Urogenital infections in girls. Urogenital infections: a bunch of unpleasant surprises

• Which doctors should you contact if you have Urogenital chlamydia?

What is Urogenital chlamydia

Urogenital chlamydia is one of the most common sexually transmitted infections. The number of people affected by chlamydia is steadily increasing, with 90 million cases of the disease being recorded annually worldwide. The widespread prevalence of chlamydia is due to the erasure of clinical symptoms, the complexity of diagnosis, the emergence of strains resistant to antibiotics, as well as social factors - an increase in the frequency of extramarital sexual relations, increased population migration, prostitution, etc. Chlamydia often causes non-gonococcal urethritis (up to 50%), infertility, inflammatory diseases of the pelvic organs, pneumonia and conjunctivitis of newborns.

What causes Urogenital chlamydia

Chlamydia is unstable in the external environment, easily killed when exposed to antiseptics, ultraviolet rays, boiling, drying.

Infection occurs mainly through sexual contact with an infected partner, transplacentally and intrapartum, rarely by everyday means through toiletries, linen, shared bed. The causative agent of the disease exhibits a high affinity for columnar epithelial cells (endcervix, endosalpinx, urethra). In addition, chlamydia, absorbed by monocytes, spreads through the bloodstream and settles in tissues (joints, heart, lungs, etc.), causing multifocal lesions. The main pathogenetic link of chlamydia is the development of a scar-adhesive process in the affected tissues as a consequence of the inflammatory reaction.

Chlamydial infection causes pronounced changes in both cellular (activation of T-helper cells) and humoral immunity, including the formation of immunoglobulins of classes A, M, G. The ability of chlamydia, under the influence of inadequate therapy, to transform into L-forms and/or change its antigenic structure, which complicates the diagnosis and treatment of the disease.

Urogenital chlamydia during pregnancy can lead to a number of serious complications- spontaneous abortion, premature birth, intrauterine infection or fetal death, untimely rupture of amniotic fluid.

Pathogenesis (what happens?) during Urogenital chlamydia

generally accepted clinical classification does not exist. There are fresh (disease duration up to 2 months) and chronic (disease duration more than 2 months) chlamydia; cases of carriage of chlamydial infection have been reported. In addition, the disease is divided into uncomplicated chlamydia of the lower parts of the genitourinary system, upper sections genitourinary system and pelvic organs, chlamydia of other localization.

Symptoms of Urogenital chlamydia

The incubation period for chlamydia ranges from 5 to 30 days, averaging 2-3 weeks. Urogenital chlamydia is characterized by polymorphism of clinical manifestations, the absence of specific signs, an asymptomatic or minimally symptomatic long-term course, and a tendency to relapse. Patients usually consult a doctor when complications develop. Acute forms of the disease have been observed in mixed infections.

Most often, chlamydial infection affects the mucous membrane of the cervical canal. Chlamydial cervicitis most often remains asymptomatic. Sometimes patients note the appearance of serous-purulent discharge from the genital tract, and when urethritis occurs, itching in the urethra, painful and frequent urination, purulent discharge from the urethra in the morning (symptom of “morning drop”).

Ascending urogenital chlamydial infection determines the development of salpingitis, salpingoophoritis, pelvioperitonitis, peritonitis, which do not have specific signs other than a protracted “erased” course with chronic inflammatory process. The consequences of chlamydia of the pelvic organs include adhesions in the area of ​​the uterine appendages, infertility and ectopic pregnancy.

Extragenital chlamydia includes Reiter's disease, which includes the triad: arthritis, conjunctivitis, urethritis.

Chlamydia in newborns manifests itself as vulvovaginitis, urethritis, conjunctivitis, and pneumonia.

Diagnosis of Urogenital chlamydia

Examination of the cervix using mirrors and colposcopy reveals serous-purulent discharge from the cervical canal, hyperemia and swelling of the mucous membrane around the external pharynx, and pseudo-erosion. The inflammatory process of the pelvic organs causes swelling and pain of the uterine appendages during a two-hand gynecological examination (salpingoophoritis), symptoms of peritoneal irritation (pelvioperitonitis, peritonitis). Suspicion of chlamydial infection is caused by planar adhesions between the liver and parietal peritoneum (perihepatitis), called Fitz-Hugh-Curtis syndrome. They are discovered during laparoscopy or laparotomy.

Due to scant and/or nonspecific symptoms, it is impossible to recognize the disease based on the clinical picture. The diagnosis of chlamydia is made only on the basis of the results of laboratory research methods. According to WHO recommendations, patients are examined for chlamydia:

• with chronic inflammatory diseases of the genitourinary system;
• with pseudo-erosion of the cervix;
• with menstrual irregularities such as metrorrhagia;
• using intrauterine contraceptives;
• frequently changing sexual partners;
• having a history of spontaneous or induced abortions;
• with reactive arthritis, chronic conjunctivitis;
• with atypical pneumonia;
• with fever unknown origin, as well as newborns with established chlamydial infection in the mother, etc.

In order to clarify the diagnosis and determine the phase of the disease, the detection of chlamydial antibodies of classes A, M, G in blood serum is used. In the acute phase of chlamydial infection, the IgM titer increases; during the transition to the chronic phase, the IgA and then IgG titers increase. A decrease in titers of chlamydial antibodies of classes A and G during treatment serves as an indicator of its effectiveness.

Treatment of Urogenital chlamydia

All sexual partners are subject to mandatory examination and, if necessary, treatment. During the treatment period and dispensary observation recommend abstaining from sexual intercourse or using a condom.

• azithromycin 1.0 g orally once;
• doxycycline 200 mg orally 1 time, then 100 mg 2 times a day for 7-10 days or
• erythromycin 500 mg orally 4 times a day for 7-10 days;
• ofloxacin 300 mg orally 2 times a day for 7-10 days or 400 mg orally once a day for 7-10 days;
• roxithromycin 150 mg orally 2 times a day for 7-10 days;
• lomefloxacin 600 mg orally once a day for 7-10 days.

For chlamydia of the pelvic organs, the same treatment regimens are used, but lasting at least 14-21 days.

