Nongonococcal Urethritis and Chlamydial Cervicitis

Nongonococcal urethritis and chlamydial cervicitis are sexually transmitted diseases usually caused by Chlamydia trachomatis or (in men) Ureaplasma urealyticum but occasionally by Trichomonas vaginalis or herpes simplex virus.

These infections are called "nongonococcal" to indicate that they aren't caused by Neisseria gonorrhoeae, the bacterium that causes gonorrhea. Chlamydia trachomatis causes about 50 percent of the urethral infections in men not caused by gonorrhea and most of the pusforming infections of the cervix in women not caused by gonorrhea. Most of the remaining cases of urethritis are caused by Ureaplasma urealyticum, a mycoplasma like bacterium.

Chlamydiae are small bacteria that can reproduce only inside cells. Ureaplasmas are very small bacteria that lack a rigid cell wall but that can reproduce outside cells.

Symptoms and Diagnosis

Usually between 4 and 28 days after intercourse with an infected person, an infected man feels a mild burning sensation in his urethra while urinating. A discharge from the penis usually develops. The discharge may be clear or cloudy, but it is generally less thick than with gonorrhea. Early in the morning, the opening of the penis is often red and stuck together with dried secretions. Occasionally, the disease begins more dramatically. The man finds urinating painful, needs to urinate frequently, and has discharges of pus from the urethra.

Although most women infected with Chlamydia have no symptoms, some have a frequent urge to urinate, pain while urinating, pain in the lower abdomen, pain during sexual intercourse, and secretions of yellow mucus and pus from the vagina.

Anal or oral sex with an infected partner can lead to infection of the rectum or throat. These infections may cause pain and a yellow discharge of pus and mucus.

In most cases, an infection with Chlamydia tra-chomatis can be diagnosed by examining discharge from the penis or cervix in a laboratory. Ureaplasma urealyticum infections are not diagnosed specifically in routine medical settings. Because culturing is difficult and other techniques for diagnosis are expensive, the diagnosis of Chlamydia or Ureaplasma infection often Is presumed on the basis of the characteristic symptoms along with evidence against the presence of gonorrhea.

Complications and Prognosis

If an infection caused by Chlamydia trachomatis isn't treated, symptoms disappear in 4 weeks in about 60 to 70 percent of the people. However, a chlamydial infection may cause a number of complications. Whether Ureaplasma has a role in these complications is unclear.

If untreated, a chlamydial infection in women often ascends to the fallopian tubes, where inflammation may cause pain, and scarring may cause infertility and ectopic pregnancy. These latter complications may occur in the absence of prior symptoms and result in considerable suffering and medical costs. In men, Chlamydia may cause epididymitis, which produces painful swelling of the scrotum on one or both sides.

Treatment

Chlamydial and ureaplasmal infections are usually treated with tetracycline or doxycycline taken orally for at least 7 days or with a single dose of azithromycin. Pregnant women should not take tetracycline. In about 20 percent of the people, the infection returns after treatment. Treatment is then repeated for a longer period.

Infected people who have sexual intercourse before completing treatment may infect their partners. Thus, sex partners are treated simultaneously if possible.

Trichomoniasis

Trichomoniasis is a sexually transmitted disease of the vagina or urethra caused by Trichomonas va-ginalis, a single celled organism with a whiplike tail.

Although Trichomonas vaginalis can infect the genitourinary tract of either men or women, symptoms are more common in women. About 20 percent of women experience trichomoniasis of the vagina during their reproductive years.

In men, the organism infects the urethra, pros-tate, and bladder, but it only rarely causes symp-toms. In some populations, Trichomonas may account for 5 to 10 percent of all cases of nongonococcal urethritis. The organism is more difficult to detect in men than in women.

Symptoms

In women, the disease usually starts with a greenish-yellow, frothy vaginal discharge. In some women, the discharge may be slight. The vulva (the external female genital organs) may be irritated and sore, and sexual intercourse may be painful. In severe cases, the vulva and surrounding skin may be inflamed and the labia swollen. Pain on urination or frequency of urination may occur, resembling the symptoms of a bladder in-fection.

Men with trichomoniasis generally have no symptoms but can infect their sex partners. Some men have a temporary frothy or pus like dis charge from the urethra, pain during urination, and a need to urinate frequently These symptoms usually occur early in the morning. The urethra may be mildly irritated, and occasionally moisture appears at the opening of the penis. Infection of the epididymis, causing pain in the testes, occurs rarely. The prostate also may become infected, but the role of Trichomonas is unclear. These infections are the only known complica-tions of trichomoniasis in men.

