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The Role of Chlamydiae in Genitourinary Disease
0022-5347 /81/1265-0625$02.00/0 Vol. 126, November Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1981 by The Williams & Wilkins Co.
THE ROLE OF CHLAMYDIAE IN GENITOURINARY DISEASE A. W. BRUCE, P. CHADWICK, W. S. WILLETT AND M. O'SHAUGHNESSY From the Departments of Urology and Microbiology, Queen's University, Kingston, Ontario, Canada
ABSTRACT
The incidence of chlamydia! organisms in early morning urine specimens obtained from 53 men and 50 women without evidence of urinary tract pathology was 2 per cent in both groups. Early morning urine specimens and/or prostatic fluid or semen was examined in 70 patients with chronic prostatitis and 39 (56 per cent) yielded this organism. Of 31 patients with epididymo-orchitis the early morning urine specimens yielded chlamydiae in 12 (39 per cent) and in those with the acute form of disease the incidence was 56 per cent. The chlamydial recovery rate was 27 per cent in 119 women with cystourethritis. Within these groups of patients approximately 50 per cent of sexual partners had urine cultures positive for chlamydia. The importance of reinfection and the need for careful treatment of patient and consort should be stressed. An appropriate transport medium is necessary for specimen collection and adequate culture facilities are required to achieve effective chlamydia! recovery. Trimethoprim-sulfamethoxazole and tetracycline were used effectively in this study for primary and secondary drug therapy. The role of chlamydiae as causal agents of disease in humans and animals has been studied intermittently since the early part of this century. Infections for which these organisms have been found responsible include trachoma, 1' 2 neonatal conjunctivitis, 3 urethritis and cervicitis, 3 lymphogranuloma venereum 4 and psittacosis. 5 In 1965 Gordon and Quan described a tissue culture technique for isolating chlamydiae, thus, providing a method simpler than the cumbersome egg yolk technique and allowing effective investigation into the role of chlamydiae in genitourinary disease. 6 The subject of chlamydia! infection has been .reviewed by Schachter. 7 Chlamydiae differ from other micro-organisms in that they have a unique developmental cycle that spans approximately 48 hours. Two morphological forms are .recognized: 1) the smaller highly infective elementary body, which is capable of extracellular survival, and 2) the larger initial body, which is found intracellularly and is the replicating form. The initial penetration of the cell is achieved by phagocytosis of the elementary body. Conversion to the initial body then occurs and, after multiplication by binary fission for 18 to 24 hours, the initial bodies recondense to form elementary bodies that on release from the host cell may invade further cells. Chlamydiae resemble viruses in their obligatory intracellular parasitism and their inability to synthesize important materials such as adenosine triphosphate. However, they differ in that they have a distinct cell wall, possess deoxyribonucleic acid and ribonucleic acid, multiply by binary fission and are susceptible to certain antimicrobial agents. Two chlamydia! species, C. trachomatis and C. psittaci, are recognized. These species share a common antigen. Differentiation between the species can be achieved by the use of iodine, which stains the inclusion bodies of C. trachomatis and not those of C. psittaci. C. trachomatis but not C. psittaci is susceptible to sulfonamides. C. trachomatis can be divided into a number of serotypes that show some association with different disease states; infections of the genitourinary tract are caused serotypes D through K. Chlamydiae can be isolated in various tissue culture systems, including McCoy, HeLa and baby hamster kidney cells, in all of which characteristic inclusions can be recognized. The availability of these simplified techniques encouraged us to investigate the frequency and significance of chlamydiae in Accepted for publication December 31, 1980. Supported by research grant from Burroughs Wellcome Foundation.
625
the genitourinary tract of patients with prostatitis, epididymoo.rchitis and cystoureth.ritis compared to control individuals, and to explore the response of these infections to antimicrobial therapy with trimethoprim-sulfamethoxazole and tetracycline. MATERIALS AND METHODS
Clinical data. Patients with clinical prostatitis: Patients were classified as having subacute or chronic prostatitis depending on the severity and duration of the symptoms. All patients had histories of bladder irritative symptoms, obstructive urinary symptoms and/or rectal-perineal discomfort, and most of the patients had some degree of prostatic tenderness on rectal examination. Microscopic examination of prostatic fluid for polymorphonuclear leukocytes was not used routinely in the diagnosis of prostatitis and, thus, the diagnosis was based on clinical grounds. Patients with chlamydia! infection ranged in age from 24 to 74 years, with a mean of 43 years. Patients with epididymo-orchitis: Acute epididymo-orchitis was diagnosed in 18 patients on the basis of pain and swelling in the epididymis and/ or testis with fever and general malaise" Occasionally, there was a history of irritative urinary symptoms and on physical examination the epididymis was swollen and acutely tender. Prostatic tenderness and bogginess usually were found on rectal examination. Chronic epididymo-orchitis was diagnosed in 13 patients with a longer history of scrotal pain and discomfort, associated tenderness and swelling at either pole of the epididymis. In some patients there was a history of repeated episodes and some had received previous courses of antibiotics. Patients with chlamydial infections ranged in age from 8 to 72 years, with a mean of 44 years. Patients with cystourethritis: We examined 119 women with a history of repeated irritative lower urinary tract symptoms and/or significant bacteriuria. Patients with chlamydial infection ranged from 18 to 73 years old, with a mean of 40 years. In the latter part of the study 31 patients were divided into those with the urethral syndrome and those with recurrent urinary tract infection. Sexual consorts: Whenever possible the consorts of the tients who were sexually active and yielded chlamydiae the urine or prostatic/seminal fluid specimens were investigated for chlamydial infection. Controls: Early morning urine specimens were obtained for culture of chlamydia in 53 male and 50 female volunteers, ranging from 7 to 72 years (mean 31 years) and 17 to 62 years old (mean 29 years), respectively. The vasa deferentia were
626
BRUCE AND ASSOCIATES
swabbed in 54 men ranging from 22 to 52 years old (mean 37 years) at the time of bilateral vasectomy done for sterilization purposes. Seminal fluid was obtained for culture of chlamydia in 20 male volunteers ranging from 22 to 28 years old (mean 24 years). Microbiological data. Investigation for chlamydiae: Specimens examined for chlamydiae included early morning urine for all patient groups and 103 controls, seminal fluid, prostatic fluid or post-prostatic massage urine specimens from patients with prostatitis, seminal fluid from 20 male controls and swabs from both vasa in 54 men who underwent bilateral vasectomy for sterilization purposes. Material was collected in a transport medium, consisting of phosphate buffer to which tryptose phosphate broth, sucrose and vancomycin had been added, and which was kept at room temperature between inoculation and processing. The transport medium was dispensed in kits of 10 ml. for urine and seminal fluid, and 2 ml. for swabs. Urine specimens consisted of the first 10 ml. of early morning urine voided directly into the 10 ml. of transport medium. Specimens were collected by the subjects and no local antiseptics were used. Isolation of chlamydiae was done in a tissue culture containing McCoy cells in which replication was inhibited by 5iodo-2-deoxyuridine. Samples of 0.5 ml. of each specimen in transport medium were inoculated into duplicate tubes of tissue culture medium. Cultures were incubated for 3 days and inclusion bodies were recognized by Giemsa staining. The presence of at least 12 inclusion bodies per specimen was the required criterion for diagnosis of chlamydia! infection. Investigation for bacteria: Midstream urine specimens from all patients were examined bacteriologically by conventional quantitative methods. In some patients with prostatitis bacterial cultures were done on seminal and/or prostatic fluid, and on post-prostatic massage urine specimens. All organisms were recorded for all specimens. Organization and timing of specimen collection. Specimens were examined for chlamydiae and bacteria before therapy in all patients and, in those patients available for followup, early morning urine specimens were examined for chlamydiae 1 month after completion of therapy. In many cases several specimens were examined during the followup interval, the number depending on the clinical and microbiological response to therapy, and on the length of clinical followup. RESULTS
Microbiological. Controls: There were 2 positive cultures for chlamydiae in the early morning urine specimens examined from the 53 male and 50 female volunteers (2 per cent incidence in each group) (table 1). Of the 54 men whose vasa deferentia were swabbed at the time of vasectomy 9 were positive (17 per cent). In 3 of these 9 patients post-vasectomy complications developed in the form of inflammatory swelling at the site of surgery or wound infection. Early morning urine specimens were examined in 4 of the 9 patients and their wives but none yielded chlamydiae. None of the specimens was positive in the 20 male volunteers who provided fluid for chlamydia! cultures. Patients with prostatitis: The early morning urine and/or prostatic fluid specimens yielded chlamydia! organisms in 39 of 70 patients (56 per cent) (table 2). Of these patients 4 had enterobacteria (3 also yielded chlamydiae) and the remaining TABLE
1. Frequency of isolation of chlamydiae from control
subjects Total No. Pts. Early morning urine: No. men No. women Vas deferens swab Seminal fluid
53 50 54 20
* Inflammatory reactions developed in 3 patients.
