Non-Gonococcal urethritis. main causative organisms are Chlamydiae, Mycoplasma, Ureaplasma. various other bacteria and viruses can cause this. this powerpoint is made in systemic manner and will be helpful for Postgraduate students.

1. By Dr. Ruqaiya Nadeem

2. Introduction
 Urethritis – is inflammation of urethra.
 Most episodes are caused by infection caused by
pathogen that enter urethra from skin around
urethral opening.
 Commensal flora of urethra-
 Enterobacteriaceae
 α/ɣ streptococci
 Enterococcus spp
 Diphtheroids
 CONS

3. URETHRITS
NON-
GONOCOCCAL
BACTERIAL
VIRAL
FUNGAL
PROTOZOAL
MECHANICAL
OR
CHEMICAL
GONOCOCCAL
NIESSERIA
GONORRHOEAE

4. Bacteria
• Chlamadia
trachomati
s
• Ureaplasm
a
urealyticus
• Mycoplasm
a hominis
• Gardnerell
a vaginalis
• Acinetobac
ter wolfii
• Acinetobac
ter
caloaceticu
s
Virus
• Herpes
virus
• CMV
Fungus
• Candida
albicans
Protozoa
• Trachomon
as
vaginalis
Mechanical
or
Chemical
irritation
NON-GONOCOCCAL URETHRITIS
(Causative agent)

5.  Non-gonococcal urethritis/ non specific urethritis
 Chronic urethritis where gonococci cannot be
demonstrated.
 Or cocci persisting in L form and hence undetectable
 NGU is 2.5 times more common

6.  Pre-disposing risk factors
 Sexual contact in which exchange of body fluid may
occur
 May report multiple sexual partners
 Non-STI: secondary to catheterization or other
instrumentation of the urethra, in association with
other factors that contribute to urinary tract infection.

7.  Incubation period- 7-21 days
 Clincal features-
 Variable dysuria
 Urethral itching
 Discharge- typically mucoid to watery, white
 10% NGU are asymptomatic

8.  Diagnosis
 Failure to demonstrate gonococci in gramstain &
culture
 >/= 4 PML/oif in urethral smear or first voided urine sample
 immunoflourescence

9.  Complications
 Epididymitis
 Urethral strictures
 Transmission
 Treatment
 Doxycycline 100mg B.D
 Azithromycin 1g once
 Ofloxacin 400mg B.D × 7days
 Whenever possible sexual partners should be treated
simultaneously

10. Chlamydia trachomatis
 It accounts for 30-50% NGU
 Genital infections are caused by serovars D-K
 Infection in men
 Urethritis, epididymitis, proctitis, conjunctivitis, and
Reiters syndrome
 Assoc. Symptoms – rectal pain, bleeding,
mucopurulent discharge & diarrhoea

11.  Infection in female
 Most infections are asymptomatic(80%)
 Urethritis
 Bartholinitis
 Mucupurulent cervicitis
 Vaginitis, vaginal discharge
 Endometritis
 Salpingitis
 PID
 Reiters Syndrome
 Genital chlamydiasis may cause infertility, ectopic
pregnancy, premature deliveries, perinatal morbidity

12. Lab diagnosis
1. Specimen collection
 Urethral scraping
 Cervical scraping
 Urine
 Other specimens- semen, aspirates from fallopian
tube/ epididymus

13. 2. Specimen transportation
 Swabs should be immediately placed into transport
medium, sucrose phosphate saline (2SP) containing
gentamicin, vancomycin, amphotericin B
 Heat inactivated fetal calf or bovine serum (5%) must
be added to protect during freezing
 If transport is delayed- store at 4°C upto 24hrs
 -60 °C/ liquid nitrogen for longer delay

14. 3. MICROSCOPY
 They are gram negative
 Chlamydial elementary bodies & inclusions
 Better stained by Giemsa, Castaneda,
Macchiavello, Giminez stains & lugol’s iodine
 Typical reniform inclusion bodies surrounding
nucleus
 Immunoflourescence (IF)
 More sensitive & specific method of microscopy by
using monoclonal antibodies
 Both inclusions & extracellular EB can be identified

17. 4 Isolation
 Inoculation into mice/ embryonated eggs
 Chlamydia can grow in yolk sac of 6-8 day old chick
embryos
 First reported isolation was by Gordon & Quan in
irradiated McCoy cells
 Cell lines supporting growth of chlamydiae
 McCoy cells
 HeLa 229 cell
 BHK cell
 BGM cell

18. 5. ANTIGEN DETCTION
 Immunoflourescence-
 Staining of smears by FITC-labelled antibodies
against species specific MOMP or genus specific
LPS
 Atleast 10 EBs should be seen for positive result
 Senstivity 90% specificity 95%
 ELISA-
 Detection of soluble genus-specific antigen
 Senstivity same as IF

