Non gonococcal urethritis

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

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

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)

 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

 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.

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

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

 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

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

 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

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

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

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

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

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

 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

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

 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

 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

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

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

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

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.

 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

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

 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

 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

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

 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

 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

Non gonococcal urethritis

More Related Content

What's hot

Viewers also liked

Similar to Non gonococcal urethritis

Recently uploaded

In this document

Non gonococcal urethritis