It is preferable to prescribe azithromycin 1.0 g orally once a week for 3 weeks.

During pregnancy use:

• erythromycin 500 mg orally every 6 hours for 7-10 days or 250 mg orally every 6 hours for 14 days;
• spiramycin 3 million units orally 3 times a day for 7-10 days;
• azithromycin 1.0 orally once;
• amoxicillin (can be with clavulanic acid) 500 mg orally every 8 hours for 7-10 days.

Newborns and children weighing up to 45 kg are prescribed erythromycin 50 mg/kg orally 4 times a day for 10-14 days. For children under 8 years of age weighing over 45 kg and over 8 years of age, erythromycin and azithromycin are used according to adult treatment regimens.

If treatment is ineffective, antibiotics of other chemical groups are used.

Due to the decrease in immune and interferon status in chlamydia, along with etiotropic treatment, it is advisable to include interferon preparations (viferon, reaferon) or inducers of endogenous interferon synthesis (cycloferon, neovir, ridostin, amixin). In addition, antioxidants, vitamins, physiotherapy are prescribed, and vaginal microbiocenosis is corrected with eubiotics.

The criterion for cure is the resolution of clinical manifestations and eradication of Chlamydia trachomatis according to laboratory tests carried out after 7-10 days, and then after 3-4 weeks.

Prevention of Urogenital chlamydia

Prevention of urogenital chlamydia involves identifying and timely treating patients and excluding casual sexual contact.

Urogenital infectious diseases: current state of the problem

List of abbreviations
BV – bacterial vaginosis
PID – inflammatory diseases of the pelvic organs
STIs – sexually transmitted infections
MOMP – monoclonal antibodies to major outer membrane protein
DIF – direct immunofluorescence
PCR – polymerase chain reaction

Introduction
To date, there are more than 20 sexually transmitted infectious agents, which is reflected in the table of pathogens of sexually transmitted infections (STIs), developed by the Alfred Fournier Institute (France) (Table 1). At the same time, in accordance with the International Statistical Classification of Diseases and Related Health Problems, tenth revision (ICD-10), introduced in Russia in 1999, only 9 diseases are classified as predominantly sexually transmitted infections: syphilis, gonorrhea, lymphogranuloma venereum (Durand-Nicolas-Favre disease), urogenital chlamydia, chancroid, inguinal granuloma (donovanosis), urogenital trichomoniasis, anogenital herpetic viral infection, anogenital (venereal) warts. The listed infections are subject to mandatory statistical registration, which provides for the implementation of sanitary and epidemiological measures to interrupt their spread. The most common STIs, which have not only medical but also important social significance, include gonorrheal and chlamydial infections.

Table 1. Causative agents of STIs (Alfred Fournier Institute, 1997, France)

Gonorrheal infection
In Russia, the incidence of gonorrhea reached its highest level in 1993 (230.9 per 100,000 population), after which it began to gradually decline. It is quite obvious that this decrease is not true, as evidenced, in particular, by the existing ratio of patients with gonorrhea and syphilis - 1: 2.4 (instead of the usual 6: 1 - 8: 1). Among the adult population, men with gonorrhea are registered almost 2.2 times more than women, since infection of men with N.gonorrhoeae more often leads to the appearance of subjective symptoms forcing them to seek treatment. medical care. In women, gonococcal infection is often mild or asymptomatic and is detected during various preventive examinations, including as sexual partners, and with the development of complications. Apparently, this circumstance can explain the lower independent seeking of medical help among women.
Men play a more important epidemiological role in the transmission of infection. The assessment of the risk of gonorrhea transmission depending on the type of sexual contact (per 1 contact) is: from the urethra to the cervix, rectum - 70%; from the cervix to the urethra – 20%; from the rectum to the urethra – 20%; from the urethra to the pharynx – 20–30%; from the pharynx to the urethra - less than 3%; from the cervix to the pharynx – less than 2%; from throat to throat – rarely.
Currently, along with genital localization, gonococcal infection is often detected in extragenital organs: rectum, pharynx, conjunctiva of the eye, liver.
Anorectal gonorrhea occurs in 5% of women with gonorrhea; in men it occurs exclusively in homosexuals.
During heterosexual orogenital contact, in 10–20% of women with urogenital gonorrhea, N.gonorrhoeae is also found in the pharynx, and isolated lesions of the pharynx N.gonorrhoeae occur in less than 5% of women with gonorrhea. Fellacio is considered a high risk factor for contracting pharyngeal gonorrhea.

Table 2. Classification of gonorrhea (ICD-10)

A54.0 – Gonococcal infection of the lower genitourinary tract without abscessation of the periurethral and accessory glands
A54.1 – Gonococcal infection of the lower genitourinary tract with abscess formation of the periurethral and accessory glands
A54.2 – Gonococcal pelvioperitonitis and other gonococcal infections of the genitourinary organs
A54.3 – Gonococcal eye infection
A54.4 – Gonococcal infection musculoskeletal system
A54.5 – Gonococcal pharyngitis
A54.6 – Gonococcal infection of the anorectal area
A54.8 – Other gonococcal infections
A54.9 – Gonococcal infection, unspecified

In recent years, the emergence of urogenital infections of the “second” generation (chlamydial, mycoplasma, viral) has seemed to push gonorrhea into the background. However, clinical data indicate the prematureness of such an attitude towards this disease. An indirect indicator of the true state of affairs with the incidence of gonorrhea is the increase in the number of women with chronic inflammatory diseases of the pelvic organs (PID).
PID is the spread of an infectious-inflammatory process above the cervical canal with damage to the endometrium, fallopian tubes and other adjacent pelvic organs. According to various authors, it occurs in gonorrhea from 30 to 80% of cases.
A complication of PID is perihepatitis (Fitz-Hugh–Curtis syndrome), in which numerous adhesions are formed connecting the hepatic capsule with the parietal peritoneum and intestinal loops. Despite the fact that the leading role in the etiology of this syndrome is played by C. trachomatis and other pathogenic microorganisms, gonococci are isolated from such patients in up to 10% of cases.
The close attention of clinicians to the problem of PID is due to the severe consequences of the disease for the reproductive health of women: infertility develops in 13, 36 and 75% of patients who have suffered 1, 2, 3 or more episodes of PID, respectively.
Currently, in accordance with ICD-10, the following forms of gonorrheal infection are distinguished (Table 2).

