1. MY REFERENCES:
1. King homes
2. Wilcox
3. Internet

2. 1.
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10.
INTRODUCTION AND HISTORY
DEFINITION
AEITOLOGY
CHLAMEDIA AND PGU
MYCOPLASMA
SYMPTOMS AND SIGNS IN MALE,FEMALE
DIAGNOSIS
TREATMENT AND FOLLOW UP
COMPLICATIONS IN MALE AND FEMALE
TREATMENT OF COMPLICATIONS

3. 
1800, even prior to the discovery of N. gonorrhoea, the
existence of several types of urethritis was already suspected.

Gonorrhoea is known since Greek-roman period.

Galen coined the word gonorrhoea

1880s◦ The isolation of N. gonorrhoea
◦ introduction of Gram stain
◦ differentiation of gonococcal from Non Gonococcal Urethritis.

4. 
Early part of the twentieth century◦ Intra cytoplasmic inclusions were seen in urethral smears of some men
with urethritis suggesting Non gonococcal aetiology.

Insight into the etiology of NGU
◦ Discovery of Ureaplasma urealyticum in 1954.

1965-the cell culture isolation techniques for C. trachomatis were
developed.

1990-Nucleic acid amplification tests (NAATs) for sexually
transmitted diseases (STDs).

5. 
Urethritis:
◦ Characterised by urethral discharge, dysuria, or itching at the end
of the urethra, in the response of the urethra to inflammation, of
any aetiology.

Non gonococcal urethritis (NGU) :
◦ Urethritis caused by any aetiology other than N. gonorrhoea or
wherein N.gonorhea is not detected.

PGU :
◦ It is NGU occurring after curative therapy for gonorrhoea, is called
postgonococcal urethritis (PGU).

6. 
Ch. trachomatis (15-40%)

Mycoplasma genitalium (15-25%)

OTHERS (20-50%)
◦ T Vaginalis
◦ U Urealiticum
◦ HSV (In absence of skin lesions)
◦ Adeno Virus
◦ Haemophilus

7. ◦ Miscellaneousin association with urinary tract infection,
bacterial prostatitis,
urethral stricture,
phimosis,
 secondary to instrumentation of the urethra,
congenital abnormalities,
chemical irritation
and tumors.

8. 
13 mycoplasma species known to infect humans

four are found in the genital tract:
◦ Mycoplasma hominis,
◦ M. genitalium,
◦ Ureaplasma parvum, and
◦ U. urealyticum.

9. 
Prevelence
◦ M. genitalium - 21.1% in men with chlamydia-negative
NGU.
◦ U. urealyticum 18%
◦ U. parvum 9.9%

10. 

C. trachomatis first visualized -1907 by
Halberstaedter and von Prowazek
Isolated
◦ 25-60% (usually 30-40%) NGU,
◦ 4-35% (usually 15-25%) gonorrhea,
◦ 0-7% men without obvious urethritis

Chlamydia pneumoniae -respiratory
pathogen of humans, possible cause of CAD.

11. S.NO
SPECIES
SEROVAR
DISEASE
O1
C. PSITTACI
02
C. PNEUMONIAE
03
C.TRACHOMATIS L1, L2, L3
Lymphogranuloma venereum
04
C.
TRACHOMATIS
A, B, Ba, C
Hyperendemic blinding trachoma
05
C.
TRACHOMATIS
B, D, E, F, G,
H, I, J, K
Inclusion conjunctivitis (adult and
newborn), nongonococcal urethritis,
cervicitis, salpingitis, proctitis,
epididymitis, pneumonia of newborns
Many
unidentified
Psitacosis
TWAR
Respiratory disease

12. 
C. trachomatis 15-40% of NGU.

Rationale:
◦ Gonorrhea has a shorter incubation period 2-6days
◦ chlamydial IP 1-5 weeks
◦ so men with both infections can present with gonorrhea
while the chlamydial infection is still incubating.

13. 
When gonorrhea is treated and do not eradicate
C. trachomatis

Hence, concurrently Chlamedial/NGU/PGU
develops who have concurrent C. trachomatis
infection.

Hence PGU - provides assessment of the ability of
C. trachomatis to produce urethritis.

14. 



Burning micturition,
Dysuria
Urethral discharge,
meatitis, inguinal lymphadenitis.

The symptoms and signs of GU and NGU are
similar but differ significantly in severity.

Both may cause urethral discharge, dysuria, or
urethral itching.