Diagnosis

In women, the diagnosis can usually be made within minutes by examining a sample of vaginal secretions under a microscope. Tests for other sexually transmitted diseases are usually performed as well.

In men, secretions from the end of the penis should be obtained in the morning before urination. The secretions are examined under a microscope, and a sample of the secretions is sent to the laboratory for culture. A urine culture may also be helpful, because this is more likely to detect Trichomonas missed by microscopic exami-nation.

Treatment

A single oral dose of metronidazole cures up to 95 percent of infected women, provided their sex partners are treated simultaneously. Because it's not known whether a single dose treatment is effective in men, men are usually treated for 7 days.

If taken with alcohol, metronidazole may cause nausea and flushing of the skin. The drug also may cause a decrease in white blood cells and, in women, an increased susceptibility to vaginal yeast infections (genital candidiasis). Metronidazole is probably best avoided during pregnancy, at least during the first 3 months. Infected people who have sexual intercourse before the infection is cured are likely to infect their part-ners.

Genital Candidiasis

Genital candidiasis is a yeast (fungus) intection of the vagina orpenis, commonlyreferred to as thrush, caused by Candida albicans.

The Caadida yeast normally resides on the skin or in the intestines. From these areas, it can spread to the genitals. Condida isn't usually transmitted sexually.

Candidiasis is a very common cause of vaginitis. Genital candidiasis has become more common mainly because of the increasing use of antibiotics, oral contraceptives, and other drugs that change the environment in the vagina in a way that favors the growth of Cartdida. Candidiasis is more common in women who are pregnant or menstruating and in diabetics. Less commonly. the use of drugs (such as corticosteroids or cancer chemotherapy) and diseases that suppress the immune system (such as AIDS) can facilitate the infection.

Symptoms and Diagnosis

Women with genital candidiasis usually develop itching or irritation of the vagina and vulva and may have a vaginal discharge. Frequently. the irritation is severe, but the discharge is light. The vulva may be reddish and swollen. The skin may be raw and may crack. The vaginal wall is usually covered with a white cheese-like material. but it may look normal.

Men often have no symptoms, but the end of the penis (the glans) and the foreskin (in uncircumcised men) may be sore and irritated, especially after sexual intercourse. Occasionally, men may notice a slight discharge from the penis. The end of the penis and the foreskin may be reddish, may have small crusted blisters or sores, and may be covered with white cheese-like material. Immediate diagnosis can be made by taking specimens from the vagina or the penis and ex-amining them under a microscope. Specimens also may be sent to the laboratory for culture.

Treatment

In women, candidiasis can be treated by washing the vagina with soap and water, drying it with a clean towel, and then applying an antifungal cream containing clotrimazole, miconazole, butoconazole, or tioconazole and terconazole. Alternatively, ketoconazole, fluconazole, or itraconazole can be taken orally. In men, the penis (and foreskin in uncircumcised men) should be washed and dried before an antifungal cream (containing, for example, nystatin) is applied.

Occasionally, women who take oral contraceptives must stop using them for several months during treatment for vaginal candidiasis because they can make the infection worse. Women who are at unavoidable risk of vaginal candidiasis, such as those who have an impaired immune system or who are taking antibiotics for a long period of time, may need an antifungal drug or other preventive therapy.

Genital Herpes

Genital herpes is a sexually transmitted disease of the genital area, the skin around the rectum, or ad-jacent areas caused by herpes simplex virus.

There are two types of herpes simplex virus, called HSV-1 and HSV-2. HSV-2 is usually transmitted sexually, whereas HSV-1 usually infects the mouth. Both herpes simplex virus types may infect the genitals, the skin around the rectum, or the hands (especially the nail beds) and may be transmitted to other parts of the body (such as the surface of the eyes). Herpes sores don't usually become infected with bacteria, but some people with herpes also have other sexually transmitted organisms, such as syphilis or chancroid, in the same ulcers.

Symptoms

Symptoms of the initial (primary) outbreak begin 4 to 7 days after infection. The first symptoms are usually itching, tingling, and soreness. Then comes a small patch of redness, followed by a group of small, painful blisters. The blisters break and fuse to form circular sores. The sores, which are usually painful, usually become crusted after a few days. Urinating may be difficult, and walking may be painful. The sores heal in about 10 days but may leave scars. Lymph nodes in the groin are usually slightly enlarged and tender. The first outbreak is more painful, prolonged, and widespread than subsequent ones and may be associated with fever and feeling ill.

In men, the blisters and sores may develop any-where on the penis, including the foreskin if the penis is uncircumcised. In women, the blisters and sores may develop on the vulva in and around the vagina, and on the cervix. Those who have anal intercourse may develop blisters and sores around the anus or in the rectum.

