Chlamydia Infection: Symptoms, Complications & Treatment

Sexually transmitted infection [STI] is a leading cause of infertility, acute illness, long-term disability, and even death across the world. Affecting all - men, women, infants - medically as well as psychologically, STIs can hardly be ignored.

The term Sexually Transmitted Infections (STIs) is used to refer to those communicable diseases or infections which are primarily transmitted through sexual contact. ^[1] Some of the common STIs include herpes, syphilis, bacterial vaginosis, gonorrhoea, Human Immunodeficiency Virus (HIV)/AIDS, Hepatitis B virus, trichomoniasis and chlamydia.

The classification of STI is as per the type of organism causing the infection, which can be either due to a bacterium, fungus, parasite or virus. Chlamydia trachomatis is the bacterium responsible for causing chlamydia ^[2] . While chlamydia can affect both men and women, it is more commonly witnessed in women. Around 70-80% of the genital tract infections in women that can be attributed to Chlamydia trachomatis are asymptomatic or without symptoms.

Symptoms

Chlamydia is more common than you think. Transmitted through sexual contact with someone, it affects a large number of people all over the world. Usually, many people who have chlamydia are themselves not suffering from it. Such people are just carriers who can easily pass the infection forward to anyone who has sexual contact with them.

Chlamydia trachomatis is usually transmitted through semen and vaginal discharge. Globally speaking, chlamydia infection is most common among men and women in the age bracket of 14 to 25 years ^[2] .

While chlamydia can affect both men as well as women, the symptoms differ between the two.

[I] Men

Studies have revealed that while fewer instances of chlamydia are reported in men, once the infection has been established, it takes much longer to clear as compared to that in a woman ^[3] .

Often with very few or no signs at all in the initial days after infection, symptoms usually start surfacing around one to two weeks after the exposure to the bacteria. Once symptoms set in, being quite mild in nature they are often overlooked by the person infected.

Some commonly reported symptoms and signs of Chlamydia trachomatis infection in men are as follows:

• Pain in the lower abdominal area
• Dysuria, that is, painful or difficult urination ^[4]
• Discharge from the penis
• Pain and/or tenderness in the testicles
• Inflammation of the epididymides or the duct behind the testes ^[5]
• If the rectum is also infected, there can be bleeding, discharge or rectal pain
• Watery or mucoid discharge from the urethra ^[6]

Despite considered to be probably the most common sexually transmitted infection among people all across the world, many people do not even realize that they are suffering from chlamydia as the symptoms are barely noticeable.

[II] Women

Despite the recent advancements in the field of medical science, public understanding of chlamydia remains somewhat limited ^[7] . In addition to limited patient knowledge, the fact that chlamydia usually does not have any symptoms are the two main reasons why medical intervention is not sought by people suffering from chlamydia.

Chlamydia has the following symptoms in women:

• Bleeding that can be intermittent, intermenstrual and/or post-coital
• Changes in vaginal discharge
• Increase in frequency of urination
• Dysuria, or painful and/or difficult urination

While symptoms are either absent altogether or quite mild, if left untreated, chlamydia can lead to various complications.

Complications

If chlamydia infection lasts for a long period of time, without any medication being administered for countering it, certain complications can arise with the passage of time.

[I] Men

Chlamydia trachomatis is the primary factor behind nongonococcal urethritis in men. This may lead to a watery or mucoid discharge from the urethra. Dysuria or pain and/or difficulty at the time of urination is also present.

Chlamydia in men may also lead to epididymitis or swelling of the epididymides ^[8] , a duct placed behind the testis, responsible for letting the sperm pass on to the vas deferens. Epididymitis causes a number of symptoms like pain and tenderness in the testes, swelling in the epididymides and hydrocele. The term 'hydrocele' is used to refer to the swelling in the scrotum caused by the accumulation of fluid in the thin sheath that encloses a testicle.

Studies have revealed that there is a causative role of Chlamydia trachomatis in chronic bacterial prostatitis or inflammation of the prostate gland ^[9] .

Out of the men with nongonococcal urethritis, about 1% develop Reactive Arthritis [ReA] ^[10] which is a type of inflammatory arthritis caused by bacterial infection usually in the genital region. Though quite rare, with only 0.6 to 27 per 100,000 cases ^[11] . Reactive arthritis is more commonly witnessed in males that are at either the second or the third decade of their lives.

Another complication of Chlamydia trachomatis in men is a condition referred to as chlamydial proctitis, or inflammation of the rectum. Caused by anal sex, clinical proctitis is a common occurrence when men have sex with men [MSM]. Anal sex might lead to various kinds of STIs, such as gonorrhoea, seen in 30% of the patients; chlamydia, in 19% patients; herpes in 16%; followed by syphilis in 2% ^[12] .

[II] Women

As Chlamydia trachomatis is frequently asymptomatic, a majority of the women are unaware that they are infected. Studies have shown a higher rate of Chlamydia trachomatis infection in infertile women ^[13] . As mostly the symptoms go unnoticed and unreported, screening of infertile women for the bacterium is advisable.

