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APPROACH TO A CASE OF URETHRAL DISCHARGE

AIMS --------
1. TO IDENTIFY THE CAUSE OF THE URETHRAL DISCHRAGE
2. TO FIND OUT THE SEVERITY OF THE CONDITION AND EXTENT OF INVOLVEMENT OF URINARY TRACT
3. TO TREAT THE CONDITION
4. TO TREAT ANY COMPLICATIONS IF THEY HAVE OCCURRED ---------- eg. prostatitis, URETHRAL
STRICTURE
5. TO FOLLOW UP THE PATIENT IN ORDER TO SEE IF TREATMENT HAS SUCCEEDED.
6. TO DETECT ANY COEXISTING STDs ---------- eg. syphilis.
7. MOTIVATE PATIENT FOR VOLUNTARY SCREENING FOR HIV
8. COUNSEL THE PATIENT on safe sex practices.

TO IDENTIFY THE CAUSE OF URETHRAL DISCHARGE ------------------


(A) HISTORY TAKING --------------- Should include severity of signs and symptoms, duration,
constitutional symptoms, H/o sexual exposure, genital ulcers, STDs in sexual partner, drug history,
trauma, contact of the genitals with chemical agents.
(B) EXAMINATION ------ Male patients complaining of urethral discharge and/or dysuria should be
examined for evidence of urethral discharge. If none is seen, the urethra is gently massaged from
the ventral part of the penis towards the meatus. Sometimes the patient notices discharge only in
the morning or there is only dysuria without discharge, in such cases the surest method of
diagnosis is to ask the patient to return in the early morning having held the urine overnight for 8
hours or more. Next with the discharge we proceed to do the following tests ----
1. GRAM STAIN ------------ The swab containing the discharge is gently rolled backward and forward
over a glass slide to cover an area of about 1 sq. cm -------- then do gram stain --------- examine
under x100 magnification --------- the area showing the highest numbers of PMNL is then examined
under oil immersion (x1000) and the number of PMNL in each field is noted ----------- PRESENSE OF 5
WBCs per field is considered to be a sign of urethritis. IF GRAM NEGATIVE DIPLOCOCCI ARE FOUND
WITHIN PMNL ------------PRESUMPTIVE DIAGNOSIS OF GONORRHEA. IF NOT --------- NON
GONOCOCCAL URETHRITITS.
2. CULTURE ---------- GOLD STANDARD for diagnosis of gonorrhea. Transport media: STUART’S
MEDIA( 0.3% agar). The organisms stay for 24hrs. Growing medium: MTM media. Culture
plates are examined after 24-48 hrs. Colony character: SMALL, ROUND, TRANSLUSCENT, CONVEX,
SLIGHLY GRANULAR SURFACE, LOBATE MARGIN, SOFT AND EASILY EMULSIFIABLE

Oxidase test: Into a colony, freshly prepared oxidase reagent(1% tetramethyl paraphenylene diamine) is
added. Colonies turn pink rapidly deepening to purple. Not a specific test.
Fermentation reaction: A pure subculture of the org is grown. This is inoculated on to 4 hydrocele-agar
slopes containing 1% glucose, maltose, sucrose and lactose respectively. When the slopes are incubated,
an indicator phenol red is added. Acid formation changes colour from red--- yellow. N. gonorrhoea
shows +ve test with glucose.

