Dysuria in the Emergency Department: Missed Diagnosis of Chlamydia trachomatis

INTRODUCTION The clinical presentation of genital Chlamydia trachomatis infection (chlamydia) in women is often indistinguishable from a urinary tract infection. While merited in the setting of dysuria, emergency department (ED) clinicians do not routinely test for chlamydia in women. The primary aim of our study was to evaluate the frequency of chlamydia testing among women presenting to the ED with dysuria. METHODS We conducted a retrospective chart review of women 19-25 years of age presenting with dysuria to an urban ED and who had been coded with urinary tract infection (UTI) as their primary diagnosis (ICD-9 599.0) from October 2005 to March 2011. We excluded women who were pregnant, had underlying anatomical or neurological urinary system pathology, had continuation of symptoms from UTI or a sexually transmitted infection (STI) diagnosed elsewhere, or were already on antibiotics for a UTI or STI. We identified the rates of sexual history screening, pelvic examination and chlamydia assay testing and evaluated predictors using univariate and multivariate analyses. RESULTS Of 280 women with dysuria and a UTI diagnosis, 17% were asked about their sexual history, with 94% reporting recent sexual activity. Pelvic examination was performed in 23%. We were unable to determine the overall chlamydia prevalence as only 20% of women in the cohort were tested. Among the 20% of women tested for chlamydia infection, 21% tested positive. Only 42% of chlamydia-positive women were prescribed treatment effective for chlamydia (azithromycin or doxycycline) at their visit; the remaining were prescribed UTI treatment not effective against chlamydia. Predictors of sexual history screening included vaginal bleeding (OR 5.4, 95% CI=1.5 to 19.6) and discharge (OR 2.8, 95% CI=1.1 to 6.9). Predictors of a pelvic examination being performed included having a complaint of vaginal discharge (OR 11.8, 95% CI=4.2 to 32.9), a sexual history performed (OR 2.5, 95% CI=1.1 to 5.8), abdominal pain (OR 2.2, 95% CI=1.1 to 4.4), or pelvic pain (OR 15.3, 95% CI=2.5 to 92.2); a complaint of urinary frequency was associated with a pelvic examination not being performed (OR 0.34, 95% CI=0.13 to 0.86). CONCLUSION Sexual histories, pelvic examinations, and chlamydia testing were not performed in the majority of women presenting with dysuria and diagnosed with UTI in the ED. The performance of a sexual history along with the availability of self-administered vaginal swab and first-void urine-based chlamydia tests may increase identification of chlamydia infection in women with dysuria.