15. 
Discharges - profuse and purulent in
men with gonorrhoea, but are
generally scanty and mucoid in men
with NGU.

Discharge may be detected only in
the morning or noted as crusting at
the meatus or as staining on
underwear.

Gonorrhoea usually develops 2-6
days after exposure, whereas NGU
generally develops between 1 and 5
weeks after the acquisition of
infection.

16. 
In urethritis caused by HSV and adenovirus,
dysuria is severe.
viral urethritis presents with meatitis, but
is seen in a minority of cases caused by bacteria.


Adenovirus cases tend to occur in the winter and
often associated with conjunctivitis.

17. 
Following are seen with primary HSV urethritis.
◦
◦
◦
◦
◦
◦
◦

Regional lymphadenopathy,
constitutional symptoms,
pain in groin/leg/buttock,
scanty discharge,
disproportionate dysurea,
intra-meatal ulcer,
blood stained discharge
Asymptomatic urethritis common in chlamydial
infections. Constitutes a large reservoir of infection.

18. 
Atypical presentations of NGU
a) Meatitis with urethral inflamation
b) Lymphadinitis
c) Periurethral abscess
d) Associated disease manifestations
◦ classic urinary tract infection,
◦ acute prostatitis/flare-up of chronic prostatitis,
◦ acute epididymitis or orchitis

hematuria, chills, fever, frequency, hesitancy, nocturia,
urgency, perineal pain, scrotal masses, postvoid dribbling,
genital pain other than dysuria.

19. 
Gram staining of discharge or sediment of First Voided Urine:
(Symptomatic/asymptomatic)
◦ Absence of Gonnorheal Diplococci
◦ Presence of leukocytosis
◦ i.e.more than 5 PMNs per high power field.(in Minimum of 5 fields
observed)

20. AND / OR



Leukocyte esterase testing on FVU or
gram stained specimen of centrifuged sediment of FVU with
>10 PMNL/x1000 microscopic field.
In pts who are symptomatic without evidence of urethritis
(i.e., discharge on examination or the presence of PMNL in
the stained urethral smear),
non sexually transmitted
causes of urethritis considered.(-like urinary tract infection)

21. Diagnostic Options
Chlamydia
•
•
•
•
Cell Culture
Direct Fluorescence Assay
Enzyme Immunoassay
Hybridisation Assay
• Nucleic Acid Amplification Tests

22. S.NO Disease
01
Clinical criteria
Chlamedial Dysuria, urethral
NGU
discharge
Presumptive
diagnosis
diagnostic
Gram Stain, 5 or
more PMN/high
power field
Or
pyuria on FVU
Positive
culture or
NAAT

24. •
Diagnostic tests for U. ureaplasma, M. genitalium, and T.
vaginalis either lack sensitivity or specificity.
•
Clinical circumstances, identification of C. trachomatis as
the cause of NGU is not necessary, as recommended
antibiotic therapy currently is the same for both chlamydiapositive and chlamydia negative NGU. (King Homes)

25. 


Disease may be asymptomatic (40%)
On examination:
• Minimal cervical mucoid/mucopurulent discharge
(IUD in situ)
• Cervical erosion/cervicitis(OCP users)
• Microfollicles in cervical mucosa are diagnostic of
chlamedial NGU.

26. 
Bartholinitis

Salpingitis

Salpingo-oophoritis (PID)

Fitz Hugh Curtis syndrome

Peritonitis
Peri-hepatic adhesions
On Glisson's capsule

27. 
Salpingitis is imp complication.
◦ B/L low abdominal pain, involving both adnexae
◦ Often with uterine bleeding,
◦ Constitutional symptoms: fever, headache, vomiting
◦ can lead to ectopic pregnency, Infertility

28. 


Gram stain of Cx smear is of little
significance. As pus cells in Cx may even be
seen physiologically.
Numerous pus cells in absence of Gonococci,
may be due to NGU.
Male partner should be investigated for NGU.

29. 
STD treatment guidelines from the CDC 2010 and the World
Health Organization currently recommends
◦ doxycycline 100 mg twice daily for 7 days. OR
• Azithromycin 1G orally
Alternatives
◦ Erythromycin base 500mg four times for 7days OR
◦ Ofloxacin 300mg twice daily for 7 days OR
◦ Levofloxacin 500 mg once daily for 7days

30. All Sex Partners In Last 60 Days Should Be Evaluated And
Treated
Sexual abstinence till completion of treatment.
Pts with NGU reviewed 2-3 weeks after treatment to confirm
resolution of symptoms and treatment of sexual contacts.
Should be checked for other STIs including Syphilis and
HIV,Results of tests checked during review.