Pos. Cultures No.(%)
1 9* 0
(2) (2) (17) (0)
2. Frequency of isolation of chlamydiae and gram-negative bacteria from 70 patients with prostatitis and 23 consorts
TABLE
Pos. Cultures
Pts. with prostatitis Consorts
Chlamydia No.(%)
Gram-Neg. Bacteria No.(%)
39 (56) 11 (48)
4* (6) 0 (0)
No Organisms No.(%) 30 (43) 12 (52)
* 3 also yielded chlamydiae. TABLE
3. Source of isolation of chlamydiae in patients with
prostatitis No. Examined Early morning urine Semen Prostatic fluid Post-prostatic massage specimen
39 9 4 4
No. Pos.* 35 7 (6) 4 (1) 3 (3)
* Numbers in parentheses indicate positive early morning urine also.
30 patients (43 per cent) had negative specimens for chlamydiae or gram-negative bacteria. All 39 patients had early morning urine specimens examined for chlamydiae and 35 were positive (of the remaining 4, 3 had positive prostatic fluid cultures and 1 had a positive seminal fluid culture) (table 3). Seventeen of these 39 patients also had prostatic fluid, or semen or post-prostatic massage urine cultured and 14 were positive. Of these 14 patients 10 had chlamydiae in urine and prostatic fluid. Three of the 39 patients and 1 negative for chlamydiae yielded enterobacteria from urine (~10 5/ml.) prostatic fluid. A total of 23 female consorts of the 39 patients from whom chlamydiae were isolated provided early morning urine specimens for chlamydia! culture and 11 (48 per cent) were positive. Table 4 illustrates the problem of reinfection between sexual partners. Patients with epididymo-orchitis: In 31 patients with epididymo-orchitis the early morning urine specimens were examined for chlamydia! organisms, and midstream urine and/ or post-prostatic massage urine specimens were examined for gram-negative bacteria (table 5). Twelve of the early morning urine specimens (39 per cent) were positive for chlamydiae and 7 (23 per cent) yielded enterobacteria with counts > 10 5/ml. Thirteen (42 per cent) of the urine specimens were negative for all organisms studied. When these patients were subdivided into those with acute and chronic epididymo-orchitis 16 of the 18 patients with acute disease yielded organisms from the specimens, whereas in the chronic group only 3 of 13 patients had positive urine cultures. The percentage incidence of chlamydiae in patients with acute epididymo-orchitis was 56 per cent compared to 15 per cent in those with chronic infection. Patients with cystourethritis: The early morning urine specimens in 31 of 119 patients (27 per cent) yielded chlamydia! organisms (table 6). Of these 31 patients 6 also had positive bacterial cultures (~10 5 organisms per ml.). The specimens in the remaining 88 patients (74 per cent) failed to yield either chlamydiae or gram-negative bacteria. The cultures in 6 of 13 male consorts of the 31 women with positive chlamydia! cultures (46 per cent) were positive for evidence of chlamydiae. In the latter part of the study an attempt was made to relate the incidence of chlamydia! infection more specifically in patients with the urethral syndrome compared to those with recurrent urinary tract infection; 31 of the 119 patients studied were subdivided into these 2 categories (table 7). Seven (37 per cent) of 19 patients with the urethral syndrome and 6 (50 per cent) of 12 patients with recurrent urinary tract infection were positive for chlamydia. TREATMENT
All patients and consorts with positive chlamydia! cultures received treatment. In the group with prostatitis sexually active
627
ROLE OF CHLAMYDIAE IN GENITOURINARY DISEASE
________________T_A_B_L_E_4_._In_fl,_u_en_ce~of sexual consorts on chlamydia! reinfection Pts. With Prostatitis Duration of Treat-
Date Culture
Pos. Neg. Pos. Pos. Neg. Neg. Neg.
Nov. 14, 1977 Dec. 13, 1977 Jan. 18, 1978 Mar. 20, 1978 Apr. 24, 1978 June 6, 1978 Apr. 6, 1979
Consort
Drug
ment
ment
(wks.)
(wks.)
2
Trimethoprim-sulfamethoxazole
2 2
Trimethoprim-sulfamethoxazole Tetracycline
5. Frequency of isolation of chlamydiae and gram-negative
TABLE
Culture
Duration of Treat-
TABLE
bacteria from patients with epididymo-orchitis
Neg. Neg. Pos. Pos. Neg. Neg. Neg.
Drug
2
Trimethoprim-sulfamethoxazole
2 2
Trimethoprim-sulfamethoxazole Tetracycline
8. Over-all treatment results in patients with prostatitis,
epididymo-orchitis and cystourethritis
No. Pos. Cultures (%) Total No. Pts. Acute Chronic Totals
Chlamydia
Gram-Neg. Bacteria
10' (56) ~ 12* (39)
LJil.L
18 13 31
No Organisms No.(%)
6 (33)
3 (16) 10 (76) 13 (42)
7 (23)
' 1 patient had both organisms.
Pt. Cure Rate With Primary or Sequential Treatment No./Total (%)
No. Pts. Treated Prostatitis Epididymo-orchitis Cystourethritis Totals
31 12 29 72
(92) (91) (100) (95)
24/26* 11/12 25/25' 60/63
' Patients requiring but not receiving secondary drug therapy excluded. TABLE
6. Frequency of isolation of chlamydiae from 119 patients TABLE
with cystourethritis and 13 consorts
No. pts. Consorts
and tetracycline
Pos. Chlamydia! Cultures No.(%)
No Organisms No.(%)
31' (27)
88 (74)
6
9. Treatment results with trimethoprim-sulfamethoxazole Success Rate No. Treatment Courses
7 (53)
(46)
* 6 also yielded gram-negative bacteria. TABLE
7. Frequency of isolation of chlamydiae from patients with
cystourethritis according to clinical presentation No. Pts.
