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Chlamydial genital tract infections

Introduction

The first indication of chlamydial genital tract infections was in 1910, when Heyman claimed to have observed in genital tract material the trachoma inclusions described in 1907 by Halberstaedter & von Prowazek in trachoma. This was confirmed by Fritsch and colleagues in 1910, who infected the conjunctivae of monkeys with scrapings from the eyes of babies with (chlamydial) neonatal conjunctivitis, cervical secretions from their mothers and urethral secrtions from men with urethritis [cited in Hare & Thin, 1983]. In each case the monkeys developed conjunctivitis with identical pathological changes, irrespective of the source of the infecting material. The first isolation of chlamydiae from the genital tract was reported by Jones et al., (1959), using the embryonated hen's egg, a technique which had been first used by T'ang et al (1957) for trachoma. Thus the inter-relationship between ocular and genital C. trachomatis infections was established very early on.

Chlamydial genital tract infections are reproductive tract infections. A unique feature ofthis group of infections is that, like no other infectious diseases, they are inextricably linked to a highly emotive issue: that of sexuality. Sexuality is central to people's intimate personal lives. Gender is a pivotal fact in personal identity, determining both life experience and options. Sexuality is the very mechanism of social survival, hence the cultural norms and values which regulate it. Expectations and practice are often very different. Social factors and advertising play a dramatic role in the spread of STDs and influence attempts to control RTIs. A further feature of RTIs (excluding HIV) is that women, in particular, suffer the worst complications. Thus:

• Women are less likely to be able to prevent STD exposure than men. There are no widely acceptable female-controlled barrier methods of contraception and STD prevention, (despite the recent development of the "female condom"). Some female contraceptives, eg the pill, increase the susceptibility to STD pathogens, although paradoxically it may also reduce complications. Sexual and economic relationships often limit the feedom of women to negotiate the conditions for sexual intercourse;

• Following exposure to STD, anatomy makes women more susceptible. Transmission of HIV, gonorrhoea, Chlamydia and trichomoniasis (see later) is more efficient from male to female than the other way around. In women the abdominal cavity and its organs can be infected by STD agents via ascending infection through the uterus and Fallopian tubes. Susceptibility varies with the menstrual cycle;

• Women are more likely than men to be asymptomatically infected, and therefore not to seek treatment;

• If the woman is symptomatic, there are male-inspired social stigmas against gynaecological examination in many countries and religions;

• Diagnosis of STDs is more difficult in women than men;

• The complications of many STDs are more severe in women than in men. Infertility following STD is commoner in women than in men. Men don't get ectopic pregnancy or cervical cancer! Nor do they suffer from puerperal fever, post partum sepsis or septic abortion. The latter are the main causes of maternal deaths in developing countries.

C. trachomatis is the most common sexually transmitted pathogen of humans, with an estimated 89 million new cases occurring world wide each year [Gerbase et al., 1998]. While gonorrhea has decreased in many parts of the developed world, chlamydial genital tract infections remain a refractory problem world wide. In the US, the incidence of new cases of chlamydial genital tract infection is approximately 4 million a year. Given that the reporting of new cases and the use of laboratory diagnostic tests is inconsistent, these figures are probably an underestimate, particularly for men who are less likely to be screened than women [Schachter, 1999]. The burden of chlamydial genital tract infections for health services and individuals is enormous, with women particularly disadvantaged. For example; there are roughly 1 million cases of pelvic inflammatory disease in women in the US each year leading to approximately 150,000 to 200,000 becoming involuntarily infertile as a result of bilateral scarring occlusion of the fallopian tubes. At least a quarter of these cases for the US can be attributed to chlamydial infection [Westrom et al., 1992] while in the UK the figure is probably nearer 50%  [Bevan et al., 1995]. In 1990 the costs of treating pelvic inflammatory disease and its complications in the US alone were estimated at $4billion [Washington et  al, 1990].

The remainder of this section reviews chlamydial genital tract infections and their complications in each of the sexes.

[MEW] 2003

NEXT: Male genital tract infections: urethritis

References

Bevan, C. D., Johal, B. J., Mumtaz, G., Ridgway, G. L. & Siddle, N. C. (1995). Clinical, laparoscopic and microbiological findings in acute salpingitis: report on a United Kingdom cohort. British Journal of Obstetrics and Gynaecology 102, 407 - 414.

Gerbase, A. C., Rowley, J. T., Heymann, D. H., Berkley, S. F. & Piot P. (1998). Global prevalence and incidence estimates of selected curable STDs. Sexually Transmitted Infections 74, Suppl 1: S12 - 16.

Hare M. J. & Thin, R. N. (1983). Chlamydial infection of the lower genital tract of women. British Medical Bulletin 39,  138 - 144.

Jones, B. R., Collier, L. H. & Smith, C. H. (1959). Isolation of virus from inclusion blenorrhoea. Lancet i, 902 - 905.

Schachter, J. (1999). Infection and disease epidemiology. In: (Stephens, R. S. ed.,) Chlamydia: Intracellular biology, pathogenesis and immunity. Pages 139 - 169.  American Society of Microbiology Press, Washington D.C., ISBN 1-55581-155-8.

T'ang, E-F., Chang, H-L.., Huang, Y-T. & Wang, K-C. (1957). Trachoma virus in chick embryo. National Medical Journal of China 43, 81 - 85.

Washington, A. E., Aral, S. O., Wolner-Hanssen, P., Grimes, D. A.. &  Holmes, K. K. (1990). Assessing risk for pelvic inflammatory disease and its sequelae. Journal of the American Medical Association (JAMA) 266, 2581 - 2586.

Westrom, L. R., Joesoef, R., Reynolds, G., Hagdu, A. & Thompson, S. E. (1992). Pelvic inflammatory disease and fertility. A cohort study of 1,844 women with laparoscopically verified disease and 657 control women with normal laparoscopic results. Sexually Transmitted Diseases 19, 185 - 192. 

NEXT: Male genital tract infections: urethritis