31.  Abstinence
 Avoid
Self examination, squeezing urethra
 Ensure
 Hold
visit.
from alcohol during treatment
partner treatment, and follow up.
urine at least for 4 hours before next

32. 



1 Week- repeat 2 glass test, repeat staining,
check test reports.
2/3 week- check 2 glass test and stain
smear, clear
cured.
4/6weeks-Symptomatic for urethritis
recurrent/relapse
3 months- check for syphilis

33. 
Epidydimo-orchitis

Reiter's syndrome/sexually acquired reactive
arthritis

Urethral strictures.

Prostatitis

Chronic and refractory urethritis.

34. 1. Symptoms of urethritis+ O/E: supportive signs of
urethritis
The following should be checked:
 Abstinence- chance of re-infection
 Compliance/drug interaction eg: milk/liver enzyme
inducers
 Self examination: Repeated/habitual milking of urethra
by patient or H/O masturbation.

35.  Wrong diagnosis:
a. UTI
b. Trichomonal urethritis
 Stricture: suspect in all chronic cases until
proved otherwise.
 Neurosis: often seen in patients with
habitual self examination.

36. 2. Iatrogenic:
over enthusiastic treatment of pus cells during
follow up in asymptomatic patients.
Diagnosis:
◦ reinfection/ relapse suspected◦ 2 glass test -abnormal in both glass
prostatitis as seat of infection
suspect

37. 
Prostatic massage




Prostatic massage
Gram stain,
AFB
Culture from Mid Stream Urine
(On three successive days)

Urethroscopy and IVU-
higher seated source of infection
 anterior urethroscopy
 1. stricture
 2. reassurance of neurotic patient
 3. VUR/hydronephrosis/pyelonephritis

38. 
UTI: C&S followed by antibiotics

Trichomoniasis: secnidazole 2g stat

Stricture: urology for opinion and Rx

Symptoms disproportionate to signs:
◦ Strong reassurance
◦ Test and Strong reassurance

39. 
Reported by Hans Reiter 1916.

Described by sir benjamin brodie.

40. 
“Reiter’s Syn. is an infectious induced systemic
illness characterized by an aseptic inflammatory
joint involvement occurring in a genetically
predisposed patient with a bacterial infection
localized in a distant organ/system”.

Incidence varies widely (1% to 20%).

Consists of :
◦ Urethritis
◦ Conjuctivitis
◦ Asceptic arthritis

41. 
Cause unknown

Post dysenteric and urethritis
Chlamedia Trachomatis
◦ Shigellosis
◦ Salmonellosis
◦ Yersinia enterocolitica
◦ Campylobacter

42. 
h/o sexual exposure/diarhea within 4 weeks

S/S Urethritis

S/S Cystitis/prostatitis

Eye: Conjuctivitis, Episcleritis, Iritis,
superficial punctate keratitis, corneal
ulceration.

43. 
Arthritis
◦ Recurrent attacks
◦ Constitutional symptoms
◦ Asymmetric polyarthritis
◦ Knee, ankle, feet, sacro-iliac joint.
• Inflamation of achiles tendon (MC)
• Plantar fascitis

44. •Pericarditis,myo
carditis, aortic
regurgitation
•Pleurisy,pulm
onary fibrosis
•meningoencephalitis
•Amyotropic lateral
sclerosis
•Circinate balanitis
•urethritis
Conjuctivitis, Episcleritis,
Iritis, superficial punctate
keratitis, corneal
ulceration.
Asymmetric polyarthritis
Subungual keratosis
Peripheral neuropathy
sacro-ilitis
•Keratoderma
blenorrhagica
Erosions tongue, palate
Plantar fascitis

49. 
Associated with HLA B 27

anemia,leucocytosis, ESR >100

Normal- RA factor, ANA, ASO titre

Synovial fluid- >Neutrophils 5-50

X ray =>
◦
◦
◦
◦
periosteal newbone formation
Sacroiliac joint involvement
Fluffy calcaneal spur
Periosteitis at the insertion of plantar fasciae.

50. 
Topical steroids-conjunctivitis and uveitis.

Urethritis – Rx NGU

Keratoderma blenorrhagica-1%
hydrocortisone

51. 
•
•
•
Acute –
Rest, analgesics- first line of treatment.
Splint/ immobilisation
Joint aspiration

Physiotherapy

Chronic/Recurrent
•
•
•
DMARDS- sulfasalazine or methotrexate
axial involvement-benefit from TNF-alpha blockers.
Monoarthritis- steroid injections.

52. Thank you