Table 3. Classification of chlamydial infection (ICD-10)

A56.0 – Chlamydial infection of the lower genitourinary system
A56.1 – Chlamydial infection of the pelvic organs and other genitourinary organs
A56.3 – Chlamydial infection of the anorectal area
A56.4 – Chlamydial pharyngitis
A56.8 – Chlamydial sexually transmitted infections, other localization

The clinical course of most diseases undergoes significant changes over time, which can be designated by the term “pathomorphosis” (from the Greek pathos - suffering, disease and morphe - type, form). The concept of pathomorphosis implies a change in the clinical and morphological manifestations of the disease under the influence of various exogenous factors and/or due to changes in the properties of the microorganism. The term “pathomorphosis” is fully applicable in relation to gonorrheal infection, which, in particular, is associated with the beginning of the era antibacterial therapy: the incubation period of gonorrhea has lengthened, the number of patients with acute course diseases, the number of subjectively asymptomatic forms of gonorrheal infection has increased, there is a higher incidence among people over 50 years old, etc.
Due to changes in the clinical course of gonorrhea, laboratory diagnosis of the disease becomes important. For this purpose, bacterioscopic and cultural methods are used, regulated by relevant regulatory documents. Most researchers believe that the bacteriological method increases the detection of gonococcus by 2–3 times.
Before the discovery of antibiotics and sulfa drugs, treatment of gonorrhea with the help of topical use of antiseptic drugs was protracted, unsuccessful and often led to the development of complications, including urethral strictures, which occurred in 3-4% of patients.
Since the beginning of the use of antibiotics, there have been qualitative changes in the timing and outcome of gonorrhea therapy. At the same time, wide and not always justified application antimicrobial drugs has led to the emergence and growth of resistant strains of microorganisms, including N.gonorrhoeae. Currently, throughout the world there is a significant increase in the resistance of N.gonorrhoeae to penicillin, caused by the formation of both chromosomal and plasmid b-lactamases in pathogens.
It is interesting to analyze the time dynamics of increasing the dose of penicillin in the treatment of gonorrhea. If in the first years of its use the course doses were 150–200 thousand units, then subsequently these doses increased by 10–15 times for uncomplicated gonorrhea, and by 20–30 times for complicated gonorrhea.
In Russia, until recently, there was no targeted monitoring of the sensitivity of gonococci to antibacterial drugs, which, in particular, is due to the complexity and high cost of methods for determining sensitivity. In 1999, L.S. Strachunsky published the results of studies that established general level resistance to penicillin of N.gonorrhoeae strains isolated from patients with gonorrhea in the Smolensk region is 78%, which significantly exceeds that in the USA (15.6%) and is comparable to the developing countries of Southeast Asia: in Malaysia - 74%, in Vietnam - 98% (WHO, 1997). The least active of the drugs studied by the authors against N.gonorrhoeae were tetracyclines: 96% of the studied clinical strains of the pathogen were resistant to them, which is comparable to South Korea, where the resistance level is 100%. In connection with the above, it seems important to choose antibacterial drugs for gonococcal infection based on current data on the sensitivity of N.gonorrhoeae.
Considering the results obtained, penicillin should not be used to treat an infection caused by N.gonorrhoeae, since resistance to it many times exceeds the maximum permissible level of 3%, as well as ampicillin, amoxicillin, ampiox, bicillin due to the cross-resistance of gonococci resistant to them to penicillin. Also, tetracycline and doxycycline cannot be recommended due to the presence high level resistance of N.gonorrhoeae to tetracycline (96%). According to WHO, only 4 antibiotics are the drugs of choice for the treatment of gonorrheal infection: ceftriaxone, ciprofloxacin, ofloxacin and spectinomycin.
Ciprofloxacin and ofloxacin belong to fluoroquinolones, which are reasonably considered as the most important independent group of highly effective drugs - DNA gyrase inhibitors. The pharmacokinetics of fluoroquinolones (regardless of the form and methods of administration) allows their use in any localization of the infectious process. They are distinguished by good penetration into various organs and tissues, low coagulation of plasma proteins, and slow elimination from the body in the absence of a cumulative effect.
Ofloxacin, since 1985, has been successfully used in world clinical practice for the treatment of various diseases bacterial etiology and some other infections. The drug has a wide spectrum of antibacterial activity against almost all aerobic gram-negative bacteria. About 40 different microorganisms are characterized by high sensitivity to ofloxacin. An important advantage of ofloxacin, in contrast to ciprofloxacin, is the high activity of the drug against the causative agent of urogenital chlamydia - C. trachomatis, which makes it possible to prescribe it for associated gonorrheal-chlamydial infection.
During treatment acute salpingitis caused by N.gonorrhoeae And C. trachomatis, ofloxacin (orally 400 mg 2 times a day for 10 days), clinical cure is achieved in 94.6%, etiological cure in 100% of women.
Treatment of patients with chlamydial urethritis with ofloxacin (300 mg 2 times a day for 10 days) and doxycycline (100 mg 2 times a day for 7 days) leads to bacteriological cure in 100 and 88% of patients, respectively.
The use of ofloxacin (400 mg intravenously 2 times a day for at least 3 days, and then orally at the same dose for 10–14 days) in women with laparoscopic confirmation of PID (in 69% N.gonorrhoeae, in 17% – C. trachomatis) led to the recovery of the patients: elimination of gonococci was observed in all patients, only 1 patient persisted C. trachomatis.
WHO recommends prescribing ofloxacin for uncomplicated gonorrhea of ​​the lower genitourinary system (urethritis, cervicitis, cystitis, vulvovaginitis) and anorectal gonorrhea in a single oral dose of 400 mg. The combination of ofloxacin (400 mg orally) and azithromycin (1 g orally) as a single dose is one of the most effective methods for gonorrheal lesions of the larynx. Treatment of complicated and disseminated gonorrhea (PID, epididymitis, orchitis, prostatitis, musculoskeletal, cardiovascular, nervous systems etc.) it is advisable to carry out in a hospital setting. At stage 1, parenteral forms of antimicrobial drugs active against N.gonorrhoeae are prescribed; therapy continues for at least 24–48 hours after resolution of clinical symptoms. At the 2nd stage, oral forms are used for 7 days, in particular, ofloxacin - 400 mg every 12 hours, ciprofloxacin - 500 mg every 12 hours. Fluoroquinolones are not prescribed to pregnant women, lactating women and children.