Chlamydia No.(%)
No.Organ1sms No.(%)
19 12 31
7 (37) 6* (50) 13 (42)
12 (63) 6 (50) 18 (58)
Urethral syndrome Recurrent urinary tract infection Totals
* 2 also yielded gram-negative organisms.
consorts of patients with positive chlamydia! cultures were treated irrespective of the culture results. The initial protocol for all groups of patients included a 2-week interval of trimethoprim-sulfamethoxazole medication. A dosage of 160 mg. trimethoprim and 800 mg. sulfamethoxazole was given orally at 12-hour intervals. This dosage provided adequate clinical response in the women with cystourethritis and in some of the patients with prostatitis. However, the course was increased to at least l month for patients with epididymo-orchitis and in some patients with prostatitis because of inadequate response. Microbiological examination was done only after clinical response had been achieved or when medication had not effected a cure. Tetracycline was given for 2 weeks to patients with cystourethritis and for at least 4 weeks to the other groups. The dosage was 500 mg. every 6 hours for men and 250 mg. every 6 hours for women. Whenever trimethoprim-sulfamethoxazole failed tetracycline was used as the secondary drug and vice versa. Seventy-two patients with chlamydia! infection were available for treatment followup (31 with a diagnosis of chronic prostatitis, 12 with epididymo-orchitis and 29 with cystourethritis) (table 8). There were 110 urine and/or prostatic fluid/ semen cultures done on the 31 patients with prostatitis (10 patients had 2 cultures, 16 had 3 to 5 cultures and 5 had ~6 cultures), 36 urine cultures on the 12 patients with epididymoorchitis (7 patients had 2 cultures, 3 had 2 to 5 cultures and 2 had ~6 cultures) and 89 urine cultures on the 29 patients with
Prostatitis Epididymo-orchitis Cystourethritis Totals
40 13 32 85
TrimethoprimSulfamethoxazole No./Total (%) 14/26 8/9 16/22 38/57
(54) (89) (73) (67)
Tetracycline No,/Total (%) 10/14 2/4 9/10 21/28
(71) (50) (90) (75)
cystourethritis (12 patients had 2 cultures, 15 had 3 to 5 cultures and 2 had ~6 cultures). Followup varied from 3 to 24 months, with a mean of 13.5 months. Table 8 shows the patient cure rate using individual plus sequential drug therapy (if required). In all patients the cure rate was high, varying from 92 to 100 per cent. A few patients whose primary treatment failed to achieve a cure were not available for secondary treatment and were excluded from the totals. Table 9 shows the success rates for trimethoprim-sulfamethoxazole and tetracycline in terms of the number of drug courses given. Tetracycline achieved a higher cure rate in patients with prostatitis and cystourethritis, whereas trimethoprim-sulfamethoxazole showed an advantage in patients with epididymo-orchitis. However, the over-all success rates of the 2 drugs were similar. These figures are not statistically significant in view of the low number of patients studied. The results for consorts with cultures positive for chlamydia are presented in tables 10 and 11. Virtually all patients had clinical and microbiological cure and, again, both drugs were equally effective. DISCUSSION
Chlamydiae are not part of the normal flora of the male urethra and only O to 5 per cent of normal male patients this organism on culture of urethral swabs. 8 - 10 Our finding of a 2 per cent incidence is in agreement with these reports. In our control studies of 54 men who underwent vasectomy we obtained positive chlamydia! cultures in 9, an incidence of 17 per cent. On the other hand, none of the 20 specimens of seminal fluid and only 1 of 53 urine specimens (2 per cent incidence) provided by male volunteers yielded this organism. Most of the studies on the role of chlamydiae in genitourinary
628 TABLE
BRUCE AND ASSOCIATES
10. Over-all treatment results in consorts of patients with prostatitis, epididymo-orchitis and cystourethritis Cure Rate With Primary or Sequential Treatment No.(%)
No. Treated
TABLE
18 (100) 5 (100) 12 (92) 35 (97)
18
Prostatitis Epididymo-orchitis Cystourethritis Totals
5
13 36
11. Treatment results with trimethoprim-sulfamethoxazole
and tetracycline in consorts Success Rate No. Treatment Courses Prostatitis Epididymo-orchitis Cystourethritis Totals
19 6 14 39
TrimethoprimSulfamethoxazole No./Total (%) 11/12 3/4 10/10 24/26
(92) (75) (100) (92)
Tetracycline No./Total (%) 6/7 2/2 3/4 11/13
(86) (100) (75) (85)
disease have been done in patients with nongonococcal urethritis and a clear relationship has been established. 8 • 11 Approximately 40 to 50 per cent of such patients will have growth of chlamydiae on urethral swabs and, when such infection is detected, antichlamydial medication is indicated. Chlamydiae also have been identified clearly as the most likely cause of post-gonococcal urethritis and figures of up to 70 per cent recovery have been reported. 7• 11 Both organisms should be looked for at the initial visit of the patient since penicillin therapy, normally used for gonorrhea, is not effective against chlamydiae. Schachter also has suggested that ureaplasma, present frequently in the male urethra, as distinct from chlamydia, may be responsible for reinfection in some of the remaining patients with nonchlamydial, nongonococcal urethritis. 7 It may be that the ureaplasma organisms are suppressed by the chlamydiae and it would appear that they are the most likely cause of unexplained urethritis in male patients with no clear microbiological yield. Drach and associates have suggested clear criteria for the diagnosis of acute and chronic bacterial prostatitis, nonbacterial prostatitis and prostatodynia. 12 These investigators emphasize the importance of microscopy and culture of prostatic fluid. Although they regard the presence of critical numbers of white blood cells (10 to 20 per high power field) as essential for the diagnosis of bacterial and nonbacterial prostatitis considerable disagreement exists concerning the value of this finding. O'Shaughnessy and associates studied a group of patients with prostatitis and found that 54 per cent had <15 pus cells per high power field, whereas in a control group of male subjects without prostatic symptoms 38 per cent had > 15 pus cells per high power field. 13 They also found that in 25 per cent of patients who underwent weekly prostatic massage there were marked differences in the microscopic findings bearing no relationship to symptoms. In 29 patients in whom the prostatic fluid contained pus cells 3 cultures yielded growth and in only 1 of the 3 cultures was the organism a known pathogen. In addition, Bourne and Frishette found no relationship between the number of pus cells in prostatic fluid and histological evidence of inflammation in patients who underwent transurethral resection. 14 Finally, Jameson reported a marked increase of leukocytes in prostatic fluid after sexual activity and even sexual excitement alone was enough to increase the yield of pus cells. 15 Whereas infection is unlikely in the absence of polymorphonuclear leukocytes in prostatic secretion it would appear that the presence of 10 to 20 leukocytes per high power field does not necessarily indicate infection. Anderson and Weller found a high yield of macrophages in
