Chlamydial urethritis

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

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

Causes of the chlamydial urethritis

Chlamydia - obligate intracellular parasites with a unique development cycle, which consists of a change of intra-and extracellular phases. Outside, chlamydia cells are immobile spherical organisms (elementary bodies) with a size of 0.2–0.15 μm. The intracellular form is larger (about 1 micron) reticular bodies having the structure of typical gram-negative bacteria.

The highly infectious form of the pathogen, adapted to the extracellular existence, is considered an elementary body. Reticular body - a form of the parasite's intracellular existence. In their antigenic structure, pathogenic strains of Chlamidia trachomatis are differentiated into 15 serotypes. Of which serotypes D and K are associated with lesions of the urogenital tract.

Chlamydia, especially Chlamidia trachomatis. - The most common cause of non-specific urethritis in all regions. Caused on the mucous membrane of the urogenital organs, rectum or conjunctiva, chlamydia eyes are first attached to specific cells of the cylindrical epithelium, then phagocytosed elementary bodies either die under the influence of lysosomes of the cell, or enter the development cycle. The elementary bodies that have penetrated into the cell turn into reticular (initial) bodies - a form of the intracellular existence of chlamydia in the form of characteristic colonies near the cell's nucleus. 

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

On the occurrence of chlamydial infection of the urinary organs, the body responds with an immune response. With the help of microimmunofluorescent test, type-specific antibodies are detected in most patients. Having infiltrated 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 the toxic factor.

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

[5]

Symptoms of the chlamydial urethritis

It is difficult to establish the length of the incubation period for urogenital chlamydial infection. Nevertheless, many authors believe that its duration ranges from 1 to 2-3 weeks or more. Prodromal symptoms of chlamydial urethritis in the form of paresthesia are very rare. The subjective symptoms of chlamydial urethritis, which are of little concern to patients, occur only with the appearance of discharge. Chlamydial urethritis is no different from urethritis of a different etiology. There are often scanty, vitreous, mucous or mucopurulent discharges, often visible only in the morning.

In fresh cases, only the anterior section of the urethra is affected in 70% of patients; in chronic cases, urethritis becomes total and in about 60% of patients it is accompanied by chronic prostatitis, which causes increased urination. Changes detected during urethroscopy are identical to those in urethritis of a different etiology and persist for a long time when discharge from the urethra stops. In 20-30% of patients after 2-3 weeks spontaneous recovery occurs. However, in many patients, urethritis subsequently recurs and symptoms of chlamydial urethritis occur again.

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

Complications and consequences

In patients with chlamydial urethritis, urogenital and extragenital lesions may occur. Among the urogenital complications, the most common are epididymitis, orchiepididymitis, hemorrhagic cystitis, urethral stricture, defeat of the seminal vesicles. Epididymitis, apparently, a consequence of the canalicular drift of chlamydia from the posterior urethra.

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

Chlamydia, causing inflammatory diseases of the pelvic organs, contribute 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 genital organs not only adversely affects the course and outcome of pregnancy, but may be accompanied by miscarriages, premature births, untimely discharge of amniotic fluid, and stillbirth.

Extragenital complications of chlamydial urethritis are more common than they are recorded because, due to an asymptomatic course, chlamydia of the urethra may go unnoticed by both patients and doctors who are treated by patients with arthritis, subacute endocarditis and other complications that form the clinical picture of Reiter's disease.

[11], [12], [13], [14], [15], [16], [17]

Reiter's disease (syndrome)

Over the past decades, Reiter’s disease has attracted the attention of urologists, venereologists, oculists, general practitioners, dermatologists and venereologists.

In connection with the improvement of methods for laboratory diagnosis of chlamydial infection, as a rule, mixed, interest in Reiter's disease has increased again. In this disease, urethritis is combined with conjunctivitis, ravens, synoviitis, lesions of the internal organs and skin. Depending on the time of occurrence of a symptom or the degree of its severity, patients turn to the above mentioned specialists.

The reason remains little studied. It is assumed that the causative agent of this disease in 40-60% of patients - Chlamydia oculogenitalis, on the basis that it is found in sexual partners and it can be isolated from the urethra, conjunctiva, synovial membranes of such patients. However, Reiter's disease in women is extremely rare, so it is quite natural to assume that sick men have some genetic defects associated with sex (perhaps immunological). A feature of Reiter's disease is considered 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 they occur torpidly with a small number of complaints. Discharge from the urethra scanty, sometimes have a whitish hue. Microscopic examination along with leukocytes reveal a large number of epithelial cells. Multifocal lesions of the urinogenital system are characteristic (sluggish prostatitis, vesiculitis, epididymitis, inflammation of the bulbourethral glands, spermatogenesis are also possible). When urethroscopy detect dullness, haze of the mucous membrane, mild mild infiltration.

As a rule, several joints are affected; inflammation of the ankle, knee and spine is often observed. A very significant symptom of the disease is painful points at the sites of tendon attachment in the area of large and sometimes small joints, which are found on palpation.

Intensive conjunctivitis can be a transient symptom. Skin rashes are more specific than the urethritis, goniitis and conjunctivitis described above. On the head of the penis, the foreskin, sometimes polycyclic surface erosion occurs, very much resembling herpetic eruptions (the so-called balanoposthitis). On the skin of the soles and in other places there are characteristic papulo-pustular rash, similar to pustular psoriasis or papular syphilides. Note various lesions of internal organs. Hepatitis is more common.

[18], [19], [20], [21], [22], [23], [24], [25], [26]

Diagnostics of the chlamydial urethritis

Laboratory diagnosis of chlamydial urethritis is still difficult. The most frequently used methods for the diagnosis of chlamydial urethritis are: cytological, immunological (serological), isolation of the pathogen on cell cultures.

Currently, the diagnosis of chlamydial urethritis is based on the use of PCR diagnostics and the reaction of direct or indirect immunofluorescence using mono- or polyclonal antibodies labeled with fluorescein isothiocyanate. Clinical trials of immunofluorescent reagents for rapid diagnosis of urogenital chlamydia showed that the method of immunofluorescence is technically simple, sensitive, specific and reproducible. In Russia, this method is the only one regulated for making a diagnosis of urogenital chlamydia.

[27], [28], [29], [30]

Treatment of the chlamydial urethritis

Treatment for chlamydial urethritis, as well as any sluggish infection, includes the following remedies:

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

Azithromycin (1 g orally, once) and doxycycline (200 mg first dose, then 100 mg orally 2 times a day for 7 days) are considered anti-Chlamydia drugs of choice.

Alternative drugs:

• Dzhozamitsin (inside on 500 mg 3 times a day of 7 days);
• clarithromycin (by mouth 250 mg 2 times a day for 7 days);
• roxithromycin (by mouth 150 mg 2 times a day for 7 days);
• Ofloxacin (200 mg orally 2 times a day, 7 days);
• Levofloxacin (500 mg orally 1 time per day for 7 days);
• erythromycin (500 mg orally 4 times a day for 7 days).

A recent meta-analysis of randomized clinical studies 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

After the end of treatment, all patients undergo clinical and laboratory control. The first is immediately after the completion of the course of treatment. If they find single elementary bodies, the course of treatment is extended by no more than 10 days.

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

[31], [32]