1. Urethritis and Genital Discharge
Dr. Ammar Al - Faisal

2. Urethritis 1-Gonococcal urethritis (GU)
Urethritis is defined as infection-induced inflammation of the urethra.
Urethritis may occur in any sexually active person, but highest among people aged years.
it categorized into one of two forms, based on etiology:
1-Gonococcal urethritis (GU)
2- Nongonococcal urethritis (NGU).
Note; Urethritis of mixed etiology: Polymicrobial NGU and cases of urethritis due to both gonococcal infection and nongonococcal factors are possible and can explain some treatment failures.

3. Gonococcal urethritis (GU)
Caused by Neisseria gonorrhoeae (Gram Negative Intracellular Diplococci)

4. Clinical features : Incubation period (2-8) days. A symptomatic state:
(10% of male and 50% of women)
Males - urethritis
Females- urethritis, cervicitis
Both male & female presented with
“MUCOPURULENT DISCHARGE”
and its production is unrelated
to sexual activity.
Dysuria (painful voiding)

5. Complications
In men:
Cystitis, prostatitis, epididymitis-orchitis (painful swollen testis), periurethral abscess, proctitis, infertility, and reactive arthritis.
Disseminated gonococcal infection (DGI) presented with systemic symptoms (eg, fever, chills, sweats, nausea).
In women:
pelvic inflammatory disease (PID)
Infertility and ectopic pregnancy secondary to post inflammatory scar formation in the fallopian tubes
proctitis (rectal discharge, pain and tenesmus), cystitis
(DGI).

6. Notes for Physical examination
inspecting the underwear for secretions may yield additional information.
Examine the patient for skin lesions that may indicate other STDs, such as condyloma acuminatum, herpes simplex, or syphilis (chancre).
Examine the lumen of the distal urethral meatus for, obvious urethral discharge, erythema or stricture.
Gently milking the urethra from the base of the penis to the glans may exudes discharge from the urethral meatus.
Examine the testes for evidence of swelling or inflammation suggesting orchitis.
Palpate the spermatic cord, looking for swelling, tenderness, or warmth suggestive of epididymitis.
During the digital rectal examination, Palpate the prostate for tenderness or bogginess suggestive of prostatitis.
Check for inguinal lymphadenopathy.

7. Investigations: Gram’s stain GUE Culture
Nucleic Acid Amplification Test (NAAT)

8. Treatment of un complicated Gonococcal Infection:
Ceftriaxone 125 mg IM single dose
Cefixime 400 mg PO single dose
Ciprofloxacin 500 mg PO single dose
Ofloxacin 400 mg PO single dose
Levofloxacin 250 mg PO single dose
In pregnancy:
Spectinomycin 2 g

9. Non Gonococcal Urethritis
Caustive organisms;
Chlamydia trachomatis 50%. Chlamydia are intracellular bact. Larger than virus. And contain both DNA and RNA, has cell wall, divide by binary fission. more than 15 serotype, each cause one illness.
Ureaplasma urealyticum,
Mycoplasma species (Mycoplasma hominis, Mycoplasma genitalium)
Trichomonas vaginalis.
Fungi (Yeasts)
Herpes simplex virus, Adeno virus
The causative organism can not be identified in some patients with NGU.
Urethritis following catheterization occurs in 2-20% of patients practicing intermittent catheterization (more with latex than with silicone catheters).

10. Clinical features
Patients with NGU have a longer incubation period (1-5 weeks) than those with gonococcal urethritis (GU)
Patients with NGU are much more likely
to be asymptomatic than GU.
The onset of either dysuria or a mucoid
discharge, is subacute.
Burning sensation in the urethra.

11. Complications
Similar to GC, but more risk of PID in women due to ascending infection of un treated a symptomatic chlamydial infection.
Children born to mothers with Chlamydia infection may develop conjunctivitis.
Reactive arthritis (Reiter disease): Disease of male, is characterized by triad of NGU, anterior uveitis, and arthritis and is strongly associated with the gene for HLA-B27.

12. Laboratory Studies
Urethritis can be diagnosed based on the presence of one or more of the following:
(1) mucopurulent or purulent urethral discharge
(2) urethral smear that demonstrates at least 5 leukocytes per oil immersion field on microscopy
(3) first-voided urine specimen that demonstrates at least 10 white blood cells (WBCs) per high-power field on microscopy.
All patients with urethritis should be tested for N. gonorrhoeae and
C. trachomatis

13. Gram stain Traditionally, treatment was based on Gram stain results:
Patients with gram-negative intracellular diplococci on urethral smear received treatment for gonococcal urethritis,
and those without gram-negative intracellular diplococcic received treatment for nongonococcal urethritis (NGU).
Because current recommendations suggest patients receive concomitant treatment for both NGU and GU, and with the success of nucleic acid amplification tests (NAATs), a Gram stain may be unnecessary.

14. Urethral culture for N gonorrhoeae and C. trachomatis
Endourethral culture (obtained by gently inserting a malleable cotton- tipped swab1-2 cm into the urethra), rather than culture of the expressible discharge, is necessary to test for C trachomatis infection.
Endocervical cultures should also be obtained in women.
Culture is useful also for antibiotic sensitivity test.
•Potassium hydroxide preparation: This is used to evaluate for fungal organisms.
•Wet preparation: reveal the movement of trichomonus vagainalis.

15. Nucleic acid amplification tests (NAATs)
Polymerase chain reaction assays are available for gonococcal urethritis and Chlamydia, Mycoplasma species, Ureaplasma species, and T vaginalis
they are expensive.
NAATs are the preferred test for Chlamydia and are more sensitive than traditional culture methods.
For Chlamydia, DNA probe results are 60%-70% sensitive and nearly 100% specific while ligase chain reaction is 90%-95% sensitive and nearly 100% specific.
NAATs, unlike culture, do not allow for antibiotic susceptibility testing.

16. Other tests
STD testing: Patients with urethritis should be counseled about the risk for more serious STDs .
They should be offered syphilis serology (Venereal Disease Research Laboratory test or Rapid Plasma Reagin test) and HIV serology.
Patients with reactive arthritis are diagnosed based on the presence of NGU and clinical findings of uveitis and arthritis. HLA-B27 testing is of value. elevated erythrocyte sedimentation rate (ESR) in the absence of rheumatoid factor, may be helpful.

17. Treatment of NGU: Azithromycin 1 g PO single dose.
Doxycycline 100 mg orally twice daily for 7 Days
In pregnancy: Erythromycin 500 mg four times daily for 7 days.
Note: 10-30% of GU has co infection with NGU, thus dual therapy (especially in limited facility diagnostic setting) is recommended.

18. Prognosis and prevention
With the correct diagnosis and treatment, urethritis usually clears up without any complication
Some causes of urethritis may be avoided with good personal hygiene and by practicing safer sexual behaviors such as using condoms.
Number of sexual partners: Individuals with multiple partners are more likely to have contracted an STD. Long-term monogamous(one sexual partner only) couples are extremely unlikely to contract an STD.
Sexual preference: Homosexual men have the highest rate of STDs.
Concurrent STDs may also occur. A high level of suspicion for other STDs, such as syphilis and HIV infection, should be maintained.
People with urethritis who are being treated should avoid sex or use condoms during sex.
the sexual partner must also be treated.

19. Thank you