Urogenital chlamydia
The causative agent of the disease is C. trachomatis(serovars D, E, F, G, H, J, K).
Infection with urogenital chlamydia occurs through sexual contact (both genital and extragenital). Antenatal infection of the fetus is possible when a newborn passes through the birth canal of a woman with chlamydia. The incubation period for urogenital chlamydia ranges from 10 to 30 days (for most, 10–20 days).
More often, chlamydia is subjectively asymptomatic, and patients who do not know about their disease continue to lead a normal lifestyle and are a source of spread of infection. Cervical infection caused by C. trachomatis, may remain unrecognized for a number of years.
Urogenital chlamydia does not have specific clinical manifestations or pathognomonic symptoms. The initial site of infection is most often the mucous membrane of the urethra in men and the cervical canal in women.
With the further development of chlamydial infection, various organs of the genitourinary, gastrointestinal, respiratory, and cardiovascular systems may be involved in the pathological process, which should be regarded as complications of chlamydia, the most serious of which is the development of inflammatory processes in the pelvic organs, leading to disruption reproductive function. Patients may experience bartholinitis, vulvovaginitis, pelvioperitonitis, appendicitis, cholecystitis, perihepatitis, pleurisy, vesiculitis, epididymitis, prostatitis, conjunctivitis. There have been reports of proctitis caused by C. trachomatis, occurring atypically and associated with cicatricial changes and stenosis of the anal area.
Infection with chlamydia during genital-oral sexual contact can lead to the development of chlamydial pharyngitis, and sometimes to damage to the oral mucosa.
The clinic of the consequences of urogenital chlamydia also includes chronic arthritis, Reiter's disease and other manifestations that can lead to long-term impairment and disability. Reiter's disease (urethro-oculosynovial syndrome), described in 1916 by H. Reiter (Germany) and N. Fissinger and E. Leroy (France), occurs in 2-4% of patients with urogenital chlamydia. The presence of a connection between the disease and the HLA-B27 genotype has been established in 85–95% of patients with Reiter's disease, the development of which is divided into 2 stages: the first is infectious, characterized by the presence of an infectious agent in the genitourinary organs, the second is immunopathological (damage to the synovial membrane of the joints and the conjunctival mucosa.
The traditional method for diagnosing chlamydia, which has the highest specificity, is isolating the causative agent of the disease in cell culture. Unfortunately, its use in practical healthcare is limited by high cost and labor intensity.
In recent years, for identification C. trachomatis use molecular biological methods, in particular polymerase chain reaction(PCR). Despite high sensitivity of this test, there is a danger of overdiagnosis of chlamydia when introducing PCR into healthcare practice. The possibility of using PCR as a routine diagnosis of chlamydial infection requires further study.
Currently, the main method of isolation throughout the world is C. trachomatis is direct immunofluorescence (DIF) using monoclonal antibodies to the main outer membrane protein (MOMP) of the pathogen. PIF detects the presence of chlamydia antigen in a clinical sample.
Choice antimicrobial drug for the treatment of chlamydial infection is determined by the clinical form of the disease. In accordance with ICD-10, the following forms are distinguished (Table 3).
The drugs of choice for the treatment of urogenital chlamydia are tetracyclines (doxycycline), macrolides (azithromycin) and the only drug from the fluoroquinolone class - ofloxacin. The latter is prescribed for uncomplicated chlamydia 300 mg 2 times a day for 7 days (for complicated - 14 days).
A repeat examination to determine whether chlamydial infection has been cured is carried out 3-4 weeks (for gonorrhea - 7-10 days) after completion of therapy. Detection of STI pathogens within the specified time frame requires the appointment of a second course of antibacterial drugs of other groups.

Bacterial vaginosis
Against the background of a high incidence of STIs, bacterial vaginosis (BV) has become widespread, the registration frequency of which, depending on the contingent of women examined, ranges from 12 to 80%. The history of BV begins in 1955, when H. Gardner and C. Dukes described a new microorganism, which, in their opinion, was the cause of nonspecific vaginitis.
The modern name for VWD syndrome was adopted in 1984 at the 1st International Conference on Vaginitis in Sweden.
By modern ideas, BV is a non-inflammatory syndrome of polymicrobial etiology, characterized by a sharp increase in the vaginal biotope of obligate and facultative anaerobic opportunistic pathogens and a decrease or disappearance of lactobacilli, especially H2O2-producing ones.
Currently, the issue of sexual transmission of BV remains controversial. A number of authors, based on certain facts (simultaneous isolation of G. vaginalis from the genital tract of women with BV and their sexual partners; cases of development of BV in healthy women after sexual contact with men in whom G. vaginalis was detected) came to the conclusion that BV is transmitted sexually ; other researchers have not found statistical significance for sexual transmission of BV.
Clinically, BV is manifested by prolonged, heavy vaginal discharge; 25–30% of patients complain of burning, itching in the external genital area, and dysuria. More than half of all patients with BV have no subjective signs at all.
BV itself does not pose a threat to life, however, prolonged and heavy vaginal discharge is accompanied by a significant decrease in the woman’s quality of life (impaired sexual function, performance decreases, etc.).
At the same time, the presence of BV in women is a risk factor in the development of pregnancy complications PID. According to a number of authors, the risk of premature birth with BV it increases 2.3 times.
Diagnosis of BV is currently not difficult. Complex diagnostic criteria, proposed by R. Amsel et al. , is the “gold diagnostic standard”:
pathological nature of vaginal discharge;
pH of vaginal discharge is more than 4.5;
positive amino test (with 10% KOH);
identification of “key” cells during microscopic examination.
BV therapy represents difficult task: firstly, it is necessary to achieve eradication of BV-associated microorganisms; secondly, to prevent superinfection (the growth of other opportunistic microorganisms, fungi).
Since the advent of antibiotics, they have been widely used in patients with BV. Further studies showed that the effectiveness of tetracycline, ampicillin, and erythromycin in the treatment of BV does not exceed 43–54%.
Currently, the drugs of choice for etiotropic therapy of BV are metronidazole and clindamycin. Considering the development of undesirable side reactions when using drugs general action, preference should be given to the intravaginal route of administration in the form of 2% clindamycin phosphate and 0.75% metronidazole gel, which avoids systemic exposure to the body. The clinical effectiveness of topically applied clindamycin and metronidazole reaches 85–99%.
A particular problem is the treatment of BV in patients with STIs, including gonorrhea and chlamydia, the treatment of which requires the prescription of antibacterial drugs that can aggravate the dysbiotic processes of the vaginal biotope, and therefore the use of short (one-time) methods of therapy for STIs (for uncomplicated forms) has important.
Currently, in accordance with the order of the Ministry of Health of the Russian Federation No. 347 dated December 22, 1998, a group of experts is developing federal industry standards “Protocol for the management of patients with STIs” using medical approaches based on evidence and the results of pharmacoeconomic studies, as well as on international and domestic experience. The purpose of introducing standards into the work of practical healthcare is to improve the quality of treatment and diagnostic measures and increase economic efficiency in the management of patients with urogenital infections.

