2.5.2 Chlamydial Urethritis

Grading & Level of Importance: B


W. Burgdorf, Munich; J. McGrath, London
Revised by A. Salava, E. Hiltunen-Back, A. Ranki, Helsinki




Most common sexually transmitted infection (STI) in Europe Worldwide 127 million adults aged 15-49 years had chlamydia infection in 2016. For 2017, 26 EU/EEA Member States reported 409 646 cases of chlamydia infection, with the crude notification rate 146 cases per 100 000 population.


Chlamydia trachomatis caused urogenital infection.

Aetiology & Pathogenesis

Caused by strains D-K of the intracellular Gram negative bacterium Chlamydia trachomatis. Can also cause acute eye infections, trachoma, ano-rectal infections and lymphogranuloma venereum. Sexually active young people are at the greatest risk.

Signs & Symptoms

Incubation period usually 1-3 weeks. Often asymptomatic. 70% of genital C. trachomatis infections in women and 50% in men are asymptomatic at the time of diagnosis. Mild mucoid or mucopurulent urethral discharge in the morning is less profuse than in gonorrhea. Males may complain testicular pain and epididymitis. In women, chlamydia urethritis can similarly cause dysuria and pollakisuria. Cervicitis can cause vaginal discharge, postcoital bleeding and abdominal pain. Proctitis and pharyngitis are often asymptomatic. Ano-rectal infection can cause discharge and discomfort and pharyngeal chlamydia mild sore throat. Conjunctivitis can be the result of contact with contaminated hands, or direct exposure to semen and vaginal fluids.


See symptoms


Based on localisation

Laboratory & other workups

Nucleic acid amplification tests are the most sensitive and the most widely used tests for the detection of genital chlamydia. Positive NAAT result can be observed within a few days of exposure but at the latest 2 weeks later. Point of Care Tests can be used for self-collected swabs and allows for self-testing outside of the clinic.


Complications in men include epididymitis, epididymo-orchitis and sexually acquired reactive arthritis. In women chronic pelvic pain and infertility can be sequelae.


Based on clinical features and confirmatory microbiological tests

Differential diagnosis

Gonorrhoea and other causes of urethritis (Mycoplasma genitalium, Ureaplasma urealyticum, Trichomonas vaginalis); urethral Herpes simplex infection.

Prevention & Therapy

Prevention: barrier contraception.

First-line treatment: doxycycline 100 mg twice a day for seven days (contraindicated in pregnancy) or azithromycin 1 g as a single dose. The second-line treatment includes erythromycin 500 mg twice a day for seven days or levofloxacin 500 mg once a day for seven days. Tests for other STIs, like gonorrhea, syphilis and HIV are strongly recommended.


Test-of-cure 4 weeks not recommended routinely; but should be offered to pregnant women, in patients with complicated or persisting clinical findings, with second-line treatment, and suspicion of non-compliance or re-exposure. Evaluation and testing of the patient’s sex partners from a period of the preceding six months.

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