TO FIND OUT THE EXTENT OF INVOLVEMENT OF THE URINARY TRACT: Involvement of following
structures can occur during the course of infection especially in cases which have been neglected and
treatment not instituted at the right time. They are -------------
1. Parafrenal glands of TYSON: If the duct gets obstructed, it presents as red moderately
tender swelling on the side of the frenum.
2. Preputial sac: This occurs as shallow ulceration in the region of the frenum.
3. Paraurethral ducts: Infection of these ducts is evident as a small bead of pus seen at the
opening of the duct + margins of the duct are red and swollen.
4. Median raphe: Seen on ventral surface of penis as sinus tract expressing pus on pressure.
5. Ducts and gland of Litter and lacunae of Morgagni: This infection is symptomless.
Involvement is shown by the presence of threads (cast of ducts) in the 1st glass of urine. If
the ducts are blocked, small follicular abscess occur on the wall of the urethra.
6. Periurethral tissue/abscess: It occurs from fusion of follicular abscess(discussed above). This
results in the formation of large periurethral abscess and may interfere with micturition.
Such abscess may open into the urethra or may point to the surface. Occasionally abscess
may track to the corpus spongiosum and lead to painful erection and ventral angulaton of
the penis (Chordee). Abscess forms mostly in 2 regions: FOSSA NAVICULARIS and BULB OF
THE PENIS. Sometimes urinary fistula results.
7. Subepithelial tissue of urethra: org. reach the submucosal tissue---produce inflammation---
soft infiltration----later, fibrous stricture of the urethra.
8. Cowper gland and duct: If the ducts get blocked, it produces a unilateral abscess. It
produces symptoms like ---------
 Aching and throbbing pain in the perineum
 Sense of fullness and heat in the perineum
 Pain on defecaetion
 Frequency of micturition
 Strangury --------- acute retention of urine due to irritative spasm of compressor urethrae
muscle.
 Increased temperature
 It is examined per rectally ----------- the abscess is UNILATERAL and mistaken for perianal or
ischiorectal abscess.
 Abscess may point in the perineum

9. Prostatic gland and duct: Its occurs from inflammation of the gland substance and manifests
as
 Malaise,
 Fever,
 Perineal pain,
 Suprapubic discomfort.
 On P.R. prostate is tender, swollen and indurated.
 When the ducts get blocked, prostatic abscess result. Symptoms of acute prostatitis
increases along with
 Terminal dysuria, increased frequency, acute retention of urine,
 Rectal discomfort, tenesmus and pain on defecation. P.R. reveals large, tense and
very tender swelling.
 Urethral discharge may decrease in amount or may cease.
 Pus may track into urethra, into rectum and into perineum.

10. COMMON EJACULATORY DUCT AND SEMINAL VESCICLE: Acute infection of the seminal
vescicle is likely to invade the whole thickness of the wall and extend to the perivescicular
area causing the S.V. to be adherent to the upper surface of the prostate. If duct gets
blocked, abscess results. The S/S are:
 Like in acute prostatitis
 Increasing fever with constitutional symptoms
 Urgency of micturition
 Terminal hematuria: indicates severe infection and needs prompt treatment
 Frequent erections and ejaculations
 More associated with metastatic complications of gonorrhoea.
 On P.R. , one or both S.V. are felt as elongated swollen sausage shaped masses
extending upward and outward from the center of the upper border of prostate.
11. VASA DEFERENTIA & EPIDIDYMES: The infection reaches the lower part of epididymes via
vasa deferentia through: retrograde passage of urine; lymphatics; blood stream. S/S
includes:
 Pain and tenderness in the lower pole of the epididymes. This progressively increases
and becomes agonizing involving the whole of epididymes.
 Fever
 Symptoms of acute urethritis subsides
 Scrotum is swollen, red, tender and may be associated with hydrocele.
 On recovery, fibrous thickening of Globus minor.
 Complication: blocked duct. If B/L, patient becomes sterile.