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Sexually transmitted diseases (STDs) also include urogenital chlamydial infection, or chlamydia. The causative agent of this infection, Chlamydia trachomatis (C. trachomatis), has 18 varieties (so-called serological strains), which were identified relatively recently using the monoclonal antibody method. Strains A, B, Ba and C cause the severe blinding eye disease trachoma. Strains D-K- genital tract infections, inflammatory diseases pelvic organs(cervicitis, salpingitis, endometritis, urethritis, epididymitis, conjunctivitis). Strains L1-L3 cause lymphogranuloma venereum.

Chlamydia infection is one of the most common infections in many countries around the world. Thus, in the United States, about 4 million new cases of chlamydial infection are registered annually, a fairly large proportion of which are people who are actively sex life. According to World Organization In the middle of the last decade, about 89 million cases of infection with C. trachomatis were registered around the world, of which a fairly large proportion were urogenital infections. Quite often (up to 22%) pregnant women are infected with C. trachomatis. In such cases, the pathogenic organism, being in the birth canal, causes infection in half of the children born to infected mothers.

Risk factors

Risk factors for urogenital chlamydial infection include: dark color skin, the presence of a large number of sexual partners, young (under 19 years of age) age, low socio-economic status, lack of family, rejection of condoms as a means of contraception and protection against STDs.

Clinical manifestations

Unlike gonorrhea, most men and women infected with C. trachomatis are asymptomatic and are often diagnosed during a random examination or when a sexual partner has symptoms of the disease. It is individuals with asymptomatic disease (both women and men) who are the source of new cases of urogenital chlamydial infection. Only about half of all infected men have manifestations of nongonococcal urethritis.

The incubation period for chlamydia is approximately 1-3 weeks.

Main clinical manifestations chlamydial urogenital infections in women are frequent bleeding from the easily vulnerable cervix, mucopurulent intracervical discharge, intermenstrual bleeding, dysuria (unpleasant sensations in the urethra during urination), abdominal pain.

In men, chlamydial infection is manifested by glassy discharge from the urethra, mainly in the morning, increased frequency of urination and/or inability to hold in urine, dysuria, pain or tenderness in the scrotum, and a feeling of pressure in the perineum, which in most cases indicates the presence of prostatitis associated with the infection (see. below). Sometimes it suffers general state patient - weakness is noted, body temperature may rise slightly. Characteristic feature urogenital chlamydial infection is the disappearance of all symptoms of the disease a few weeks after their appearance, even without treatment. Thus, chlamydial infection is, as it were, “preserved” in the body, waiting for an opportunity to remind itself again, that is, it becomes chronic.
Complications

The main danger of chlamydial infection lies precisely in the complications it can cause. Chlamydia can penetrate the prostate gland and seminal vesicles, causing, respectively, chronic prostatitis and vesiculitis. In the absence of adequate treatment, chronic inflammation spreads to the epididymis, which can lead to the development of male infertility. Chlamydia can also get on the bladder wall and cause hemorrhagic cystitis.

Chronic inflammation of the urethra caused by chlamydia leads to the development of its narrowing (stricture). In women, chlamydial infection often causes obstruction of the fallopian tubes, ectopic pregnancy, postpartum or post-abortion endometritis. Pregnancy in a patient with chlamydia often occurs with complications. Besides various complications Concerning the genitals, chlamydia can cause damage to other organs. Then this disease will already be called disease, or Reiter's syndrome. Reiter's syndrome can affect the eyes (chlamydial conjunctivitis), joints (usually ankles, knees and spine), skin, internal organs (usually hepatitis, but almost any organs can be affected).

Diagnosis of C. trachomatis infection as a cause of pelvic organ diseases requires examination of both sexual partners.

