I need a response to this post! this is a discussion post from a classmate
Sean Riley is a 26 year old white male presenting to the office with concerns for urinary tract infection. He reports an increase in urination, burning and a slight mucus discharge that he notices in his boxers early in the morning. Mr. Riley denies fever, back pain, lower abdominal pain or any history of UTIs’. He does report a new sexual partner with their first time being approximately 8 days ago while out drinking with friends. He reports that he did not use protection. He does not know her sexual history, how many partners, use of protection, birth control, or STI history.
Chief complaint: urinary frequency, burning, mucoidal discharge.
Demographics: White, heterosexual male
Previous medical history: Patient reports no health history. Various sprains and strains from high school sports.
Previous surgical history: Tonsillectomy at 6 years old, Appendectomy at 8 years old.
Allergies: No known drug allergies, seasonal allergies.
Lifestyle: active in outdoors activities. Denies smoking cigarettes, occasional marijuana use. Drinks alcohol on the weekends or social events.
History of present illness: the patient is a 26 year old white male presents to the office with complaints of dysuria with burning, frequency, urgency, and new onset of mucosal discharge from the urethra for the past two days. The patient reports new sexual partner with the first intercourse time 8 days ago. He says that they did not utilize protection and is unknown of her STI history. Patient denies fever, nausea, vomiting, CVA tenderness. Upon physical examination the testes are even bilaterally non tender there is no evidence of epididymitis development. There is scant green mucoid discharge from the urethra. Patient reports no pain to the penile shaft. And denies any pubic symphysis pain as well. Will complete a clean catch urinalysis to rule out uncomplicated cystitis, chlamydia, and gonorrhea. Will treat empirically for chlamydia and gonorrhea Pending result from the NAAT test.
Mr. Riley exhibits various risk factors for developing STI symptoms. He is a heterosexual male with anew sexual partner. Mr. Riley reports social alcohol consumption with the occasional use of marijuana. Intoxication of either alcohol or drug use inhibits a person’s ability to make appropriate decisions as seen by lack of protection during sex. With introducing a new partner within your sexual life it is good practice to know that person and their prior history of STI’s regardless of treatment. Women often are asymptomatic carriers of STI’s like chlamydia and may pass this infection to their sexual partners (Hsu, K., 2024).
Differential diagnosis:
Uncomplicated lower urinary tract infection
The uncomplicated urinary tract infection is most caused by Escherichia Coli (E. Coli) entering the urinary tract by ascending the urethra. Being uncomplicated entails that the patient has no structural abnormalities with no comorbidities recent surgery or is immunocompromised (Bono, M., et. al., 2023). This is the first diagnosis to rule out as it is the easiest and most common to treat. Urinary tract infections can present from asymptomatic concerns to severe and potentially life-threatening symptoms.
Chlamydia
Chlamydia Trachomatis presents with two individual forms, the elementary body (EB) and the reticulate body (RB). The most common form is the infectious elementary body that is taken on by the host cell where it turns into its metabolic stage of the reticulate body (Mohseni, M., et. al., 2023). During the reticulate stage the infection is passed on through direct contact to uninfected cells. Chlamydia is a common diagnosis in persons complaining about mucoidal urethral discharge.
Gonorrhea
Neisseria Gonorrhoeae is a bacterial infection that begins with the adhesion of gonococci to epithelial cells (Springer, C. & Salen, P. 2023). This adhesion to epithelial cells allow the bacteria to infect non-occupied cells through direct contact. Gonorrhea is often a secondary infection that is found with chlamydia and responds to similar treatment.
Urinary tract infections, chlamydia, and gonorrhea are common infectious processes that primarily effect the urinary system in both men and women. Left untreated, these infections can spread to the reproductive system causing pain, further infection leading to sepsis, and in some cases increasing potential development of some cancers. Urinary tract infections are common in both men and women. Symptoms are more commonly reported in women due to urethral length leading to bladder and kidney infections. Chlamydia and gonorrhea are both sexually transmitted infections affecting the urinary tract system. Chlamydia can be asymptomatic in both sexes; presentation occurs often with complaints of UTI like symptoms with a differing symptom of urethral discharge. Gonorrhea is like chlamydia; however, with differing symptoms of developing unusual sores along either the penile shaft or labia. According to the Center for Disease Control and Prevention Chlamydia and Gonorrhea are similarly found in your adults ages 15-24 who are sexually active. The uncomplicated urinary tract infection may present with urinary urgency, burning and frequency coupled with painful urination. Chlamydia presents similarly as the UTI with the added symptom of mucoidal urethral discharge where Gonorrhea is often asymptomatic.
Testing required to rule out or confirm each differential involves a clean catch urine, urine cultures, and clean swab collection from the effected area. The UTI will be ruled on a urine dipstick and quickly identified and treated. Chlamydia and Gonorrhea both require the nucleic acid amplification test (NAAT) (Ghanem, K., 2023).
Guidelines for diagnosing and treating a UTI indicate a urine dipstick is only needed to confirm diagnosis, and recommend one of three first line medications that include Fosfomycin, nitrofurantoin, and Bactrim (Colgan, R., & Williams, M., 2011). The guidelines related to diagnose and treat Chlamydia indicate the use of the NAAT procedure to confirm Chlamydia and to treat with doxycycline 100mg for 7 days while abstaining from sexual intercourse (CDC.gov, 2021). Gonorrhea follows the same guideline recommendation for diagnosis, Using the NAAT testing procedure will provide efficient results leading to timely treatment. Per the guidelines set out by the Centers for Disease Control and Prevention the recommended treatment of Gonorrhea is a single dose of Ceftriaxone 500mg IM (CDC.gov, 2023). Given the increased rate of Chlamydia and Gonorrhea occurring together it is common practice to treat empirically with Ceftriaxone 500mg IM and Doxycycline 100mg PO for 7days, during treatment the patient should abstain from sexual intercourse and notify any current and recent sexual partners.
Reference
Hsu, K. (2024). Clinical manifestations and diagnosis of Chlamydia trachomatis infections. UpToDate. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-chlamydia-trachomatis-infections?search=chlamydia&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2
Mohseni, M., Sung, S., & Takov, V. (2023) Chlamydia. https://www.ncbi.nlm.nih.gov/books/NBK537286/