The diagnosis should be confirmed by either:
Visible mucopurulent urethral discharge
OR one of the following
>/= 5 PMN/oil immersion field on gram-stained urethral smear
Positive leukocyte esterase (LE) test on urine dip
>/= 10 PMN/HPF in first voided sediment without voiding for two hour
The most likely causes of urethritis in males and females and of cervicitis in females are chlamydia followed by gonorrhea. Another frequent cause in females is trichomonas vaginalis infections.
In males, chlamydia and gonorrhea can cause a symptomatic infection that usually involves a purulent discharge with gonorrhea and non-purulent discharge with chlamydia. The infection can also frequently be asymptomatic. Left untreated, some males can develop prostatitis, epididymitis, seminal vesiculitis, and infection of Cowper's and Tyson's glands. In females, the signs and symptoms are less specific. Sometimes there is a complaint of a vaginal discharge, dysuria, or frequency. Other women are asymptomatic. In women, untreated infections can lead to bartholonitis, endometritis, salpingitis, tubo-ovarian abscess or a perihepatitis (Fitz-Hugh-Curtis syndrome). These teens may present with right upper quadrant pain.
In males, a presumptive diagnosis can be made by symptoms and the presence of a urethral discharge. In males with a discharge, a gram-stain can be performed looking for gram negative intracellular diplococci as seen below. In females, a gram stain is much less specific.
click for full-size image
Many individuals may have no symptoms, so screening sexually active adolescents can be important. The diagnosis and screening has become easier with the use of nucleic acid amplified tests such as PCR and LCR. These tests are both more sensitive and specific than prior tests and in addition can be done on urine samples, sometimes alleviating the need for a pelvic examination or intraurethral specimen.
Some differences between the two techniques include:
The LCR can be done on all urine, cervical and urethral specimens
The PCR is not approved for GC testing in urine specimens in females
Both tests are very sensitive (92-100%) and specific (95-100%)
Comparison of sensitivity and specificity include:
EIA: 50-70% sensitive, 95-99% specific
DNA probe: 65-70% sensitive, 95-99% specific
DFA: 70-75% sensitive, 95-99% specific
Culture: 75-80% sensitive, 100% specific
NAAT: 90-95% sensitive, 98-100% specific
Or looking at this another way shows that:
The EIA would require 5000 organisms per sample for a positive result compared to:
The DNA probe which requires 500 organisms
The DFA non amplified test which requires 10 organisms
A culture which requires 5 organisms/sample and the most sensitive
The PCR/LCR which requires only 1 organism/sample
However, it is critical to remember that the lower the prevalence in a population the higher the proportion of false positives to true positives. So, one must be very careful in counseling a teen with a positive screening test who has a low risk profile and comes from a population with a low prevalence rate.
Complete treatment guidelines and up to date changes and recommendations can be found at the CDC web site either by searching at www.cdc.gov or going to STD branch at http://www.cdc.gov/std/. The ultimate goal would be to be able to treat both chlamydia and gonorrhea with a single dose of an oral medication. In addition, such a regimen would treat resistant gonorrhea and also incubating syphilis. Currently, while there are many recommended therapies, there is no "perfect" regimen.
If there is a question of compliance, or if one cannot test for both chlamydia and gonorrhea, it would be important to use medications that covers both conditions.
Following diagnosis and treatment it is important to discuss with the adolescent:
- The nature of transmission
- The importance of abstaining from sex for 3-4 days (GC) and 7 days (CT) during treatment
- The importance of treating sexual partners during the previous 60 days and if none then the most recent partner
- Warning signs of reinfection and the need for follow-up
- The importance of repeating Chlamydia testing in 3-4 months after treatment to test for reinfection.
There are some particular issues for screening in adolescent males who are having sex with males. Obviously, conducting a straightforward, nonjudgmental sexual history is critical. In addition, these teens should have:
- STD screening every year and more frequent if they are having anonymous or multiple partners
- HIV serology testing
- Syphilis serologic testing
- A pharyngeal culture for GC and a rectal culture for both GC and chlamydia for those males with a history of anal receptive intercourse
- Hepatitis serology and immunizations