prostatic fluid of patients with nonbacterial prostatitis and suggested that this finding may be helpful in differentiating this group of patients from those with prostatodynia. 16 In our studies chlamydiae were isolated from either the early morning urine or prostatic/seminal fluid specimens in 56 per cent of patients with a clinical diagnosis of chronic prostatitis. Of the 39 patients with positive chlamydia cultures 17 had semen or prostatic fluid, or post-prostatic fluid massage urine samples examined and positive cultures were obtained. The low incidence of chlamydial organisms in the early morning urine specimens of control subjects (2 per cent) contrasts markedly with these figures. Furthermore, those patients had no clinical evidence of urethritis. Differential urine cultures were not used for chlamydial recovery because of the inability to quantitate culture results. In all patients urine specimens, either midstream or post-prostatic massage, were examined for bacterial pathogens. Our findings differ markedly from the report by Mardh and associates who studied 53 patients with nonacute prostatitis and isolated this organism in urethral discharge in only 1 patient and in none of the 28 specimens of prostatic fluid examined. 17 Significant titers of chlamydia! antibodies were demonstrated in the serum of 6 patients and in the prostatic fluid of 2. However, these investigators believed that chlamydiae could be accepted as the etiological agent in only 7 of the 53 patients, and in those 7 patients the presenting symptoms were suggestive of nongonococcal urethritis rather than prostatitis. However, it should be noted that 4 patients were receiving tetracycline at the time of study, 21 had received this antibiotic between 1 week and 6 months before the investigation and the remaining 28 patients had completed the therapy (mostly tetracycline) approximately 6 months before evaluation. Our findings suggest that chlamydial organisms may have an etiological role in this disease and that a specific microbiological diagnosis may be possible, allowing adequate therapy and accurate followup clinically and microbiologically. Berger and associates studied 23 men with acute idiopathic epididymo-orchitis and found a chlamydial infection rate of 48 per cent (11 of 23 patients), which increased to 85 per cent (11 of 13 patients) when patients <35 years old were examined separately. 18 Similarly, they reported an over-all isolation rate of coliform organisms of 35 per cent (8 of 23 patents) but an incidence of 80 per cent (8 of 10 patients) in the >35-year age group. In our studies the incidence of chlamydial infection in patients with acute epididymo-orchitis was 56 per cent compared to the coliform isolation rate of 33 per cent. We did not find a clear relationship between age and frequency of chlamydial and coliform infections. We used the early morning urine specimen for all our patients and, in a number, seminal fluid or prostatic fluid specimens also were examined. Berger and associates used urethral swabs, prostatic and seminal fluid specimens and, in 66 per cent of the patients, epididymal aspirate for culture in addition to immunofluorescent studies of the serum. 18 As noted, both studies show a significant chlamydial infection rate in the acute form of this disease. Studies on the incidence of chlamydia! growth in the female genitourinary tract have been concentrated on the cervix and in a number of reports an incidence of 2 to 12 per cent has been found in women during routine gynecological examination without evidence of cervicitis or cervical erosion. 19• 20 When cervicitis is present incidence rates of up to 34 per cent have been reported21 and with hypertrophic cervical erosion 50 to 85 per cent of these women will yield growth of chlamydiae. 22 ' 23 The relationship between chlamydial infection and cervical erosion, however, has not been established clearly and there is no proof that chlamydiae are responsible for cervical erosion. It may be that the ectopic columnar epithelium simply allows growth of this organism. 7 We have used the term cystourethritis to describe the clinical
ROLE OF CHLAMYDIAE IN GENITOURINARY DISEASE
condition of female patients who have repeatedly irritative lower urinary tract symptoms and/or significant bacteriuria. We believe this definition includes true recurrent cystitis, asymptomatic bacteriuria and the urethral syndrome, and are justified in considering them as 1 group because their etiological, pathological and clinical features may be similar. 24 In our study of 119 such female patients we found 27 per cent recovery rate of chlamydia! organisms in the urine with a similar incidence in µaic,ti"u" having recurrent urinary tract infection and in those with the urethral syndrome. This is in marked contrast to the 2 per cent recovery rate found in female controls without a history of irritative symptoms or bacteriuria. vVe believe that for some of these women we can now obtain a microbiological diagnosis and offer rational treatment appropriate followup. Furthermore, we also have noted the important finding of chlamydia! and gram-negative orga11isms in a number of these patients and, when followup standard cultures are negative in those with symptoms, search should be made for chlamydiae. studies on chlamydial urethritis in male patients demonstrated the importance of investigation and treatment of sexual partners of these patients. 7 It has been shown that 60 per cent of consorts of such patients will have this organism in urine or cervical specimens. 25 In our study 50 per cent of the female sexual partners of the patients with chlamydial prostatitis also had positive chlamydia! urine cultures. In addition, un,uv·u1,,u our figures for consort study in patients with cystoand epididymo-orchitis were small similar recovery rates were found. Two-thirds of the male and female consorts were asymptomatic and only a third had irritative lower urinary tract symptoms. It is clear that both partners should be investigated and treated. However, this may not be practical and treatment of both partners without investigation of the consort may have to be accepted as a workable alternative. We believe the results in chronic prostatitis to be particularly interesting not only in view of the lack of a clear etiology for this syndrome but also because of the notorious failure rate in the treatment of this disease entity with various antibiotics. It would appear that reinfection as welJ as relapse may be responsible for at least a proportion of those patients with recurrent disease. A high percentage of patients responded satisfactorily, cliniand microbiologically to primary or sequential treatment with either trimethoprim-sulfamethoxazole or tetracycline. In the patients with chronic prostatitis we compared the yield of chlamydia! organisms in early morning urine specimens to fluid obtained massage or in seminal fluid and all 3 specimens to be useful. Prostatic fluid or the first of the ejaculate should be used for a more definite uu,;e;,",v""' of chlamydial prostatitis and should be collected after the urethral swab has been obtained. This will help to differentiate urethral from prostatic infection, although contamination of the urethra may occur from the prostatic fluid. Similarly, in women with cystourethritis a urethral swab should be collected before the early morning urine specimen. When indicated a cervical swab also should be taken. We used a transport medium consisting of phosphate buffer with the addition of sucrose, tryptose, phosphate broth and vancomycin. Excellent recovery rates of chlamydiae have been reported with the use of McCoy cells treated l-iodo-2'deoxyuridine and this method of culture was used throughout the study. However, Evans and Taylor-Robinson have shown that McCoy cells treated with cycloheximide are more effective in the detection of inclusion bodies 26 and we currently are using this technique. REFERENCES
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Classification of benign diseases associated with prostatic prostatitis or prostatodynia? Letter to the Editor. J" UroL, 266, 1978. 13. O'Shaughnessy, E. J", Parrino, P" S" and White, J. n: Chxonic prostatitis-fact or fiction? J,A.M,A,, 160: 540, 1956. 14. Bourne, C. W. and Frishette, W. A.: Prostatic fluid analysi.s and prostatitis. J" Urol., 97: 140, 1967. 15. Jameson, R. M.: Sexual activity and the variations of the white ceJJ content of the prostatic secretion. Invest. U:roL, 5: 297, 1967. 16. Anderson, R. U. and Weller, C.: Prostatic secretion leukocyV,
studies in non-bacterial prostatitis (prostatosis). J" UroL, 121: 292, 1979. 17. Mardh, P" A., Ripa, K. T., Colleen, S., Treharne, J. D. and Darougax,
S.: Role of Chlamydia trachomatis in non-acute p:rostatitis. Brit. J. Vener. Dis., 54: 330, 1978. 18. Berger, R" E., Alexander, E. R., Monda, G" D", Ansell, J,, McCormick, G. and Holmes, K K.: Chlamydia trachomatis as a cause of acute "idiopathic" epididymitis. New Engl. J" Med., 298:: 301, 1978. 19" Thygeson, P. and Stone, W., Jr.: Epidemiology of inclusion conjunctivitis. Arch. Ophthalmol., 27: 91, 1942. 20, Alexander, E. R., Chandler, J., Pheifer, T. A., Wang, S"·"P., English,
21. 22.
23.
24.
