Chlamydia urethritis

Chlamydial urethritis is a disease of the urinary tract caused by chlamydia.

[ 1 ], [ 2 ], [ 3 ], [ 4 ]

Causes chlamydia urethritis

Chlamydia are obligate intracellular parasites with a unique development cycle consisting of alternating intra- and extracellular phases. Outside the cell, chlamydia are immobile spherical organisms (elementary bodies) measuring 0.2-0.15 µm. The intracellular form is larger (about 1 µm) reticular bodies with the structure of typical gram-negative bacteria.

The elementary body is considered to be a highly infectious form of the pathogen adapted to extracellular existence. The reticular body is a form of intracellular existence of the parasite. According to their antigen structure, pathogenic strains of Chlamidia trachomatis are differentiated into 15 serotypes, of which serotypes D and K are associated with damage to the urogenital tract.

Chlamydia, especially Chlamidia trachomatis, is the most common cause of non-specific urethritis in all regions. Chlamydia that enter the mucous membrane of the urogenital organs, rectum or conjunctiva of the eye first attach to specific cells of the columnar epithelium, then the phagocytized elementary bodies either die under the influence of the cell lysosomes or enter the development cycle. Elementary bodies that penetrate the cell turn into reticular (initial) bodies - a form of intracellular existence of chlamydia in the form of characteristic colonies near the cell nucleus.

In a mature inclusion, all reticular bodies are gradually replaced by elementary ones, the host cell ruptures, accompanied by damage to the cell membrane and the release of elementary bodies. All chlamydia have a common group antigen, which is a lipopolysaccharide complex. In the process of evolution, chlamydia have adapted to survive not only in epithelial cells, but also in cells of the immune system.

The body responds to the occurrence of chlamydial infection of the urogenital organs with an immune reaction. Using the microimmunofluorescence test, type-specific antibodies are detected in most patients. Having penetrated the urogenital organs, chlamydia multiply in the epithelial cells of the urethra, causing an inflammatory reaction. Since the pathogens are strictly localized in the epithelium, deeper, subepithelial changes can be explained by the action of a toxic factor.

The introduction of chlamydia into the genitourinary tract does not always cause vivid symptoms of chlamydial urethritis, which can be submanifest or asymptomatic. Sometimes the asymptomatic course is transformed into a pronounced disease.

[ 5 ]

Symptoms chlamydia urethritis

It is difficult to establish the duration of the incubation period for urogenital chlamydial infection. However, many authors believe that its duration is from 1 to 2-3 weeks or more. Prodromal symptoms of chlamydial urethritis in the form of paresthesia are very rare. Subjective symptoms of chlamydial urethritis, which are of little concern to patients, arise only with the appearance of discharge. Chlamydial urethritis is no different from urethritis of other etiologies. Often there are scanty, glassy, mucous or mucopurulent discharges, often noticeable only in the morning.

In recent cases, only the anterior urethra is affected in 70% of patients; in chronic cases, urethritis becomes total and is accompanied by chronic prostatitis in approximately 60% of patients, causing increased urination. The changes revealed by urethroscopy are identical to those in urethritis of other etiologies and persist for a long time after discharge from the urethra has ceased. Spontaneous recovery occurs in 20-30% of patients after 2-3 weeks. However, in many patients, urethritis subsequently recurs and symptoms of chlamydial urethritis appear again.

[ 6 ], [ 7 ], [ 8 ], [ 9 ], [ 10 ]

Complications and consequences

Urogenital and extragenital lesions may occur in patients with chlamydial urethritis. Among urogenital complications, the most common are epididymitis, orchiepididymitis, hemorrhagic cystitis, urethral stricture, and seminal vesicle lesions. Epididymitis is apparently a consequence of canalicular introduction of chlamydia from the posterior urethra.

As a rule, they develop without noticeable subjective disorders and at normal body temperature. Clinically, chlamydial epididymitis resembles tuberculous lesions in the sluggish course of the disease, the density of the infiltrate and some tuberculousness of the surface of the appendage. According to many authors, chlamydial epididymitis is rarely accompanied by funiculitis. Strictures of the urethra after chlamydial urethritis, as a rule, do not cause a violation of the outflow of urine ("wide" strictures); this is due to the fact that the paraurethral passages are lined with stratified squamous epithelium, which is little susceptible to infection with chlamydia.

Chlamydia, causing inflammatory diseases of the pelvic organs, contributes to the development of infertility due to obstruction of the tubes or ectopic pregnancy, as well as post-abortion or postpartum endometritis. Chlamydial infection of the genitals not only adversely affects the course and outcome of pregnancy, but can be accompanied by miscarriages, premature births, untimely rupture of membranes, stillbirth

Extragenital complications of chlamydial urethritis occur more often than are registered, since due to the low-symptom course of chlamydia of the urethra, it can remain unnoticed by both patients and doctors who are treated by patients with arthritis, subacute endocarditis and other complications that make up the clinical picture of Reiter's disease.