In people with impaired immune systems. such as those with human immunodeficiency virus (HIV) infection, herpes sores may be severe, spread to other areas of the body, persist for weeks or longer, and, uncommonly, become resistant to treatment with acyclovir.

The symptoms tend to recur in the same or adjacent areas, because the virus persists in nearby pelvic nerves and reactivates to reinfect the skin. HSV-2 is better able to reactivate in the pelvic nerves. HSV-1 reactivates more effectively in the facial nerves, where it causes fever blisters or herpes labialis (herpes of the lips). Nonetheless, either virus can cause disease in either area. Prior infection with either virus provides partial immunity to the other, making symptoms of the second virus less severe.

Diagnosis

A doctor suspects herpes based on the person's symptoms. A diagnosis can be made immediately by examining samples from the sores under a microscope. To confirm the diagnosis, swabs from a sore are sent to special laboratories for culture. The results may be available in as little as 48 hours. Blood tests may show evidence of past infections or suggest a recent one if antibody levels are rising.

Treatment

No treatment can cure genital herpes, but treatment may shorten an outbreak. The number of outbreaks can be reduced by continuous low- dose therapy with antiviral drugs.

Treatment is most effective if started early. usually within 2 days of the start of symptoms. Acyclovir or re-lated antiviral drugs can be taken orally or applied in a cream directly on the sores. These drugs reduce the shedding of the live virus from the sores, thus reducing the risk of transmission.

The drug can also lessen the severity of symptoms during the initial outbreak. However, even early treatment of the first attack doesn't prevent recurrences.

Patients with a history of herpes may be infectious to their sexual partners even when they are not aware of an outbreak.

Genital Warts

Genital warts (condylomata acuminata) are warts in or around the vagina, penis, or rectum caused by sexually transmitted papillomaviruses.

Genital warts are common and cause concern because they are unsightly, may become infected with bacteria, and may indicate an impaired immune system.

In women, papillomavirus types 16 and 18, which occur in the cervix but do not cause warts on the external genitals, may cause cervical cancer. These types and other papillomaviruses may cause cervical intraepithelial neoplasm (indicated by an abnormal Pap test result) or cancer of the vagina, vulva, anus, penis, mouth, throat, or esophagus.

Symptoms and Diagnosis

Genital warts occur most often on warm, moist surfaces of the body. In men, the usual areas are on the end and shaft of the penis and below the foreskin (if the penis is uncircumcised). In women, genital warts occur on the vulva, the vaginal wall, the cervix, and the skin surrounding the vaginal area-rectal warts may develop in the area around the anus and in the rectum, especially in homosexual men and in women who en-gage in anal sex.

The warts usually appear 1 to 6 months after infection, beginning as tiny soft, moist, pink or red swellings. They grow rapidly and may develop stalks. Multiple warts often grow in the same area, and their rough surfaces give them the appearance of a small cauliflower. The warts may grow very rapidly in pregnant women, in people with an impaired immune system (for example, from AIDS or treatment with immunosuppressive drugs), and in those who have inflammation of the skin.

Genital warts usually can be diagnosed from their appearance. However, they may be mistaken for sores found in the secondary stage of syphilis. Unusual looking or persistent warts may be removed surgically and examined under a microscope to make sure that they aren't cancerous. Women who have warts on the cervix should undergo regular Pap tests.

Treatment

No treatment is completely satisfactory. External genital warts may be removed by laser, cryotherapy (freezing), or surgery using local anesthetics. Chemical treatments, such as podophyllum resin or purified toxin or trichloroacetic acid, can be applied directly to the warts. This approach, however, requires many applications over weeks to months, may burn the surrounding skin, and frequently fails.

Warts in the urethra may be treated with anti-cancer drugs, such as thiotepa or fluorouracil. Alternatively, the warts may be removed from the urethra by endoscopic surgery (a procedure in which a flexible viewing tube with surgical attachments is used). Interferonalfa injections into the wart are under study as a possible treatment, but their usefulness isn't yet known. Genital warts return frequently and require repeated treatment. In men, circumcision may help to prevent recurrence. All sex partners should be examined and treated, if necessary.

Sexually Transmitted Intestinal Infections

Various bacteria (Shigella, Campylobacter, and Salmonella), viruses (hepatitis A), and parasites (Giardia and other amebas) that cause intestinal infections may be transmitted sexually particularly by activities in which the mouth comes into contact with the genitals or anus.

Symptoms are typically those of the specific organism transmitted and may involve combinations of diarrhea, fever, bloating, nausea and vomiting, abdominal pain, and jaundice. Infections recur frequently, es-pecially in homosexual men with many sex partners. Some infections cause no symptoms.

Source : Family Physicians.

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