M, and Holmes, K. K.: Prospective study of perinatal vu~cuuy•um trachomatis infection, In: Nongonococcal Urethritis and Infections. Edited by D. Hobson and K. K. Holmes, Washington, D. C.: American Society for Microbiology, pp, 148-152, 1977. Kuo, C.-C., Wang, S.-P., Wentworth, B. B. and Grayston, J" T": Primary isolation of TRIC organisms in HeLa 229 cells treated with DEAE-Dextran. J, Infect, Dis., 125: 665, 1972. Hobson, D., Johnson, F. W. A., Rees, E. and Tait, I. A,: uuupuucu method for diagnosis of genital and ocular infections mydia, Lancet, 2: 555, 1974. Rees, E., Tait, I. A., Hobson, D. and Johnson, W. F. A.: Chlamydia in relation to cervical infection and pelvic inflammatory disease, In: Nongonococcal Urethritis and Related Infections. Edited by D. Hobson and K. K. Holmes. Washington, D. C.: American Society for Microbiology, pp. 67-76, 1977. Seddon, J, M" and Bruce, A. W.: Cystourethritis, Urology, 11:
1978. 25. Handsfield, !-L H., Alexander, E. R., Wang, S. P., Pedersen, A. H,
and Holmes, K. K.: Differences in the therapeutic response of chlamydia-positive and chlamydia-negative forms of non-"gonococcal urethritis. J. Amer. Vener. Dis. Ass., 2: 5, March 1976 26. Evans, R. T and Taylor-Robinson, D.: Comparison of vaJious McCoy cell treatment procedures used for detection of Cl:JJa·· mydia trachomatis. J. Clin" Microbiol., 10: 198, 1979. B,
THE JOURNAL OF UROLOGY
Copyright© 1981 by The Williams & Wilkins Co.
THE ROLE OF CHLAMYDIAE IN GENITOURINARY DISEASE A. W. BRUCE, P. CHADWICK, W. S. WILLETT AND M. O'SHAUGHNESSY From the Departments of Urology and Microbiology, Queen's University, Kingston, Ontario, Canada
ABSTRACT
The incidence of chlamydia! organisms in early morning urine specimens obtained from 53 men and 50 women without evidence of urinary tract pathology was 2 per cent in both groups. Early morning urine specimens and/or prostatic fluid or semen was examined in 70 patients with chronic prostatitis and 39 (56 per cent) yielded this organism. Of 31 patients with epididymo-orchitis the early morning urine specimens yielded chlamydiae in 12 (39 per cent) and in those with the acute form of disease the incidence was 56 per cent. The chlamydial recovery rate was 27 per cent in 119 women with cystourethritis. Within these groups of patients approximately 50 per cent of sexual partners had urine cultures positive for chlamydia. The importance of reinfection and the need for careful treatment of patient and consort should be stressed. An appropriate transport medium is necessary for specimen collection and adequate culture facilities are required to achieve effective chlamydia! recovery. Trimethoprim-sulfamethoxazole and tetracycline were used effectively in this study for primary and secondary drug therapy. The role of chlamydiae as causal agents of disease in humans and animals has been studied intermittently since the early part of this century. Infections for which these organisms have been found responsible include trachoma, 1' 2 neonatal conjunctivitis, 3 urethritis and cervicitis, 3 lymphogranuloma venereum 4 and psittacosis. 5 In 1965 Gordon and Quan described a tissue culture technique for isolating chlamydiae, thus, providing a method simpler than the cumbersome egg yolk technique and allowing effective investigation into the role of chlamydiae in genitourinary disease. 6 The subject of chlamydia! infection has been .reviewed by Schachter. 7 Chlamydiae differ from other micro-organisms in that they have a unique developmental cycle that spans approximately 48 hours. Two morphological forms are .recognized: 1) the smaller highly infective elementary body, which is capable of extracellular survival, and 2) the larger initial body, which is found intracellularly and is the replicating form. The initial penetration of the cell is achieved by phagocytosis of the elementary body. Conversion to the initial body then occurs and, after multiplication by binary fission for 18 to 24 hours, the initial bodies recondense to form elementary bodies that on release from the host cell may invade further cells. Chlamydiae resemble viruses in their obligatory intracellular parasitism and their inability to synthesize important materials such as adenosine triphosphate. However, they differ in that they have a distinct cell wall, possess deoxyribonucleic acid and ribonucleic acid, multiply by binary fission and are susceptible to certain antimicrobial agents. Two chlamydia! species, C. trachomatis and C. psittaci, are recognized. These species share a common antigen. Differentiation between the species can be achieved by the use of iodine, which stains the inclusion bodies of C. trachomatis and not those of C. psittaci. C. trachomatis but not C. psittaci is susceptible to sulfonamides. C. trachomatis can be divided into a number of serotypes that show some association with different disease states; infections of the genitourinary tract are caused serotypes D through K. Chlamydiae can be isolated in various tissue culture systems, including McCoy, HeLa and baby hamster kidney cells, in all of which characteristic inclusions can be recognized. The availability of these simplified techniques encouraged us to investigate the frequency and significance of chlamydiae in Accepted for publication December 31, 1980. Supported by research grant from Burroughs Wellcome Foundation.
625
the genitourinary tract of patients with prostatitis, epididymoo.rchitis and cystoureth.ritis compared to control individuals, and to explore the response of these infections to antimicrobial therapy with trimethoprim-sulfamethoxazole and tetracycline. MATERIALS AND METHODS
Clinical data. Patients with clinical prostatitis: Patients were classified as having subacute or chronic prostatitis depending on the severity and duration of the symptoms. All patients had histories of bladder irritative symptoms, obstructive urinary symptoms and/or rectal-perineal discomfort, and most of the patients had some degree of prostatic tenderness on rectal examination. Microscopic examination of prostatic fluid for polymorphonuclear leukocytes was not used routinely in the diagnosis of prostatitis and, thus, the diagnosis was based on clinical grounds. Patients with chlamydia! infection ranged in age from 24 to 74 years, with a mean of 43 years. Patients with epididymo-orchitis: Acute epididymo-orchitis was diagnosed in 18 patients on the basis of pain and swelling in the epididymis and/ or testis with fever and general malaise" Occasionally, there was a history of irritative urinary symptoms and on physical examination the epididymis was swollen and acutely tender. Prostatic tenderness and bogginess usually were found on rectal examination. Chronic epididymo-orchitis was diagnosed in 13 patients with a longer history of scrotal pain and discomfort, associated tenderness and swelling at either pole of the epididymis. In some patients there was a history of repeated episodes and some had received previous courses of antibiotics. Patients with chlamydial infections ranged in age from 8 to 72 years, with a mean of 44 years. Patients with cystourethritis: We examined 119 women with a history of repeated irritative lower urinary tract symptoms and/or significant bacteriuria. Patients with chlamydial infection ranged from 18 to 73 years old, with a mean of 40 years. In the latter part of the study 31 patients were divided into those with the urethral syndrome and those with recurrent urinary tract infection. Sexual consorts: Whenever possible the consorts of the tients who were sexually active and yielded chlamydiae the urine or prostatic/seminal fluid specimens were investigated for chlamydial infection. Controls: Early morning urine specimens were obtained for culture of chlamydia in 53 male and 50 female volunteers, ranging from 7 to 72 years (mean 31 years) and 17 to 62 years old (mean 29 years), respectively. The vasa deferentia were