Methods:

• cytological examination of the mucosa obtained by endocervical curettage (the method has low sensitivity and specificity)
• isolation of a microbe from cell culture(C. trachomatis grows well on special cell cultures) followed by verification of intracellular microorganisms using Giemsa staining or using fluorescent monoclonal antibodies (the method has an absolute -100% specificity, and therefore is used mainly in forensic medicine to confirm infection in crimes of a sexual nature )

To simple and accessible methods Diagnosis of infection caused by C. trachomatis includes:

• determination of direct fluorescent antibodies (sensitivity - 90 - 95%, specificity - up to 98%, advantages - speed with high accuracy, direct determination of the pathogen during the study by nonspecific luminescence)
• enzyme immunoassay (based on the detection of genus-specific lipopolysaccharide, sensitivity is 80-95%, specificity is 90%, the advantage is the ability to use for screening examination)
• determination of the titer of anti-chlamydial immunoglobulins M (in acute infection) in combination with eosinophilia (sensitivity and specificity are inferior to previous methods, the limitation is that a positive test does not always indicate infection, and a negative result does not exclude the presence of a current or previous chlamydial infection)
• determination of chlamydial ribosomal RNA in cervical and urethral smears or urine sediment by hybridization with DNA (sensitivity and specificity - 80-100%, features - the need for special equipment and a high risk of transfer of contaminants between samples and reagents, and therefore the likelihood of false positive or false negative results)
• Correct and reliable diagnosis of urogenital chlamydia, as well as control of cure for the disease, require several (at least 2 simultaneously) laboratory diagnostic methods.

Treatment

Since chlamydia are obligate intracellular microorganisms, antibiotics that can penetrate and accumulate in the affected cells and block intracellular protein synthesis should be used in the treatment of chlamydial infections.

It is from this position that the main drugs in the treatment of chlamydia infections are tetracycline drugs and macrolides. Tetracyclines require fairly long-term use, which significantly increases the risk of severe adverse effects associated with their use.

In accordance with European recommendations for the treatment of acute inflammatory diseases of the pelvic organs caused by chlamydia, it is recommended to use azithromycin 1 g orally once or doxycycline 0.1 g orally 2 times a day for 7 days. If the effectiveness of these drugs is almost equal, then based on pharmaco-economic indicators and the likelihood of developing adverse effects from antibacterial therapy, it is not difficult to understand which regimen is more preferable. That is why azithromycin is the drug of choice for this infection.

A very important medical and social task is the treatment of acute urogenital chlamydia in pregnant women. Previously, the most widely used drug was erythromycin (high availability, low cost, fairly high efficacy and safety from the point of view of perinatology), which, however, is characterized by a low placental permeability index. In addition, it is contraindicated in the first trimester of pregnancy. That is why, in the treatment of this category of patients, preference is increasingly given to azithromycin, which is prescribed once 1 g orally.

Treatment of ascending urogenital chlamydia is longer, at least 10-14 days, preferably with determination of the sensitivity of chlamydia to antibiotics in cell culture.

Macrolides in general and azithromycin in particular are among the most safe antibiotics. They are characterized by a small number of side effects and good tolerability. Azithromycin, regardless of the form of administration, causes dyspeptic disorders and diarrhea in no more than 3% of cases.

The effectiveness of treatment of urogenital chlamydial infection can be significantly hampered when the microorganism is transformed into a spore-like L-form that is insensitive to any type of antibacterial therapy. This is facilitated by the use of low (fractional) antibiotics, primarily penicillin.

It is possible that methods may be useful in overcoming the antibacterial resistance of chlamydia. physical impact urogenital area: cutaneous or rectal electrical stimulation with modulated currents, thermotherapy, exposure magnetic field, microwaves of ultra-high frequencies, infrared laser radiation, low-frequency ultrasound, etc. These methods have a stimulating effect on the contractility of the pelvic floor muscles, which is especially useful for concomitant chronic prostate cancer, since the evacuation of secretions, microcirculation are improved, and metabolic processes in the prostate gland are normalized. IN Lately The possibility of the antimicrobial action of these physical factors has also begun to be discussed, although this aspect still requires comprehensive and high-quality testing.

Monitoring the effectiveness of treatment for urogenital chlamydial infection is carried out using cultural examination. It should not be carried out earlier than two weeks after completion of the course antibacterial treatment. Otherwise, non-viable microorganisms or their remains may remain in scrapings and secretions, illustrating the “ineffectiveness” of therapy. If the control examination nevertheless reveals the presence of chlamydia, then a second course of treatment is required using antibacterial drugs from other groups. The duration of the repeated course, as a rule, does not exceed 10 days.

Despite the continuous development of medicine and the introduction of new drugs, innovative treatment of infections and equipment, infectious diseases of the genitourinary system remain the most common among adults and children. The size of the urethra in men is longer than in women; diseases affect lower sections genitourinary system. The urethra is wider and shorter in women, so more are recorded frequent illnesses than men.

Urogenital infections

General description of diseases

Infectious diseases of the genitourinary organs develop due to the fact that the microbe penetrates the genitourinary tract, which causes inflammation. Some experts combine sexual diseases and genitourinary diseases.

Below are the names of microorganisms causing diseases genitourinary organs:

• trichomonas,
• Proteus,
• listeria,
• Candida fungi,
• staphylococci, streptococci,
• mycoplasma,
• chlamydia,
• gonococcus,
• treponema pallidum,
• ureaplasma,
• herpes viruses, papillomavirus, etc.
• Escherichia coli and Pseudomonas aeruginosa.

Diseases are divided into specific and nonspecific. The type of disease is determined by the type of pathogen. Appropriate treatment is carried out by influencing the pathogen.

• Nonspecific - diseases caused by a microbe that affect the genitourinary system, but do not have the distinctive characteristics of inflammation.
• Specific diseases caused by microbes affecting organs with specific features specific only this species pathogen.

Below are the names of bacteria that cause specific infections of the genitourinary system:

• syphilis,
• trichomoniasis,
• gonorrhea,
• mixed infections.

Inflammation in severe form, progressing “due to the fault” of mixed pathogens, is called a mixed infection.

The following bacteria cause nonspecific genitourinary diseases:

• sticks,
• chlamydia,
• viruses,
• cocci,
• Candida fungi,
• ureaplasma,
• Garndnerella.

Thus, adnexitis, caused by staphylococcus or chlamydia, is a nonspecific infection that has typical symptoms.

Routes of infection

Modern medicine identifies 3 groups of pathways that contribute to the transmission of genitourinary tract infections:

• Unprotected sex of any kind. The word unprotected means neglect of condoms.
• Penetration of plasma into the genitourinary organs through the blood and lymph flow from other organs where inflammation is present, which is extremely rare.
• Infection on skin covering or in the external genitalia due to non-compliance with personal hygiene rules and its ascent to the adrenal glands, etc.