CHRONIC INFECTION
Results if:
 Delay in starting treatment
 Gonococcus is refractory to treatment
 Non gonococcal urethritis manifesting after gonorrhoea and goes untreated.
Manifestations include:
1. Chronic littritis: It occurs after the subsidence of follicular abscess in the urethral wall.
 On palpation, small firm nodules are present over the urethral walls.
 Threads are present in the 1st glass of the 2 glass test.
 On urethroscopy, openings of the ducts may be seen to pout and show reddening.
2. Soft urethral wall infiltration
3. Fibrous stricture: Mostly affects the bulb.
4. Chronic cowperitis: C/B
 Morning discharge ( mucous, PMNL, org., epithelial cells)
 Morning urine contains mucous and purulent thread.
 Weight in the perineum
 On examination, gland on either side of median raphe. On pressure, tenderness over
the gland.
5. Chronic prostatitis: Features are:
 Prostate feels firm, indurated
 R/E urine: 10 or more lecocytes in several of 1000 microscopic fields
 Strongly A/W Reiter’s disease
 Express the prostatic fluid by message---Gram’s stain for organism
6. Chronic seminal vesciculitis: Features are:
 Like chronic Prostatitis
 Frequent seminal emissions
 Painful erections
 Vesicle: firm and indurated
 Examination of the contents of vescicle by digital message: reveals PMNL, granular
debris, degenerated spermatozoa surrounded by mucinous material.
7. Chronic epididymitis: C/B
 Like chronic prostatitis and chronic seminal vesciculitis.
 Firm fibrous nodule
 It may be symptomless or A/w continous or intermittent pain of aching character.
 Occasionally subacute exacerbation of the condition results in increased local pain,
swelling and tenderness.

TREAT THE CONDITION:


The most common causes of urethral discharge are infection by N. Gonorrhoea and C. trachomatis.
Unless a diagnosis of gonorrhea can be definitely excluded by laboratory tests, the treatment of the
patient with urethral discharge should provide adequate coverage of these two organisms. Recommended
regimens include ------------
 Therapy for uncomplicated gonorrhea ---------------- ciprofloxacin 500 mg SD plus
 Doxycycline --- 100 mg BD for 7 days or tetracycline --------- 500 mg QDS for 7 days or erythromycin
------ 500 mg QDS for 7 days (where tetracyclines are contraindicated or not tolerated).
Alternative regimen where single dose therapy for gonorrhea is not available -------- Co-trimoxazole ---- for
3 days.
PATIENT IS ASKED TO ABSTAIN FROM SEX UNTIL 7 DAYS OF INITIATION OF TREATMENT.

FOLLOW UP PATIENT TO SEE IF TREATMENT HAS SUCCEEDED ---------------


PATIENT IS ASKED TO COME ON 3rd, 7th and 14th day --------history about resolution of s/s is taken and
clinical and lab investigations are done. 2 GLASS URINE TEST AND URETHRAL SMEARS ARE REPEATED ON
THESE DAYS.
If a patient had been suffering from gonorrhea after treatment -------------
 Gonococci disappear from the urethral smears in 8 hours
 Urethral discharge subsides by 72 hours
 Urine on naked eye examination clears by 4 days
 Burning micturition resolves by 7 days.

Persistent or recurrent symptoms may be due to -----------

 Poor compliance.
 Reinfection.
 Infection with a resistant strain of N. gonorrhea.
 Infection with T. vaginalis ---- this is diagnosed by a combination of smear and
culture. T vaginalis can be identified in most cases by direct microscopical
examination using freshly obtained secretion on a slide with a cover slip or a hanging
drop preparation ----------- the characteristic jerky movements are seen. It can be well
seen with ordinary illumination after elimination of peripheral rays of light by partial
closure of the substage diaphragm of the microscope or with a dark ground or phase
contrast illumination. Culture media used are ----- cysteine-peptone-liver-maltose
medium and the medium of Fienberg and Whittington. TREATMENT ------
METRONIDAZOLE at a dose of 400 mg for 5 days or a single dose of 2 gm.

ORGANISMS CAUSING URETHRAL DISCHARGE


GONOCOCCAL NON GONOCOCCAL


Neisseria gonorrhoea Chlamydia trachomatis
Ureaplasma urealyticum
Mycoplasma genitalium
Trichomonas vaginalis
Herpes simplex virus
Yeast

OTHER CAUSES OF URETHRITIS ---- Traumatic, chemical, neoplastic, foreign bodies, allergic inflammation
(SJS).

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