626
BRUCE AND ASSOCIATES
swabbed in 54 men ranging from 22 to 52 years old (mean 37 years) at the time of bilateral vasectomy done for sterilization purposes. Seminal fluid was obtained for culture of chlamydia in 20 male volunteers ranging from 22 to 28 years old (mean 24 years). Microbiological data. Investigation for chlamydiae: Specimens examined for chlamydiae included early morning urine for all patient groups and 103 controls, seminal fluid, prostatic fluid or post-prostatic massage urine specimens from patients with prostatitis, seminal fluid from 20 male controls and swabs from both vasa in 54 men who underwent bilateral vasectomy for sterilization purposes. Material was collected in a transport medium, consisting of phosphate buffer to which tryptose phosphate broth, sucrose and vancomycin had been added, and which was kept at room temperature between inoculation and processing. The transport medium was dispensed in kits of 10 ml. for urine and seminal fluid, and 2 ml. for swabs. Urine specimens consisted of the first 10 ml. of early morning urine voided directly into the 10 ml. of transport medium. Specimens were collected by the subjects and no local antiseptics were used. Isolation of chlamydiae was done in a tissue culture containing McCoy cells in which replication was inhibited by 5iodo-2-deoxyuridine. Samples of 0.5 ml. of each specimen in transport medium were inoculated into duplicate tubes of tissue culture medium. Cultures were incubated for 3 days and inclusion bodies were recognized by Giemsa staining. The presence of at least 12 inclusion bodies per specimen was the required criterion for diagnosis of chlamydia! infection. Investigation for bacteria: Midstream urine specimens from all patients were examined bacteriologically by conventional quantitative methods. In some patients with prostatitis bacterial cultures were done on seminal and/or prostatic fluid, and on post-prostatic massage urine specimens. All organisms were recorded for all specimens. Organization and timing of specimen collection. Specimens were examined for chlamydiae and bacteria before therapy in all patients and, in those patients available for followup, early morning urine specimens were examined for chlamydiae 1 month after completion of therapy. In many cases several specimens were examined during the followup interval, the number depending on the clinical and microbiological response to therapy, and on the length of clinical followup. RESULTS
Microbiological. Controls: There were 2 positive cultures for chlamydiae in the early morning urine specimens examined from the 53 male and 50 female volunteers (2 per cent incidence in each group) (table 1). Of the 54 men whose vasa deferentia were swabbed at the time of vasectomy 9 were positive (17 per cent). In 3 of these 9 patients post-vasectomy complications developed in the form of inflammatory swelling at the site of surgery or wound infection. Early morning urine specimens were examined in 4 of the 9 patients and their wives but none yielded chlamydiae. None of the specimens was positive in the 20 male volunteers who provided fluid for chlamydia! cultures. Patients with prostatitis: The early morning urine and/or prostatic fluid specimens yielded chlamydia! organisms in 39 of 70 patients (56 per cent) (table 2). Of these patients 4 had enterobacteria (3 also yielded chlamydiae) and the remaining TABLE
1. Frequency of isolation of chlamydiae from control
subjects Total No. Pts. Early morning urine: No. men No. women Vas deferens swab Seminal fluid
53 50 54 20
* Inflammatory reactions developed in 3 patients.
Pos. Cultures No.(%)
1 9* 0
(2) (2) (17) (0)
2. Frequency of isolation of chlamydiae and gram-negative bacteria from 70 patients with prostatitis and 23 consorts
TABLE
Pos. Cultures
Pts. with prostatitis Consorts
Chlamydia No.(%)
Gram-Neg. Bacteria No.(%)
39 (56) 11 (48)
4* (6) 0 (0)
No Organisms No.(%) 30 (43) 12 (52)
* 3 also yielded chlamydiae. TABLE
3. Source of isolation of chlamydiae in patients with
prostatitis No. Examined Early morning urine Semen Prostatic fluid Post-prostatic massage specimen
39 9 4 4
No. Pos.* 35 7 (6) 4 (1) 3 (3)
* Numbers in parentheses indicate positive early morning urine also.
30 patients (43 per cent) had negative specimens for chlamydiae or gram-negative bacteria. All 39 patients had early morning urine specimens examined for chlamydiae and 35 were positive (of the remaining 4, 3 had positive prostatic fluid cultures and 1 had a positive seminal fluid culture) (table 3). Seventeen of these 39 patients also had prostatic fluid, or semen or post-prostatic massage urine cultured and 14 were positive. Of these 14 patients 10 had chlamydiae in urine and prostatic fluid. Three of the 39 patients and 1 negative for chlamydiae yielded enterobacteria from urine (~10 5/ml.) prostatic fluid. A total of 23 female consorts of the 39 patients from whom chlamydiae were isolated provided early morning urine specimens for chlamydia! culture and 11 (48 per cent) were positive. Table 4 illustrates the problem of reinfection between sexual partners. Patients with epididymo-orchitis: In 31 patients with epididymo-orchitis the early morning urine specimens were examined for chlamydia! organisms, and midstream urine and/ or post-prostatic massage urine specimens were examined for gram-negative bacteria (table 5). Twelve of the early morning urine specimens (39 per cent) were positive for chlamydiae and 7 (23 per cent) yielded enterobacteria with counts > 10 5/ml. Thirteen (42 per cent) of the urine specimens were negative for all organisms studied. When these patients were subdivided into those with acute and chronic epididymo-orchitis 16 of the 18 patients with acute disease yielded organisms from the specimens, whereas in the chronic group only 3 of 13 patients had positive urine cultures. The percentage incidence of chlamydiae in patients with acute epididymo-orchitis was 56 per cent compared to 15 per cent in those with chronic infection. Patients with cystourethritis: The early morning urine specimens in 31 of 119 patients (27 per cent) yielded chlamydia! organisms (table 6). Of these 31 patients 6 also had positive bacterial cultures (~10 5 organisms per ml.). The specimens in the remaining 88 patients (74 per cent) failed to yield either chlamydiae or gram-negative bacteria. The cultures in 6 of 13 male consorts of the 31 women with positive chlamydia! cultures (46 per cent) were positive for evidence of chlamydiae. In the latter part of the study an attempt was made to relate the incidence of chlamydia! infection more specifically in patients with the urethral syndrome compared to those with recurrent urinary tract infection; 31 of the 119 patients studied were subdivided into these 2 categories (table 7). Seven (37 per cent) of 19 patients with the urethral syndrome and 6 (50 per cent) of 12 patients with recurrent urinary tract infection were positive for chlamydia. TREATMENT
All patients and consorts with positive chlamydia! cultures received treatment. In the group with prostatitis sexually active
627
ROLE OF CHLAMYDIAE IN GENITOURINARY DISEASE
________________T_A_B_L_E_4_._In_fl,_u_en_ce~of sexual consorts on chlamydia! reinfection Pts. With Prostatitis Duration of Treat-
Date Culture
Pos. Neg. Pos. Pos. Neg. Neg. Neg.
Nov. 14, 1977 Dec. 13, 1977 Jan. 18, 1978 Mar. 20, 1978 Apr. 24, 1978 June 6, 1978 Apr. 6, 1979
Consort
Drug
ment
ment
(wks.)
(wks.)
2
Trimethoprim-sulfamethoxazole
2 2
Trimethoprim-sulfamethoxazole Tetracycline
5. Frequency of isolation of chlamydiae and gram-negative
TABLE
Culture
Duration of Treat-
TABLE
bacteria from patients with epididymo-orchitis
Neg. Neg. Pos. Pos. Neg. Neg. Neg.
