Symptoms and diagnosis

Men:

• asymptomatic in over 50%
• urethral discharge
• dysuria.

Women:

• asymptomatic in up to 90%
• increase in vaginal discharge
• dysuria
• deep dyspareunia
• post coital, intermenstrual bleeding or breakthrough bleeding
• lower abdominal pain
• mucopurulent cervicitis with or without contact bleeding
• pelvic tenderness
• cervical motion tenderness.

Rectal Infections

Usually asymptomatic but may cause anal discharge and anorectal discomfort.Rates of rectal infections in MSM have been estimated at between 3% and 10.5%. Some studies in women report high rates (up to 77.3%) of concurrent urogenital and anorectal infection. Other studies however, report lower rates. Not all women with rectal chlamydia report anal sex. Further studies are needed to ascertain the utility of targeted versus routine rectal sampling in women.

Pharyngeal Infection

Usually asymptomatic.

Rates of chlamydia carriage in MSM range from 0.5 to 2.3%. There is a paucity of good data on rates of pharyngeal infections in women.

• In all West of Scotland boards chlamydia testing is provided as a dual NAAT test for chlamydia and gonorrhoea using a variety of platforms.
• Good sample collection technique improves sensitivity.
• Patients presenting within two weeks of an exposure giving rise for concern should be asked to return for testing / retesting two weeks after the exposure.

*Several studies indicate that vulvovaginal swab sensitivities are greater than those of cervical swabs.
First void urine in females has lower sensitivity for the diagnosis of chlamydia and GC compared to other specimens so is not recommended.

Urine

20ml first void urine (NB: technique should be carefully explained to patient, to ensure that the correct sample is obtained) in a plain universal container. The patient must not have urinated for at least one hour (or 2 hrs for some kits) NB: Do not insert urinalysis dipsticks in the sample, as it may introduce contamination and adversely affect the amplification process.

Vulvovaginal swab

This may be self taken by patient (self obtained vulvovaginal swab (SOLVS) or by the clinician. Insert the dry swab approx 5 cm into the vagina and gently rotate the swab for 10 to 30 seconds.
Bleeding may reduce sensitivity.

Pharyngeal swab

Rub the swab over the posterior pharynx and tonsillar crypts.

Rectal swab

• Proctoscopy: The swab should be rubbed against the rectal wall.
• Blind: The swab should be inserted 3cm into the anus and rotated once, gently pushing upwards and keeping in place for 10-30 seconds.

1. British Association of Sexual Heath and HIV Clinical Effectiveness Unit BASHH 2015 UK
   National Guideline for the Management of Infection with Chlamydia trachomatis (2015).
   https://www.bashhguidelines.org/media/1192/ct-2015.pdf [accessed 4th August 2022]
2. Update on the treatment of Chlamydia trachomatis (CT) infection BASHH Clinical
   Effectivesness Group September 2018 [accessed 4th August 2022] https://www.bashhguidelines.org/media/1191/update-on-the-treatment-of-chlamydia-trachomatis-infection-final-16-9-18.pdf [accessed 4th August 2022]
3. British Association of Sexual heath and HIV Clinical Effectiveness Unit BASHH UK National Guideline for the Management of Lymphogranuloma Venerum (2013) https://www.bashh.org/documents/2013%20LGV%20guideline.pdf [accessed 4th August 2022]
4. 2019 European Guideline on the Management of Lymphogranuloma Venereum
   https://onlinelibrary.wiley.com/doi/full/10.1111/jdv.15729 [accessed 4th August 2022]
5. UK National Guidelines for the Management of Pelvic Inflammatory Disease 2018
   https://www.bashhguidelines.org/media/1170/pid-2018.pdf [accessed 4th August 2022]
6. United Kingdom National Guideline for the Management of Pelvic Inflammatory Disease
   (2019 Interim Update) https://www.bashhguidelines.org/media/1217/pid-update-2019.pdf[accessed 4th August 2022]
7. Scottish Bacterial Sexually Transmitted Infections Reference Laboratory (SBSTIRL)
   Samples and Request Forms | Edinburgh and Lothians Laboratory Medicine LGV PCR form Dec 20.pdf (edinburghlabmed.co.uk) [accessed 4th August 2022]
8. Dr Kate Templeton, Head of Service, Regional Virus Laboratory Specialist Virology
   Centre, Edinburgh [pers comm. 4th August 2022]