There are many microorganisms that can cause infection in the genitourinary system and throughout the body. They are divided into 2 types:

• Pathogenic,
• Opportunistic.

The natural environment of human organs contains opportunistic bacteria that do not cause any infections. While pathogenic bacteria are not included in healthy microflora and can cause infection in the genitourinary system.

Immunity disorders, hypothermia, viral infections, injuries to the mucous membrane and skin, etc. contribute to the fact that opportunistic bacteria turn into pathogenic ones, thereby causing diseases of the genitourinary system.

Some pathogenic bacteria, being related to certain organs, cause disease there. Some microorganisms are similar to several organs and can cause inflammation in one or another organ, and sometimes in several at once. For example, group B streptococcus provokes a sore throat, however, being similar to the kidneys and tonsils. This microorganism penetrates through the bloodstream into the kidney tissue and causes inflammation of the organ.

Features of the manifestation of diseases in both sexes

As stated above, the peculiarity of the male urethra contributes to damage to the lower parts of the genitourinary system. Diseases of the genitourinary system in men are noted as follows:

• cutting pain when emptying the bladder,
• nagging pain in the groin area.

These symptoms require immediate attention to a specialist. Urethritis and prostatitis are the most common diseases of the genitourinary system in men. The causes of such diseases in men are as follows:

• in case of non-compliance with the rules of personal hygiene, especially if the foreskin is not circumcised,
• abnormality of the urinary tract,
• anal sex,
• microflora of the partner, contributing to the development of infections.

Physiological differences in the genitourinary system in women, namely: a wide and short channel allows for easy penetration of microorganisms into the bladder, and from there through the ureters to the kidneys.

The symptoms are not as severe as in men. This leads to the disease progressing into a chronic form. Mostly in women, infections of the genitourinary system such as urethritis, cystitis, and pyelonephritis are recorded. Asymptomatic bacteriuria is detected only after the results of microflora tests, when bacteria are detected in the urine of women.

Childhood infections

The determining factors for the prevalence of infections in children are age and gender. Thus, among newborn children, boys are sick more than girls. Closer to the age of 1 year, girls get sick four times more than boys.

Infections in children are provoked in the following ways:

• hematogenous,
• ascending,
• lymphogenous.

In newborns and infants, the hematogenous route is especially significant. The general lymph circulation system between the intestines and the compulsory medical system is conducive to the development of genitourinary infections in children.

Normal urodynamics (collection, reserve and urination) in children prevent the entry of infection.

Children of the 3rd and 4th blood groups most often experience urinary tract infections. Also, the following risk groups among children should be examined in more detail:

• Babies with impaired urodynamics.
• Children suffering from frequent constipation and intestinal diseases.
• Girls, as well as all children with 3rd and 4th blood groups, etc.

Treatment of children involves compliance with diet and sleep.

Symptoms

Let's look at some genitourinary diseases and their symptoms. Urethritis is a disease that predominantly occurs in both sexes. Has the following symptoms:

• Frequent urge to urinate, accompanied by a burning sensation.
• The patient may also complain of discharge, as a result of which the opening of the urethra may stick together and turn red,
• The specialist may not detect the presence of pathogens, however, the level of leukocytes in the urine will be high.

Urethritis is contracted when the rules of individual and sexual hygiene are not observed, and in some cases, pathogens can pass into the genitourinary system through the blood and lymph if pathogens of periodontitis or tonsillitis are present in the body.

Experts identify the presence of E. coli as a pathogen when diagnosing urethritis, however, the real pathogens are Ureaplasma urealyticum or Chlamydia trachomatis. To identify the latter, it is necessary to use special methods.

Cystitis is a disease caused by irritation of the mucous membrane of the bladder. Causes of irritation:

• the presence of stones in the bladder,
• urinary retention,
• tumor in the bladder
• exposure to cold temperatures
• abuse of smoked and spicy foods,
• non-compliance with personal/sexual hygiene,
• existing inflammation in other organs of the genitourinary system,
• the presence of anomalies of the genitourinary organs from birth.

Acute cystitis is expressed by a frequent urge to urinate. In some cases, the patient may “run” to the restroom up to 5 times within an hour. At the end of urination, pain may be felt in the form of cutting, burning or dull pain above the pubis.

The causative agents of cystitis are highly sensitive to antibiotics. That is, a specialist can prescribe antibiotics high efficiency without performing additional bacteriological analysis. After the first dose, the attacks stop, however, for prevention purposes, experts recommend taking the drugs for another 4-5 days. Treatment lasts a week; if attacks continue, the specialist will prescribe tests for the sensitivity of the microflora to active substances drug. Recurrent attacks indicate a new infection. The presence of the same pathogen in the first and second cases indicates the need to prescribe treatment for 14 days. Frequent recurrences of cystitis can occur due to the use of vaginal diaphragms and spermicides, along with infection with the Candida fungus. To diagnose acute cystitis, these types of examinations are carried out: urine test, blood test, ultrasonography Bladder.

Chronic cystitis has the same symptoms as acute cystitis. Possible reasons:

• the presence of pathology of the urethra,
• diseases of the genitourinary system,
• prostate adenoma in men, etc.

Diagnosis of chronic cystitis involves several urological studies, as well as cystoscopy.

Pyelonephritis is a disease of the kidneys, namely the renal pelvis, which is responsible for collecting urine secreted by the kidneys. Pyelonephritis that develops as a result of complications after other genitourinary diseases is called secondary. Primary pyelonephritis – independent disease. In accordance with this, the necessary treatment is prescribed.

Depending on the damage to one or both kidneys, pyelonephritis is called unilateral and bilateral, respectively.

In men, this disease develops after 50 years, as a consequence of adenoma, when the outflow of urine is disrupted. In women, pyelonephritis can develop while expecting a child, when the ureters are compressed by the uterus. It is quite possible that women who suffered from chronic pyelonephritis, but did not know about it, will suffer from the disease during pregnancy, since previously the disease did not manifest itself in any way.