Drug
2
Trimethoprim-sulfamethoxazole
2 2
Trimethoprim-sulfamethoxazole Tetracycline
8. Over-all treatment results in patients with prostatitis,
epididymo-orchitis and cystourethritis
No. Pos. Cultures (%) Total No. Pts. Acute Chronic Totals
Chlamydia
Gram-Neg. Bacteria
10' (56) ~ 12* (39)
LJil.L
18 13 31
No Organisms No.(%)
6 (33)
3 (16) 10 (76) 13 (42)
7 (23)
' 1 patient had both organisms.
Pt. Cure Rate With Primary or Sequential Treatment No./Total (%)
No. Pts. Treated Prostatitis Epididymo-orchitis Cystourethritis Totals
31 12 29 72
(92) (91) (100) (95)
24/26* 11/12 25/25' 60/63
' Patients requiring but not receiving secondary drug therapy excluded. TABLE
6. Frequency of isolation of chlamydiae from 119 patients TABLE
with cystourethritis and 13 consorts
No. pts. Consorts
and tetracycline
Pos. Chlamydia! Cultures No.(%)
No Organisms No.(%)
31' (27)
88 (74)
6
9. Treatment results with trimethoprim-sulfamethoxazole Success Rate No. Treatment Courses
7 (53)
(46)
* 6 also yielded gram-negative bacteria. TABLE
7. Frequency of isolation of chlamydiae from patients with
cystourethritis according to clinical presentation No. Pts.
Chlamydia No.(%)
No.Organ1sms No.(%)
19 12 31
7 (37) 6* (50) 13 (42)
12 (63) 6 (50) 18 (58)
Urethral syndrome Recurrent urinary tract infection Totals
* 2 also yielded gram-negative organisms.
consorts of patients with positive chlamydia! cultures were treated irrespective of the culture results. The initial protocol for all groups of patients included a 2-week interval of trimethoprim-sulfamethoxazole medication. A dosage of 160 mg. trimethoprim and 800 mg. sulfamethoxazole was given orally at 12-hour intervals. This dosage provided adequate clinical response in the women with cystourethritis and in some of the patients with prostatitis. However, the course was increased to at least l month for patients with epididymo-orchitis and in some patients with prostatitis because of inadequate response. Microbiological examination was done only after clinical response had been achieved or when medication had not effected a cure. Tetracycline was given for 2 weeks to patients with cystourethritis and for at least 4 weeks to the other groups. The dosage was 500 mg. every 6 hours for men and 250 mg. every 6 hours for women. Whenever trimethoprim-sulfamethoxazole failed tetracycline was used as the secondary drug and vice versa. Seventy-two patients with chlamydia! infection were available for treatment followup (31 with a diagnosis of chronic prostatitis, 12 with epididymo-orchitis and 29 with cystourethritis) (table 8). There were 110 urine and/or prostatic fluid/ semen cultures done on the 31 patients with prostatitis (10 patients had 2 cultures, 16 had 3 to 5 cultures and 5 had ~6 cultures), 36 urine cultures on the 12 patients with epididymoorchitis (7 patients had 2 cultures, 3 had 2 to 5 cultures and 2 had ~6 cultures) and 89 urine cultures on the 29 patients with
Prostatitis Epididymo-orchitis Cystourethritis Totals
40 13 32 85
TrimethoprimSulfamethoxazole No./Total (%) 14/26 8/9 16/22 38/57
(54) (89) (73) (67)
Tetracycline No,/Total (%) 10/14 2/4 9/10 21/28
(71) (50) (90) (75)
cystourethritis (12 patients had 2 cultures, 15 had 3 to 5 cultures and 2 had ~6 cultures). Followup varied from 3 to 24 months, with a mean of 13.5 months. Table 8 shows the patient cure rate using individual plus sequential drug therapy (if required). In all patients the cure rate was high, varying from 92 to 100 per cent. A few patients whose primary treatment failed to achieve a cure were not available for secondary treatment and were excluded from the totals. Table 9 shows the success rates for trimethoprim-sulfamethoxazole and tetracycline in terms of the number of drug courses given. Tetracycline achieved a higher cure rate in patients with prostatitis and cystourethritis, whereas trimethoprim-sulfamethoxazole showed an advantage in patients with epididymo-orchitis. However, the over-all success rates of the 2 drugs were similar. These figures are not statistically significant in view of the low number of patients studied. The results for consorts with cultures positive for chlamydia are presented in tables 10 and 11. Virtually all patients had clinical and microbiological cure and, again, both drugs were equally effective. DISCUSSION
Chlamydiae are not part of the normal flora of the male urethra and only O to 5 per cent of normal male patients this organism on culture of urethral swabs. 8 - 10 Our finding of a 2 per cent incidence is in agreement with these reports. In our control studies of 54 men who underwent vasectomy we obtained positive chlamydia! cultures in 9, an incidence of 17 per cent. On the other hand, none of the 20 specimens of seminal fluid and only 1 of 53 urine specimens (2 per cent incidence) provided by male volunteers yielded this organism. Most of the studies on the role of chlamydiae in genitourinary
628 TABLE
BRUCE AND ASSOCIATES
10. Over-all treatment results in consorts of patients with prostatitis, epididymo-orchitis and cystourethritis Cure Rate With Primary or Sequential Treatment No.(%)
No. Treated
TABLE
18 (100) 5 (100) 12 (92) 35 (97)
18
Prostatitis Epididymo-orchitis Cystourethritis Totals
5
13 36
11. Treatment results with trimethoprim-sulfamethoxazole
and tetracycline in consorts Success Rate No. Treatment Courses Prostatitis Epididymo-orchitis Cystourethritis Totals
19 6 14 39
TrimethoprimSulfamethoxazole No./Total (%) 11/12 3/4 10/10 24/26
(92) (75) (100) (92)
Tetracycline No./Total (%) 6/7 2/2 3/4 11/13
(86) (100) (75) (85)
disease have been done in patients with nongonococcal urethritis and a clear relationship has been established. 8 • 11 Approximately 40 to 50 per cent of such patients will have growth of chlamydiae on urethral swabs and, when such infection is detected, antichlamydial medication is indicated. Chlamydiae also have been identified clearly as the most likely cause of post-gonococcal urethritis and figures of up to 70 per cent recovery have been reported. 7• 11 Both organisms should be looked for at the initial visit of the patient since penicillin therapy, normally used for gonorrhea, is not effective against chlamydiae. Schachter also has suggested that ureaplasma, present frequently in the male urethra, as distinct from chlamydia, may be responsible for reinfection in some of the remaining patients with nonchlamydial, nongonococcal urethritis. 7 It may be that the ureaplasma organisms are suppressed by the chlamydiae and it would appear that they are the most likely cause of unexplained urethritis in male patients with no clear microbiological yield. Drach and associates have suggested clear criteria for the diagnosis of acute and chronic bacterial prostatitis, nonbacterial prostatitis and prostatodynia. 12 These investigators emphasize the importance of microscopy and culture of prostatic fluid. Although they regard the presence of critical numbers of white blood cells (10 to 20 per high power field) as essential for the diagnosis of bacterial and nonbacterial prostatitis considerable disagreement exists concerning the value of this finding. O'Shaughnessy and associates studied a group of patients with prostatitis and found that 54 per cent had <15 pus cells per high power field, whereas in a control group of male subjects without prostatic symptoms 38 per cent had > 15 pus cells per high power field. 13 They also found that in 25 per cent of patients who underwent weekly prostatic massage there were marked differences in the microscopic findings bearing no relationship to symptoms. In 29 patients in whom the prostatic fluid contained pus cells 3 cultures yielded growth and in only 1 of the 3 cultures was the organism a known pathogen. In addition, Bourne and Frishette found no relationship between the number of pus cells in prostatic fluid and histological evidence of inflammation in patients who underwent transurethral resection. 14 Finally, Jameson reported a marked increase of leukocytes in prostatic fluid after sexual activity and even sexual excitement alone was enough to increase the yield of pus cells. 15 Whereas infection is unlikely in the absence of polymorphonuclear leukocytes in prostatic secretion it would appear that the presence of 10 to 20 leukocytes per high power field does not necessarily indicate infection. Anderson and Weller found a high yield of macrophages in
