for 7 days is the alternative therapy toazithromycin. Pregnant patients should have a test of cure 4 weeks after treatment and be retested within 3 months.

These regimens do not reliably treat gonorrhea, which coexists in many patients with chlamydia. Therefore, treatment should include a single dose of ceftriaxone 500 mg IM (1 g IM for patients weighing ≥ 150 kg) unless the patient has tested negative for gonorrhea (These regimens do not reliably treat gonorrhea, which coexists in many patients with chlamydia. Therefore, treatment should include a single dose of ceftriaxone 500 mg IM (1 g IM for patients weighing ≥ 150 kg) unless the patient has tested negative for gonorrhea (2).

In areas where trichomoniasis is prevalent, empiric treatment with metronidazole, tinidazole, or secnidazole is recommended for patients with chlamydia unless nucleic acid amplification testing (NAAT) indicates patients are negative for trichomoniasis.is prevalent, empiric treatment with metronidazole, tinidazole, or secnidazole is recommended for patients with chlamydia unless nucleic acid amplification testing (NAAT) indicates patients are negative for trichomoniasis.

Patients who relapse (up to 13% within 12 months) (3) are usually coinfected with microbes that do not respond to antichlamydial therapy, or they were reinfected since treatment. They should be retested for chlamydia and gonorrhea and, if possible, for mycoplasma and trichomoniasis.

Sex partners within the past 60 days and prior to the patient's development of symptoms (or the most recent sex partner if the last sexual contact was > 60 days) should be evaluated, tested, and presumptively treated (2). Patients should abstain from sexual activity until they and their partners have been treated for ≥ 1 week.

Expedited partner therapy (EPT) is a practice in which patients with an infection are given a prescription or medications to deliver to their partner without a health care professional first examining the partner. EPT may enhance partner adherence and reduce treatment failure due to reinfection. It may be most appropriate for partners of women with gonorrhea or chlamydia. However, a health care examination is preferable to ascertain histories of medication allergies and to screen for other STIs (2).

Postexposure prophylaxis with doxycycline taken orally within 72 hours of condomless sex has been shown to significantly reduce the incidence of chlamydia, gonorrhea, and syphilis in men who have sex with men and transgender women (4).

If chlamydial genital infections are untreated, symptoms and signs subside within 4 weeks in about two-thirds of patients. However, in women, asymptomatic cervical infection may persist, resulting in chronic endometritis, salpingitis, or pelvic peritonitis and associated sequelae—pelvic pain, infertility, and increased risk of ectopic pregnancy. Because chlamydia can have serious long-term consequences for women, even when symptoms are mild or absent, detecting the infection in women and treating them and their sex partners is crucial.