In women, Chlamydia trachomatis can lead to a number of complications affecting the lower genital tract, such as ^[14]

• Cervicitis or inflammation of the cervix. Chlamydial cervicitis can cause serious complications like ectopic pregnancy, infertility or pelvic inflammatory disease ^[15]
• Endometritis or inflammation of the inner lining of the uterus or endometrium ^[16]
• Acute urethral syndrome or increase in frequency and dysuria, that is, pain and/or difficulty in urination ^[17]
• Bartholinitis or inflammation of either both or one of the two Bartholin's glands, located at either side of the vaginal opening ^[18]
• Fitz-Hugh-Curtis syndrome ^[19] , where Pelvic Inflammatory Disease [PID] causes swelling of the tissues surrounding the liver. Fitz-Hugh-Curtis syndrome is also referred to as gonococcal perihepatitis ^[20]
• Salpingitis or inflammation of the fallopian tubes ^[21]
• Peritonitis or inflammation of the peritoneum, the tissue lining of the inner abdominal wall ^[22]
• Reactive Arthritis ^[23] [ReA]. While ReA in women is believed to be usually caused by Chlamydia trachomatis, the instances reported in women are lesser as compared to male patients. The main cause for ReA ^[24] being underdiagnosed in women as a genital infection might be due to the fact that it is asymptomatic
• Chlamydia trachomatis can lead to many complications in a pregnant woman such as low birth weight, perinatal mortality, preterm labour and delivery ^[25] .
• Babies born to a woman with Chlamydia trachomatis infection are at risk for developing pneumonia and neonatal inclusion conjunctivitis ^[26] .

Despite concerted efforts for effectively diagnosing and treating genital chlamydial infections, there have been an increase in the number of cases. Development of a vaccine, though being considered, has met with many roadblocks ^[27] .

Diagnosis

For diagnosis, a woman will have to get her cervix examined and a swab taken.

A man suffering from chlamydia infection, on the other hand, will have to undergo a urine test. For the results to be accurate, men are advised against urinating at least two hours prior to the test sample is taken.

Once the vaginal or urine sample is obtained, the Chlamydia trachomatis bacteria is isolated by either probing for the DNA of the microbe in the sample, or by culturing (growing of the microbe within a cup).

Treatment

Chlamydia can be treated with the help of antibiotics. As per the recommendation of the Centres for Disease Control and Prevention (CDC), the two main courses prescribed for the treatment of genital chlamydia in the absence of any complications are ^[28] as follows:

• Doxycycline for a period of 7 days. Doxycycline, as well as ofloxacin, is not to be given to pregnant women.
• Azithromycin as a single, one-time dose. This is also the medicine of choice for treating chlamydia infections in pregnant women. Amoxicillin can also be used as an alternative medicine for pregnant women.

The choice between doxycycline and azithromycin depends on a variety of factors such as cost-effectiveness, the convenience of the patient and quality of the medicine available. For patients looking at a cost-effective solution for their ailment, doxycycline is more appropriate. On the other hand, when the priority of the patient lies with convenience rather than cost, a single dose of azithromycin is generally the better option.

In certain cases of heavy infection, there might be a requirement for drainage or aspiration to rule out the possibility of formation of ulcers. When a patient is undergoing antibiotic treatment for genital chlamydia, the concerned sexual partner should also be evaluated, screened and treated accordingly.

Certain key points to keep in mind when being treated for genital chlamydia are as follows:

• Always complete the course prescribed for the medication. Do not stop mid-way even if you feel better.
• Your sexual partner also has to be treated simultaneously with you, or there is the risk that you will keep re-infecting each other unknowingly.
• Avoidance of sex for 7 days is required for the medication to take effect, irrespective of the fact that whether a single dose is administered or the 7-day course is given.
• Do not share your medicines with your partner, as the doctor might have prescribed a different dosage for both of you.
• Be prepared to get re-tested in the next 3 to 4 months to ensure that the infection has gone for good.
• Once you contract chlamydia, the chances of a recurrence in future are somewhat higher as compared to someone who has never been infected. It is for this reason that preventive measures such as wearing a condom at the time of engaging in sex are advisable.

Risk Factors

While chlamydia can affect almost anyone, routine tests should be conducted for women who fall in the high-risk group for contracting chlamydia - below 20 years of age, more than one sexual partners in previous 3 months or those with mucopurulent cervicitis or those who are sexually active.

Prevention

Though a fairly common STI, testing, as well as treatment for chlamydia, is fairly easy. Prevention is the best cure nevertheless. While the best course of action would be to forgo all sexual activity completely, that is highly impractical, to say the least. Some steps that you can take nonetheless include the following.

• Use condoms each time you engage in sexual activities with your partner. While the female can wear a female polyurethane condom, the male can make use of a male latex condom. The risk of contracting chlamydia is significantly reduced with the help of condoms.
• Limit the number of sexual partners. With a few sexual partners, the risk of catching the infection also goes down.
• Regular screenings are essential when you are indulging in sex frequently and have more than one sexual partners.
• No douching. As douching reduces the good bacteria in the vagina, it may put you at a greater risk for infection.

With proper preventive measures, the instances of developing chlamydia infection are greatly reduced.

Despite being a sexually transmitted infection and generally targeting the vagina or penis, chlamydia infection can also affect anus, cervix, urethra, throat as well as eyes. Chlamydia can also be passed on from an infected pregnant woman to her child at the time of delivery.