Urinary incontinence: what the GP can do
Dr Richard Burack passes on his tips gained as a GP he practises in Romford,
Essex, and is a member of the RCGP adolescent task group
1. Chlamydia is the UK's most prevalent STI and is caused by the bacterium Chlamydia trachomatis. It affects
3-5 per cent of sexually active women attending practices. The rollout of chlamydia screening has found as
many as 10 per cent of women under
25 to be infected and a higher rate in the under-20s.
2. Chlamydial infection is symptomless in 80 per cent of men and 50 per cent of women. It often goes untreated unless proactively screened for. The complications from chronic chlamydial infection are believed to cost the UK £50 million annually. Some 40 per cent of non-gonococcal urethritis is caused by chlamydia.
3. If symptomatic, chlamydia can cause postcoital bleeding; intermenstrual bleeding; lower abdominal pain; purulent vaginal discharge; muco-purulent cervicitis and/or contact bleeding. In men, it can cause dysuria, urethral discharge or meatal irritation which disappears without treatment, although the organism is still present and can be passed on.
4 Risk factors include being under 25, having several sexual partners, changing sexual partners, not using barrier contraception, use of the
contraceptive pill and women undergoing termination of pregnancy (TOP). Indications for chlamydia screening are women under 25, those with more than one partner in the past year and those undergoing TOP.
5. Complications of chlamydial infection include pelvic inflammatory disease, Fitz-Hugh-Curtis syndrome (perihepatitis), tubal damage resulting in infertility or ectopic pregnancy, chronic pelvic pain, neonatal transmission (conjunctivits or pneumonia), adult conjunctivitis, epididymo-orchitis in men and Reiter's syndrome (sexual-acquired reactive arthritis) more commonly in men.
6. The incidence of chlamydia has risen by nearly 200 per cent between 1995 and 2003 with nearly 60,000 cases in 16- to 24-year-old women and 90,000 in all age groups diagnosed in 2003 in GU clinics. It is estimated there could be another 300,000 cases as yet undetected in the under-25s.
7. Diagnosis of chlamydia has progressed rapidly. The current recommended method is one of the nucleic acid amplification techniques (NAAT). Roche PCR and Becton Dickinson SDA are two popular examples. NAAT has a high sensitivity (>90 per cent) and specificity (>99 per cent) and can be used on swabs or first-catch urine tests.
8. Enzyme immunoassays (EIA) produce lower sensitivities. They cannot be used on female urine samples and perform poorly on male urines. With £7 million support from the Department of Health, all labs will be changing from EIA to NAATs to facilitate a national screening programme.
9. Treating chlamydia remains straightforward. Use regimes like doxycycline 100mg bd for seven days or azithromycin 1g orally in a single dose. Do not use penicillin or ciprofloxacin as these do not clear chlamydial infection. If treating PID empirically, use a regime that treats chlamydia, as this is the commonest cause.
10. All chlamydia positive patients should be screened for other STIs and partner notification should be proactively undertaken for current sexual partner(s) and past partners at least as far back as the previous partner. This is to avoid reinfection and complications and is best done at a GU clinic.