URETHRITIS

Urethritis
Inflammation of the urethra.

Discharge +/- dysuria or may be

asymptomatic.
Causes of urethritis
Infectious causes-
- Gonococcal – Neisseria gonorrhea (50-90%)
- Non gonococcal –
- Chlamydia trachomatis. (20-50%)
- Ureaplasma urealyticum. (20-80%)
- Mycoplasma genitalium. (10-30%)
- Trichomonas vaginalis. (1-70%)
- Yeast.
- HSV (Herpes Simplex Virus)
 Non Infectious Causes

- Trauma

- Urethral stricture.

- Catheterization.

- Chemical irritants.

- Dehydration.
Gonococcal Urethritis
1. Neisseria gonorrhea – gram negative, non motile, non
spore forming diplococci.
2. Oxidase positive

3. Ferments glucose

4. PPNG – Penicillinase Producing N. gonorrhoea:

cefotaxime, ceftriaxone, ciprofloxacin, tetracycline
can be used.
N gonorrhoea – present predominantly intracellularly
in the polymorphonuclear leucocytes (PMN).
Penetrates columnar epithelium.
Clinical features :
Affects urethra in both sexes.

Transmission – sexual contact

Incubation period – 2-5 days

Intense burning sensation.

Fever & malaise.

In men anterior urethritis is more
common.
Discharge – profuse, purulent &
yellowish green.
15% males – mild or
asymptomatic.
In females – 90% infection
50% of infected females are
asymptomatic.
Primary site - endocervical canal
Symptoms of urethritis includes -
- Discharge - scanty, mucopurulent cervical discharge.
- Vaginal pruritus
- Dysuria
Treatment – uncomplicated gonorrhoea
 Cefixime 400 mg stat or
 Ceftriaxone 125 mg stat IM or
 Ciprofloxacin 500 mg stat or
 Ofloxacin 400 mg stat or
 Levofloxacin 250 mg stat
+
If chlamydia infection is not ruled out
 Azithromycin 1 gm stat or
 Doxycycline 100 gm BD for 7 days.
Treatment – DGI

 Ceftriaxone 1 gm IM or IV every 24 hrs or

 Cefotaxime 1 gm IV every 8 hrly or

 Ciprofloxacin 400 gm IV every 12 hrs or

 Ofloxacin 400 gm IV every 12 hrs or

 Levofloxacin 250 gm IV daily. or

 Spectinomycin 2 gm IV every 12 hrly.

Non
gonococcal
urethritis
CHLAMYDIA TRACHOMATIS
C. trachomatis – gram negative obligate intracellular micro

organism that preferentially infect squamo-coloumnar

epithelium.
Based on monoclonal antibody assay – 18 serological variants.

 A, B, Ba & C – trachoma.

 D-K – genital tract infections.

 L1 – L3 – LGV
Two functional & morphological forms-

 Elementary body – infectious but metabolically inert.

 Reticulate body – metabolically active but non

infectious.
The intracellular bacteria rapidly modify their

membrane bound compartment into chlamydial

inclusion to prevent the phagosome lysosome fusion.
Clinical features –

 Incubation period – 1 - 3 weeks.

 Low grade urethritis with scanty or moderate mucoid

or mucopurulent urethral discharge & variable dysuria.

 Subclinical urethritis are also common.
In men-

 Sites of infection are – urethra.

- epididymis.

- systemic.

 Clinical syndrome – urethritis, post gonococcal

urethritis & Reiter’s disease.

Urethritis –

 Dysuria with mild to moderate whitish or clear

urethral discharge.
 On examination – focal urethral tenderness

- meatal or penile lesions may mimic

herpetic urethritis.
Epididymitis – recurrent infections

 Unilateral scrotal pain, Swelling & Tenderness.

 Fever

 Urethritis may often be assymptomatic & evident only

as urethral inflammation.
Prostatitis –

 Usually asymptomatic or may

 Presents with discomfort on passing urine & vague

pain in perineum, groins, thighs, penis, suprapubic

region or back.
 Painful ejaculation.
Proctitis – repetitive anal intercourse or by lymphatic

spread from posterior urethra.