Primary pyelonephritis has the following symptoms:

• fever,
• pain in the sides of the waist,

results bacteriological research indicate that the body contains:

• bacteria,
• cylinders,
• leukocytes.

The causative agent is Escherichia coli. Abscesses and urolithiasis are detected if the patient has secondary or complicated pyelonephritis using computed tomography. In addition, experts carry out excretory urography.

Prostate disease
Prostatitis is one of the most common male genitourinary tract diseases. Experts recommend performing a rectal massage of the prostate before collecting urine for testing to identify pathogens.

One of the most common diseases of the genitourinary tract in women is adnexitis. Another name for the disease is inflammation of the ovaries. The disease comes in acute and chronic forms.

Patients with the acute form of the disease complain of the following symptoms:

• pain in the lower abdomen,
• elevated temperature,
• profuse sweating,
• headache,
• pain when pressing on the abdomen,
• disrupted menstrual cycle,
• pain during sexual intercourse,
• tension in the abdominal wall of the lower abdomen.

In the chronic form of the disease, the period of exacerbation alternates with a period of remission. Causes of exacerbation: hypothermia, stress, complications of other diseases. The exacerbation period has the same symptoms as the acute form, and changes also appear in the menstrual cycle of women:

• painful menstruation,
• increase in quantity,
• menstruation becomes longer
• rare cases record a decrease in quantity and duration.

Salpingitis has the following symptoms:

• heat,
• pain and discomfort in the sacrum and lower abdomen,
• pain is transmitted to the rectum,
• headache,
• feeling of weakness,
• the number of white cells in the urine increases,
• urinary disorders.

The above symptoms appear due to inflammation of the fallopian tubes. Pathogens: staphylococci, E. coli, Proteus, Trichomonas, streptococci, chlamydia and fungi. But most often, salpingitis is provoked by several types of microorganisms at once. Routes of infection:

• through the bloodstream or lymph flow,
• from the vagina, sigmoid colon or appendix.

Treatment of genitourinary infections

Modern medicine offers several components for the treatment of the above infections in men and women. Treatment mainly consists of taking antibacterial drugs.

• Therapy aimed at destroying the pathogen (etiotropic therapy),
• Therapy to strengthen the immune system (taking special medications),
• Taking medications that reduce discomfort and pain in diseases. It is very important to choose the right combination of drugs.

The type of pathogen determines the choice required drug. Infections can affect the surfaces of organs. They are treated with local antiseptic drugs.

For re-infection, treatment lasts as long as for the first case. If the disease is chronic, treatment lasts at least 1.5 months.

Urogenital infections or urinary tract infections usually refer to a group of bacterial, fungal and viral diseases leading to inflammation of the urinary tract and causing wide range inflammatory conditions. Urinary tract infections are widespread throughout the world.

Tens of millions of patients turn to doctors with this problem every year. It should be noted that, along with sexually transmitted infections, this group of diseases includes a large number of opportunistic infections. In the aggregate of urological pathologies, opportunistic infections are much more common.

Quite often, urogenital infections recur, become chronic and lead to severe complications. In women, urogenital infections are more common than in men, which is due to the structural features of the female genitourinary system. Depending on the type of infection leading to the development of inflammation, hypothermia, colds, alcohol abuse, and poor nutrition often play a significant role in the occurrence of diseases. Typically, the peak of urological diseases increases during the cold season and often coincides with an epidemic of acute respiratory viral infections and influenza.

There are three main groups of routes through which infection with urogenital or genitourinary infections is possible:

– sexual contact any type (vaginal, oral, anal) without the use of barrier contraceptives (condom),

– ascending infection (germs from the skin enter the urethra or vagina, and rise to the kidneys or ovaries) as a result of neglect hygiene rules,

– transfer through the blood and lymph flow from other organs in which there are various diseases of inflammatory origin (caries, pneumonia, influenza, colitis, enteritis, tonsillitis, etc.).

Diseases of the urogenital tract caused by urinary tract infections

Genitourinary infections include a number of diseases that affect various parts of both the urinary and reproductive systems. In this case, pathogens may belong to groups of different pathogenicity. Sexually transmitted diseases include a group that has a corresponding distribution path, but can affect many organs, and the division of infections is determined according to the type of pathogen. Urogenital infections can be caused a huge amount microorganisms, among which there are purely pathogenic and opportunistic. Pathogenic microbes always cause an infectious disease, and are never part of the normal human microflora. Opportunistic microorganisms are normally part of the microflora; they can cause an infectious and inflammatory process if they exceed normal levels and (or) change their properties. Thus, with the onset of any predisposing factors (decreased immunity, severe somatic diseases, etc.), opportunistic microorganisms become pathogenic and lead to an infectious-inflammatory process.

Most often, genitourinary infections are caused by the following microorganisms:

Gonococcus;
ureaplasma;
chlamydia;
Trichomonas;
staphylococci, streptococci;
coli;
fungi (candidiasis);
Klebsiella, Listeria and Proteus;
viruses (herpes, cytomegalovirus, papillomavirus, etc.).

All of the above infections, in turn, are divided into specific and nonspecific. Their division is based on the type of inflammatory reaction, the development of which is provoked by the causative microorganism. Thus, a number of microbes form inflammation with distinctive features, inherent only to this pathogen and this infection, which is why it is called specific. If a microorganism causes inflammation without any specific symptoms or course, then we're talking about about a nonspecific infection. Thus, we are talking about classifications according to different criteria.

According to the existing classification, genitourinary infections mean the following diseases:

Urethritis (inflammation of the urethra);
cystitis (inflammation of the bladder);
pyelonephritis or glomerulonephritis (kidney inflammation);
adnexitis (inflammation of the ovaries);
salpingitis (inflammation of the fallopian tubes);
endometritis (inflammation of the uterine lining);
balanitis (inflammation of the glans penis);
balanoposthitis (inflammation of the glans and foreskin of the penis);
prostatitis (inflammation of the prostate gland);
vesiculitis (inflammation of the seminal vesicles);
epididymitis (inflammation of the epididymis).

Clinical manifestations of genitourinary infections

Any genitourinary infection accompanied by the development of the following symptoms:
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