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 va-ginalis 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 pus-forming 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 repro-duce 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 trachomatis 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. Be-cause 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.


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 is a sexually transmitted disease of the vagina or urethra caused by Trichomonas vaginalis, 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, prostate, and bladder, but it only rarely causes symptoms. 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.


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 infection.

Men with trichomoniasis generally have no symptoms but can infect their sex partners. Some men have a temporary frothy or pus-like discharge 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 complications of trichomoniasis in men.


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 examination.


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 partners.

Genital Candidiasis

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

The Candfda yeast normally resides on the skin or in the intestines. From these areas, it can spread to the genitals. Candida 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 Candida. 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 examining them under a microscope. Specimens also may be sent to the laboratory for culture.


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. Al-ternatively, 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.

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