Let’s Talk About Sex(ually Transmitted Infections), part 2

Happy Pride Month, Philly. I hope everyone enjoyed the parade and festivities (and did so safely).

With that in mind, let’s talk about sex, again. Last month I addressed an important and rapidly increasing STI. Although syphilis is on the rise in Philadelphia, it is still much less common than several other infections. So today we will talk about the most common: chlamydia.

First, the good news: Despite nationally rising rates, the annual number of reported chlamydia infections has been fairly stable in Philadelphia over the last few years, and at times even showed signs of decreasing slightly. Don’t get too comfortable — we are still talking about a lot of infections, and we may be seeing another upswing. For perspective, just under 20,000 local cases of chlamydia were reported in 2016, up about 800 from the year before. These cases are significantly higher in females than males, and close to five-times higher for ages 15-29 than other ages combined.

The infection, caused by the Chlamydia trachomatis bacteria, can be spread through any variation of sexual activity involving the vagina, penis, anus or mouth. Barrier protection (condoms, dental dams, etc.) can help when used correctly, and with all sexual contact. Because chlamydia is susceptible to doxycycline, the “doxy PrEP” as pre-exposure prophylaxis for syphilis may also help to prevent some cases of chlamydia, although that is not currently an indication on its own.

Most people do not have symptoms when infected with chlamydia, but some develop symptoms even several weeks after infection. In the genitals, symptoms may include vaginal or penile discharge or urinary symptoms. Easy bleeding from the cervix or swelling of one testicle can also occur. In the vagina, the bacteria initially infect the cervix and can spread up to the uterus and ovaries, causing a disorder called Pelvic Inflammatory Disease (PID), which can present with abdominal or pelvic pain but can also be asymptomatic and go unnoticed. Untreated PID can permanently damage the tubes and ovaries, leading to infertility or increased risk of tubal (ectopic) pregnancy. In rare cases, PID can progress to cause an inflammation around the liver and abdomen (a.k.a. Fitz-Hugh-Curtis Syndrome).

Infections in the throat (pharynx) usually have no symptoms and are often found incidentally when oral screening is performed. Rectal infections occasionally cause discharge, bleeding and/or pain. Infections during pregnancy can result in early delivery, and eye or lung infections in newborns.

Diagnosis is simple and much more “user-friendly” today than some may remember. Since the infection often causes no symptoms, proactive screening (rather than only testing when symptoms present) is important. One comment about testing: It is important to mention that some of these official recommendations were designed for the population at large, with the understanding that healthcare providers tailor their screening recommendations to fit the risks of their patients. Some generalizations about a population aren’t perfect, but are designed to raise awareness. For example, recommendations are frequently directed to “MSM” (men having sex with men). This is not intended to assume all MSM to be cisgender males having sex (often assumed to be anal intercourse) with other cisgender males, but rather to help identify a segment of our community where infection rates are higher. Fortunately, there is a growing understanding that we need to discuss a sexual practice itself (anal intercourse or oral/anal contact, etc.) rather than the cohort group alone. This will eventually lead to a much more inclusive and empowering approach to LGBTQ+ sexual health.

The CDC recommends chlamydia screening at least annually for sexually active (or pregnant) women under age 25, sexually active MSM and sexually active people living with HIV. The recommendations for MSM also recommend screening possible sites of infection (urethra/rectum) “regardless of condom use.” Official recommendations do not include routine screening for all males, however they do suggest considering screening based on prevalence of infection. The infection is prevalent enough in our community that Mazzoni Center providers typically offer screening for all sexually active patients, and we screen any orifice they use for sex (generally urine test or vaginal self-swab, throat swab and patient- or provider-performed rectal swab).

Prompt treatment of the patient and all sex partners can usually be completed with a single dose of azithromycin (often given as two or four pills) or doxycycline (twice a day for seven days). Other antibiotics are sometimes used as alternatives. Retesting for cure is not usually needed (except in certain high-stakes situations such as pregnancy), but it is critical to abstain from sex for seven days after treatment is finished (including all partners) to prevent reinfection. 

Shanin Gross, D.O., is assistant medical director at Mazzoni Center. She is also a clinical associate professor of family medicine at Jefferson University, and currently serves as co-chair of the Society of Teachers of Family Medicine’s LGBT Health group. To learn more about Mazzoni Center’s free and confidential walk-in HIV and STI testing, visit https://www.mazzonicenter.org/health-care/community-health/walk-hiv-and-std-testing.