Male Symptoms of Chlamydia trachomatis Infection
Most men with chlamydia have urethritis with mild or absent symptoms, making asymptomatic infection more common than with gonorrhea—approximately 25% of infected men have no symptoms at all. 1, 2
Clinical Presentation
Symptomatic Urethritis
When symptoms are present, men typically experience:
- Urethral discharge (mucopurulent or purulent) 1
- Dysuria (burning during urination) 1
- Symptoms are characteristically milder than gonorrhea and often develop more gradually 1
Asymptomatic Infection: A Critical Problem
- 25% of men with chlamydial urethritis have no symptoms or signs 2
- 33% lack abnormal leukocytes on urethral Gram stain despite active infection 2
- 50% are identified only through screening cultures, not clinical presentation 2
- This high rate of asymptomatic infection means infected men unknowingly transmit the infection to partners before seeking treatment 1
Complications in Men
Epididymitis
- Unilateral testicular pain and tenderness with palpable epididymal swelling 1
- Most common in men under 35 years of age 1
- Usually accompanied by urethritis (which may itself be asymptomatic) 1
Rectal Infection
- Common in men who engage in receptive anal intercourse 1
- Generally asymptomatic, but may cause rectal discharge or pain during defecation (proctitis) 1
Other Manifestations
- Reactive arthritis (Reiter's syndrome) can occur as a complication 1
- Chronic prostatitis has been implicated in some cases 3
- Potential role in male infertility, though less well-studied than female complications 4, 3
Diagnostic Confirmation
The CDC recommends documenting urethritis by at least one of the following 5:
- Mucopurulent or purulent urethral discharge on examination 1, 5
- ≥5 WBCs per oil immersion field on Gram stain of urethral secretions 1
- Positive leukocyte esterase test on first-void urine 1, 5
- ≥10 WBCs per high-power field on microscopic examination of first-void urine 1, 5
All patients with suspected urethritis should be tested for both N. gonorrhoeae and C. trachomatis, as coinfection is common 5
First-Line Treatment
The CDC recommends either azithromycin 1g orally as a single dose OR doxycycline 100mg orally twice daily for 7 days as first-line treatment for chlamydial urethritis. 1, 5
Both regimens have equivalent cure rates of 97-98% 1. The single-dose azithromycin is particularly valuable given the high rate of asymptomatic infection and potential compliance issues with 7-day regimens 5.
For Epididymitis
Ceftriaxone 250mg IM single dose PLUS doxycycline 100mg orally twice daily for 10 days to cover both gonorrhea and chlamydia 1
Partner Management: Essential to Prevent Reinfection
All sex partners within the preceding 60 days must be evaluated and treated, regardless of symptoms 5. Partners should receive treatment effective against chlamydia even if testing is not performed 5.
Patients and partners must abstain from sexual intercourse for 7 days after initiating therapy and until symptoms resolve to prevent transmission and reinfection 5, 6
Critical Clinical Pitfalls
The Screening Imperative
- Screening cultures identify 5.5 new cases per 100 tests, compared to only 1.3 per 100 for gonorrhea 2
- Clinicians appropriately treat only 51% of chlamydial infections on initial visit before culture results, versus 91% for gonorrhea 2
- This diagnostic gap perpetuates transmission, as asymptomatic men continue sexual activity while unknowingly infected 1, 2
When to Suspect Treatment Failure
Failure to improve within 3 days requires reevaluation of both diagnosis and therapy 1. Consider:
- Non-compliance with initial treatment 5
- Re-exposure to untreated partner 5
- Alternative diagnoses (testicular torsion in epididymitis cases, other pathogens) 1
The Female Health Impact
While men rarely develop serious sequelae from chlamydia, most morbidity and economic costs result from infection of female partners who develop PID, infertility, and ectopic pregnancy 1. This makes identification and treatment of asymptomatic men a critical public health priority.