Chlamydia is among the most prevalent sexually transmitted infections in the United States, with more than 1.4 million cases being reported in 2012. “Most chlamydia cases are asymptomatic, but the infection can also present with dysuria and may resemble urinary tract infections (UTIs),” explains James W. Galbraith, MD. The CDC recommends annual chlamydia screenings for sexually active women aged 25 and older and for those considered at-risk. However, studies indicate that only about half of eligible women are actually screened, and symptomatic chlamydia infections continue to be under-recognized in ED settings.
A Closer Look
In a retrospective study published in the Western Journal of Emergency Medicine, Dr. Galbraith and colleagues examined charts on 280 women presenting to the ED with dysuria and diagnosed with a UTI to see if they underwent a sexual history and pelvic exams or received chlamydia testing. Results showed that just 17% of women in the study were asked about their sexual history, and 94% of those reported recent sexual activity.
“Only one in five of these women underwent a sexual history, pelvic examination, and chlamydia testing,” Dr. Galbraith says. “Among women who were tested for chlamydia infection, 21% tested positive.” The study also found that just 42% of women testing positive for chlamydia were prescribed treatments for the infection at their visit. The remaining women were prescribed treatments for UTIs that are ineffective against chlamydia.
Untreated chlamydia can cause serious complications, such as pelvic inflammatory disease, infertility, and ectopic pregnancies. “With only 20% of our study group receiving chlamydia tests, there were likely missed opportunities for diagnosing and treating the infection,” says Dr. Galbraith. “This leaves infected patients at risk for chlamydia-related complications.” Furthermore, he says that most genital symptoms are non-specific for chlamydia, and it is likely that the chlamydia positivity rate would have been high in women who did not have genital symptoms.
Dr. Galbraith says all women presenting to EDs with dysuria should not undergo chlamydia testing, but asking a few additional questions may allow providers to stratify chlamydia risk and the need for testing. “Younger women who have had recent unprotected intercourse, multiple sexual partners, or prior chlamydia may be at higher risk and are appropriate for chlamydia testing,” he says.
Emergency physicians should consider performing a sexual history as well as self-administered vaginal swabs and first-void urine-based chlamydia tests to increase their chances of identifying chlamydia in women with dysuria, according to Dr. Galbraith. “Considering that many of these women by have access to healthcare issues,” he says, “an ED visit for urinary symptoms might be the only opportunity to have chlamydia diagnosed and treated.”
Readings & Resources (click to view)
Wilbanks MD, Galbraith JW, Geisler WM. Dysuria in the emergency department: missed diagnosis of chlamydia trachomatis. West J Emerg Med. 2014;15:227-230. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3966459/.
Yealy DM, Greene TJ, Hobbs GD. Underrecognition of cervical Neisseria gonorrhoeae and Chlamydia trachomatis infections in the emergency department. Acad Emerg Med. 1997;4:962-967.
Stamm WE, Wagner KF, Amsel R, et al. Causes of the acute urethral syndrome in women. New Engl J Med. 1980;303:409-415.
St. John A, Boyd JC, Lowes AJ, et al. The use of urinary dipstick to exclude urinary tract infection. Am J Clin Pathol. 2006;126:428-436.
Eggleston E, Rogers SM, Turner CF, et al. Chlamydia trachomatis infection among 15–35 year-olds in Baltimore, MD, USA. Sex Transm Dis. 2012;38:743-749.