Sexually Transmissible Infections in Clinical Practice

6. A Female Contact of a Man with Presumed Non-gonococcal Urethritis

Alexander McMillan1, 2  

(1)

Department of Genitourinary Medicine, NHS Lothian, Edinburgh Royal Infirmary, Edinburgh, Uk

(2)

University of Edinburgh, Edinburgh, Uk

Alexander McMillanFormerly, Consultant Physician, part-time Senior Lecturer

Email: a.amcmm@btinternet.com

Abstract

Anne, Peter’s partner (Case 5), attends the clinic the day following Peter’s consultation. She is symptomless and she has had no other sexual contacts during her relationship with Peter. However, she had unprotected vaginal intercourse with an ex-boyfriend a week before beginning the relationship with Peter. Her last menstrual period was been 1 week previously.

Anne, Peter’s partner (Case 5), attends the clinic the day following Peter’s consultation. She is symptomless and she has had no other sexual contacts during her relationship with Peter. However, she had unprotected vaginal intercourse with an ex-boyfriend a week before beginning the relationship with Peter. Her last menstrual period was been 1 week previously.

The majority of women – at least 70% – with uncomplicated chlamydial infection are symptomless. In other cases, increased vaginal discharge with or without dysuria, post-coital bleeding, inter-menstrual bleeding, and lower abdominal pain may be features.

She is encouraged to have and accepts screening for sexually transmitted infections (STIs) (see Case 2 ).

She is certainly at risk of STIs, having had unprotected intercourse with several different and unknown partners. Failure to detect Gram-negative diplococci in a Gram-stained smear of urethral material from Peter, and the subsequent failure to culture Neisseria gonorrhoeae from his urethra does not necessarily indicate lack of such infection Anne.

There are no abnormal findings on the external genitalia, perineum, or perianal region. The vagina appears healthy, but there is an edematous, friable ectropion with a mucopurulent discharge from the endocervical canal (Fig.6.1 ).

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Figure 6.1.

Ectropion with mucopurulent discharge.

About one-third of women with chlamydial infection have a mucopurulent discharge from the endocervical canal, often with an area of ectopy1 that is edematous and bleeds easily, as in this case. These changes are not specific, however, and other conditions such as gonococcal infection, endometritis, and salpingitis need to be considered in the differential diagnosis.

6.1 What Is the Natural History of Chlamydial Infection in Women in a Woman?

The natural history of genital chlamydial infection is incompletely understood. It is likely that many infections are self-limiting, but, in some women there is evidence for persistence of infection for years. Infected women are at risk of complications:

·               Endometritis, salpingitis, and inflammation of the supporting structures of the uterus (pelvic inflammatory disease [PID]) (see Case 14). Although it is difficult to estimate the incidence of PID among infected women, some studies have suggested that between 10 and 40% develop this complication.

·               Perihepatitis. Organisms ascend along the peritoneal gutters to infect the liver. There is inflammation of the liver capsule but only superficial hepatitis (see Case 27).

·               Bartholinitis (inflammation of the greater vestibular glands that lie in the posterior half of the labia majora and whose orifice is at the junction of the junction of the anterior two-thirds and posterior one-third of the medial aspect of the labia minora).

·               Reactive arthritis. This is an uncommon complication affecting <0.5% of women. It is more frequently encountered in males (see Case 24).

·               Conjunctivitis. Chlamydial conjunctivitis in both men and women results from auto-inoculation from the genital tract.

6.2 What Is Your Immediate Management of This Case?

It is customary to offer treatment to a known contact of an individual with non-gonococcal urethritis, the most common cause of which is Chlamydia trachomatis. The reasons for this are four-fold:

1)

2)

3)

4)

If she opts to await the results of testing before treatment, then she should abstain from vaginal, oral, and anal intercourse until a negative result is received. If the test is positive, partner notification should be instituted as described in Case 5.

The treatment of contacts follows that described for chlamydial infection in Case 5.

She is offered and accepts treatment with a single oral dose of azithromycin at this initial clinic attendance. Abstention from sexual intercourse, including oral sex, for 7 days is advised.

As advised she telephones a clinic nurse about 1 week later to obtain the results of the laboratory tests: C. trachomatis was detected in endocervical material, but the other tests were negative. She tells the clinic nurse she had had no side effects from the medication, in particular she had not vomited or had diarrhea immediately after taking the capsules. She also tells the nurse that she has not had any sexual contact since treatment.

Vomiting and/or diarrhea within 2 hours of taking azithromycin may impair absorption of azithromycin, leading to sub-optimal drug concentrations in the tissues. Re-treatment or a test of cure should be considered under these circumstances.

6.3 What Action Would You Take With Respect to Her Ex-boyfriend?

It is possible that this man has been the source of Anne’s infection, and he should be advised to seek testing and treatment. Partner notification can be achieved by three means:

·               Patient referral: The index case informs the sexual partner(s) of the possibility of infection and the need to seek advice from a health-care professional.

·               Provider referral: Sometimes the index patient is reluctant to contact a sexual partner. In such cases, it is possible, with the patient’s consent, for the health-care provider to contact the sexual partner(s), provided there this/these person(s) are identifiable.

·               Conditional referral: The patient is asked to contact the partner, but if that individual does not seek testing and/or treatment within a reasonable time, say, 3 weeks, the healthcare provider will contact that/these individual(s).

Three days later, Anne telephones the Health Adviser in the clinic, and informs her that the ex-partner is symptomless and will not attend the clinic.

6.4 Under These Circumstances, What Possible Action can be Taken?

There is no place for compulsion in securing the clinic attendance of a sexual contact of an individual with an STI. Options include the following:

·               Providing the index patient with a single oral dose of azithromycin to give to the person. Although there are several drawbacks to this approach:

·               The inability to ascertain a history of drug allergy,

·               Lack of knowledge about concurrent medication that may interact with the chlamydia therapy,

·               Lack of knowledge about any intercurrent medical condition, and, importantly,

·               The inability to assess a person’s risk of STIs and to promote good sexual health.

Notwithstanding these concerns, several studies have shown that this approach reaches individuals who would not otherwise have been treated and would have continued to pose a public health threat.

Other, innovative, methods of ensuring treatment of chlamydial infection have been devised, including provision of therapy by pharmacists to individuals with documented proof of infection.

Footnotes

1

Cervical ectopy or ectropion refers to a red area of the vaginal cervix, sharply demarcated from the larger area of pink epithelium. The thin columnar epithelium of the endocervical canal is everted, and the area appears red because of the proximity of the blood vessels to the surface. The thick squamous epithelium of the vaginal cervix, however, largely conceals the vessels and hence it appears pink.