[ 11 ], [ 12 ], [ 13 ], [ 14 ], [ 15 ], [ 16 ]

Reiter's disease (syndrome)

Over the past decades, Reiter's disease has attracted the attention of urologists, venereologists, ophthalmologists, therapists, dermatologists and venereologists.

Due to the improvement of laboratory diagnostic methods for chlamydial infection, usually mixed, interest in Reiter's disease has increased again. In this disease, urethritis is combined with conjunctivitis, gonitis, synovitis, lesions of internal organs and skin. Depending on the time of appearance of a particular symptom or the degree of its severity, patients consult the above-mentioned specialists.

The cause remains poorly understood. It is assumed that the pathogen of this disease in 40-60% of patients is Chlamydia oculogenitalis, based on the fact that it is found in sexual partners and can be isolated from the urethra, conjunctiva, and synovial membranes of such patients. However, Reiter's disease is extremely rare in women, so it is quite natural to assume that male patients have some genetic defects associated with gender (possibly immunological). A feature of Reiter's disease is considered to be its dependence on some other infectious diseases. Reiter himself described this syndrome in patients with dysentery. Later, it turned out that this disease can occur (and often) in patients with gonorrhea.

Urethritis in patients suffering from Reiter's disease is rarely acute, more often it is sluggish with a small number of complaints. Discharge from the urethra is scanty, sometimes whitish. Microscopic examination reveals a large number of epithelial cells along with leukocytes. Multifocal lesions of the genitourinary system are characteristic (sluggish prostatitis, vesiculitis, epididymitis, inflammation of the bulbourethral glands, and spermatogenesis disorders are also possible). Ureteroscopic examination reveals dullness, whitish mucous membrane, and a mild soft infiltrate.

As a rule, several joints are affected; inflammation of the ankle, knee joints and spine is especially common. A very significant symptom of the disease is painful points at the attachment sites of tendons in the area of large and sometimes small joints, which are detected by palpation.

Intense conjunctivitis may be a transient symptom. Skin rashes are more specific than the above-described urethritis, gonitis and conjunctivitis. Polycyclic superficial erosions sometimes appear on the head of the penis and foreskin, very similar to herpetic rashes (the so-called balanoposthitis). Characteristic papulopustular rashes appear on the skin of the soles and in other places, similar to pustular psoriasis or papular syphilides. Various lesions of internal organs are noted. Hepatitis is more common.

[ 17 ], [ 18 ], [ 19 ], [ 20 ], [ 21 ], [ 22 ], [ 23 ], [ 24 ], [ 25 ]

Diagnostics chlamydia urethritis

Laboratory diagnostics of chlamydial urethritis is still complicated. The most commonly used methods of diagnosing chlamydial urethritis are: cytological, immunological (serological), and isolation of the pathogen in cell cultures.

Currently, diagnostics of chlamydial urethritis is based on the use of PCR diagnostics and direct or indirect immunofluorescence reactions using mono- or polyclonal antibodies labeled with fluorescein isothiocyanate. Clinical trials of immunofluorescence reagents for express diagnostics of urogenital chlamydia have shown that the immunofluorescence method is technically simple, sensitive, specific and reproducible. In Russia, this method is the only one regulated for diagnosing urogenital chlamydia.

[ 26 ], [ 27 ], [ 28 ], [ 29 ]

Treatment chlamydia urethritis

Treatment of chlamydial urethritis, like any sluggish infection, includes the following means:

• immunomodulators;
• antibiotics:
• polyene antibiotics to prevent the development of candidal lesions.

The antichlamydial drugs of choice are azithromycin (1 g orally once) and doxycycline (200 mg first dose, then 100 mg orally 2 times a day for 7 days).

Alternative drugs:

• josamycin (orally 500 mg 3 times a day for 7 days);
• clarithromycin (orally 250 mg 2 times a day for 7 days);
• roxithromycin (orally 150 mg 2 times a day for 7 days);
• ofloxacin (200 mg orally 2 times a day for 7 days);
• levofloxacin (500 mg orally once a day for 7 days);
• erythromycin (500 mg orally 4 times a day for 7 days).

A recent meta-analysis of randomized clinical trials of the comparative efficacy of azithromycin and doxycycline in the treatment of genital chlamydial infection showed equal efficacy of these drugs with microbiological eradication of the pathogen in 97 and 98% of cases, respectively.

Forecast

All patients undergo clinical and laboratory monitoring after completion of treatment. The first is immediately after completion of the course of treatment. If single elementary bodies are detected, the course of treatment is extended for no more than 10 days.

In women, a control study is conducted during the first two menstrual cycles. Men are under control (with mandatory clinical laboratory testing) for 1-2 months.

[ 30 ], [ 31 ]