prostatic fluid of patients with nonbacterial prostatitis and suggested that this finding may be helpful in differentiating this group of patients from those with prostatodynia. 16 In our studies chlamydiae were isolated from either the early morning urine or prostatic/seminal fluid specimens in 56 per cent of patients with a clinical diagnosis of chronic prostatitis. Of the 39 patients with positive chlamydia cultures 17 had semen or prostatic fluid, or post-prostatic fluid massage urine samples examined and positive cultures were obtained. The low incidence of chlamydial organisms in the early morning urine specimens of control subjects (2 per cent) contrasts markedly with these figures. Furthermore, those patients had no clinical evidence of urethritis. Differential urine cultures were not used for chlamydial recovery because of the inability to quantitate culture results. In all patients urine specimens, either midstream or post-prostatic massage, were examined for bacterial pathogens. Our findings differ markedly from the report by Mardh and associates who studied 53 patients with nonacute prostatitis and isolated this organism in urethral discharge in only 1 patient and in none of the 28 specimens of prostatic fluid examined. 17 Significant titers of chlamydia! antibodies were demonstrated in the serum of 6 patients and in the prostatic fluid of 2. However, these investigators believed that chlamydiae could be accepted as the etiological agent in only 7 of the 53 patients, and in those 7 patients the presenting symptoms were suggestive of nongonococcal urethritis rather than prostatitis. However, it should be noted that 4 patients were receiving tetracycline at the time of study, 21 had received this antibiotic between 1 week and 6 months before the investigation and the remaining 28 patients had completed the therapy (mostly tetracycline) approximately 6 months before evaluation. Our findings suggest that chlamydial organisms may have an etiological role in this disease and that a specific microbiological diagnosis may be possible, allowing adequate therapy and accurate followup clinically and microbiologically. Berger and associates studied 23 men with acute idiopathic epididymo-orchitis and found a chlamydial infection rate of 48 per cent (11 of 23 patients), which increased to 85 per cent (11 of 13 patients) when patients <35 years old were examined separately. 18 Similarly, they reported an over-all isolation rate of coliform organisms of 35 per cent (8 of 23 patents) but an incidence of 80 per cent (8 of 10 patients) in the >35-year age group. In our studies the incidence of chlamydial infection in patients with acute epididymo-orchitis was 56 per cent compared to the coliform isolation rate of 33 per cent. We did not find a clear relationship between age and frequency of chlamydial and coliform infections. We used the early morning urine specimen for all our patients and, in a number, seminal fluid or prostatic fluid specimens also were examined. Berger and associates used urethral swabs, prostatic and seminal fluid specimens and, in 66 per cent of the patients, epididymal aspirate for culture in addition to immunofluorescent studies of the serum. 18 As noted, both studies show a significant chlamydial infection rate in the acute form of this disease. Studies on the incidence of chlamydia! growth in the female genitourinary tract have been concentrated on the cervix and in a number of reports an incidence of 2 to 12 per cent has been found in women during routine gynecological examination without evidence of cervicitis or cervical erosion. 19• 20 When cervicitis is present incidence rates of up to 34 per cent have been reported21 and with hypertrophic cervical erosion 50 to 85 per cent of these women will yield growth of chlamydiae. 22 ' 23 The relationship between chlamydial infection and cervical erosion, however, has not been established clearly and there is no proof that chlamydiae are responsible for cervical erosion. It may be that the ectopic columnar epithelium simply allows growth of this organism. 7 We have used the term cystourethritis to describe the clinical
ROLE OF CHLAMYDIAE IN GENITOURINARY DISEASE
condition of female patients who have repeatedly irritative lower urinary tract symptoms and/or significant bacteriuria. We believe this definition includes true recurrent cystitis, asymptomatic bacteriuria and the urethral syndrome, and are justified in considering them as 1 group because their etiological, pathological and clinical features may be similar. 24 In our study of 119 such female patients we found 27 per cent recovery rate of chlamydia! organisms in the urine with a similar incidence in µaic,ti"u" having recurrent urinary tract infection and in those with the urethral syndrome. This is in marked contrast to the 2 per cent recovery rate found in female controls without a history of irritative symptoms or bacteriuria. vVe believe that for some of these women we can now obtain a microbiological diagnosis and offer rational treatment appropriate followup. Furthermore, we also have noted the important finding of chlamydia! and gram-negative orga11isms in a number of these patients and, when followup standard cultures are negative in those with symptoms, search should be made for chlamydiae. studies on chlamydial urethritis in male patients demonstrated the importance of investigation and treatment of sexual partners of these patients. 7 It has been shown that 60 per cent of consorts of such patients will have this organism in urine or cervical specimens. 25 In our study 50 per cent of the female sexual partners of the patients with chlamydial prostatitis also had positive chlamydia! urine cultures. In addition, un,uv·u1,,u our figures for consort study in patients with cystoand epididymo-orchitis were small similar recovery rates were found. Two-thirds of the male and female consorts were asymptomatic and only a third had irritative lower urinary tract symptoms. It is clear that both partners should be investigated and treated. However, this may not be practical and treatment of both partners without investigation of the consort may have to be accepted as a workable alternative. We believe the results in chronic prostatitis to be particularly interesting not only in view of the lack of a clear etiology for this syndrome but also because of the notorious failure rate in the treatment of this disease entity with various antibiotics. It would appear that reinfection as welJ as relapse may be responsible for at least a proportion of those patients with recurrent disease. A high percentage of patients responded satisfactorily, cliniand microbiologically to primary or sequential treatment with either trimethoprim-sulfamethoxazole or tetracycline. In the patients with chronic prostatitis we compared the yield of chlamydia! organisms in early morning urine specimens to fluid obtained massage or in seminal fluid and all 3 specimens to be useful. Prostatic fluid or the first of the ejaculate should be used for a more definite uu,;e;,",v""' of chlamydial prostatitis and should be collected after the urethral swab has been obtained. This will help to differentiate urethral from prostatic infection, although contamination of the urethra may occur from the prostatic fluid. Similarly, in women with cystourethritis a urethral swab should be collected before the early morning urine specimen. When indicated a cervical swab also should be taken. We used a transport medium consisting of phosphate buffer with the addition of sucrose, tryptose, phosphate broth and vancomycin. Excellent recovery rates of chlamydiae have been reported with the use of McCoy cells treated l-iodo-2'deoxyuridine and this method of culture was used throughout the study. However, Evans and Taylor-Robinson have shown that McCoy cells treated with cycloheximide are more effective in the detection of inclusion bodies 26 and we currently are using this technique. REFERENCES
L Halberstaedter, L. and Von Prowazek, S.: Zur Aetiologie des Trachoms. Dtsch. Med. Wochenschr., 33: 1285, 1907. 2. T'ang, F.-F., Chang, H.-L,, Huang, Y-T, and Wong, K C.: Tra-
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