19.  DNA probes
 Radioactive DNA probes for detection of C.trachomatis
in cell culture & cervical smears
 Chemiluminescence assay-
 Acridium-ester-labelled single stranded DNA probe
complementary to RNA of C.trachomatis
 PCR
 Amplification targets- omp1 gene coding for MOMP
 - 16s rRNA gene

20. 6. ANTIBODY DETECTION
 Demonstration of group specific antibody by CFT or
micro IF
 High level >64 of IgM and a rising titre of IgG is
taken diagnostic
 IgM persists for 2months
 In neonatal chlamydial infection detection of IgM is
taken diagnostic

21.  Treatment
 DOC – doxycycline in adults & erythromycin in
infants
 Since chlamydia have long replication cycle hence
short course will only suppress infection
 t/t should be given for a min of 7days/ 3 weeks in
women with ascending & complicated genital
infections
 Azithromycin provides sustained levels in tissue

22.  Ureaplasma urealyticum & Mycoplasma
 Infections caused by Ureaplasma urealyticum
 NGU
 Epididymitis
 Vaginitis, cervicitis
 It may cause chorioamnionitis, prematurity, postpartum
endometritis, chronic lung disease of premature infant
 Male and female infertility

23.  Mycoplasma hominis
 Salpingitis, tubo-ovarian abscess, pelvic abscess,
septic abortion, puerperal infection,
 Mycoplasma genitalium
 NGU
 PID
 Very difficult to recover from culture

24.  LAB DIAGNOSIS of Mycoplasma & Ureaplasma
1. Specimen collection
 Urethral, vaginal, cervical swabs
 Semen, prostatic secretions
 Urine
 Biopsy specimen

25. 2. Specimen transportation
 Standard Mycoplasma broth medium dispensed in
small vials – for swab specimens
 Other specimens – sterile screw-capped containers
 If there is delay in processing- store at 4°C for 24
hours
 Or -70°C for further delay
 Mycoplasma broth medium – penicillin, polymyxin
B, amphotericin B, glucose, phenol red
 PPLO broth medium containing 20% horse serum,
glucose, phenol red

26. 3. CULTURE
 Medium is inoculated and incubated at 37°C in an
atmosphere of 95% N2 & 5% CO2
 It usually takes 4-28 days
 Growth shows turbidity in the medium and then sub-
cultured on agar medium & incubated for 5-7 days
 Colonies of mycoplasma show characteristic ‘fried egg’
appearance while ureaplasma colonies are small & lack
peripheral zone.

27.  Haemadsorption test
 Colonies growing on surface agar
 Flooded with 2ml of 0.2-0.4% suspension of washed
guinea-pig erythrocytes in MBM
 Incubated at 35°C for 30mins
 Washed with 3ml MBM & gently rotated
 Wash fluid is removed
 Observed under 50-100x magnification

28.  Tetrazolium reduction test
 Growth can be easily screened by TR test in which
mycoplasma colonies reduce colourless tetrazolium to
red coloured formazan

29.  The colonies can be demonostrated by Dienes
method.
 Diene’s stain- azure II, methylene blue, maltose,
Na2CO3, benzoic acid & DW.
 The plate is flooded with this stain
 Then rinsed with DW
 Decolourised with 95% ethanol
 Observed under low power

33.  Oculogenital syndrome
 NGU and conjunctivitis may be seen in 4% patients &
responds to tetracyclines.
 Reiter’s syndrome( reactive arthritis)
 Some cases of NGU also present with arthritis, uveitis,
and skin/ mucous membrane lesions
 Few cases suggest antibiotic associated colitis or
cryptosporidiosis
 Post dysentric reiter’s syndrome
 More common in HLA-B27 positive patients

34. Clinical features
 NGU is initial manifestation w/i 14days of exposure
 Urethritis may be mild & unnoticed
 Other features develop after 1-5 weeks
 Arthritis develops in 4 weeks
 Knees-ankles-small joints are involved

35.  Dactylitis- sausage shaped swelling of digits is
characteristic & persistent feature
 Mild B/L conjunctivitis, iritis, keratitis, uveitis for few
days
 Dermatologic manifestation occur in 50% pts
 It includes waxy papules, central yellow spot, mostly
on soles, palms, nails, scrotum, scalp, trunk
 the initial episode of RS lasts 2-6 months

36.  Lab diagnosis
 Anaemia
 ESR
 Synovial fluid 1000-200,000 WBCs/ml
 >2/3 rds are PMNs
 Glucose in joint fluid
 Therapy
 Anti chlamydial treatment
 Tetracycline/erythromycin
 NSAIDS- indomethacin