 Rectal pain

 Discharge - mucopurrulent

 Bleeding
Reiter’s syndrome – urethritis

- conjuctivitis

- arthritis

- characteristic mucocutaneous lesions as well

as psoriasis such as circinate balanitis & keratoderma
blenorrhagicum.

Reactive arthritis is RF seronegative, HLA-B27 linked arthritis often

precipitated by genitourinary or gastro intestinal infections usually after
2-3 weks of infection.
Organisms associated with Reiter’s syndrome are

 N. gonorrhoea

 C. trachomatis

 U. urealyticum

 Salmonella

 Shigella

 Campylobacter

Treatment – antibiotics, NSAIDS, sulfasalazine, corticosteroids & immunosupressants.

In women –
 Cevicitis – mucopurulent cervical discharge
- cervical erythema & edema with an area of
ectopy
- spontaneous or easily induced cervical
bleeding
 Urethritis – dysuria
- frequency
- pyuria
 Bartholoinitis
 Endometritis – abnormal vaginal bleeding
- menorrhagia
- metrorrhagia
 PID – lower abdominal pain
- adenexal tenderness on pelvic examination
- MPC often present
- Perihepatitis (Fitz-Hugh-Curtis Syndrome)
 Lab diagnosis
Clinical syndrome Clinical criteria Presumptive Diagnostic
- male criteria criteria

NGU Dysuria, urethral Gram stian - > 5 Positive culture

discharge PMNL/hpf
Pyuria on first void
urine
Acute epididymitis Fever, epididymal Positive culture or
or testicular pain, non culture test on
evidence of NGU - do - epididymal
Epididymal aspirate.
tenderness or mass.
Clinical Clinical criteria Presumptive Diagnostic
syndrome criteria criteria
Mucopurulent Mucopurulent Cervical gram Positive culture or
cervicitis cervicitis discharge staining > 30 non culture test.
Cervical ectopy & PMNL/hpf in non
edema, menstruating
spontaneous or women
easily induced
cervical bleeding
Acute urethral Dysuria, frequency Pyuria
syndrome syndrome > 7 days No bacteria - do -
of symptom
PID Lower abdominal Cervical Positive culture or
pain, adenexal gramstaining non culture test
tenderness on positive for (cervix first void
pelvic examination gonococcus, urine,
evidence of MPC endometritis on endometrium,
often present endometrial tubal)
biopsy
Antigen detection – DFA
- enzyme linked immunosorbant
assay
- monoclonal or polyclonal Ab
against chlamydial
lipopolysacharide (LPS) or MOMP
Nucleic acid hybridization

 rRNA by hybridization with DNA probe.

 PAGE 2 assay by Genprobe

PCR

Serology – complement fixation test or

microimmunofluorescence
Treatment
- Recommended
Doxycycline 100 mg BD for 47 days or
Azithromycin 1 gm stat
 Alternative
Amoxycillin 500 mg TDS for 7 days or
Erythromycin 500 mg QID for 7 days or Erythromycin
ethylsuccinate 800 mg QID for 7 days or
Ofloxacin 300 mg BD for 7 days or
Tetracycline 500 mg QID for 7 days
Chlamydial infection in pregnancy
 In antenatal period -

1. Spontaneous abortion
2. Neonatal conjunctivitis

3. Low birth baby

4. Prematurity & preterm delivery

Postnatal infection

1. Neonatal conjunctivitis
2. Ophthalmia neonatorum

3. Pneumonia

4. Chronic lung or eye disease

Neonatal conjuctivitis
Commonlly starts within 21 days of birth.

Accounts for 5-15% of conjunctivitis in new borns

Clinical features – intense redness & swelling of

conjunctiva
- profuse purulent discharge
Complication – corneal perforation

- scarring
- blindness
Treatment Infection during Neonatal Infantile
pregnancy chlamydial pneumonia
conjunctivitis
Recommended Erythromycin 500 Syp erythromycin Syp erythromycin
regimine mg QID for 7 days 50 mg /kg /day in 50 mg/ kg/ day
or 4 divided doses for orally in 4 divided
Amoxycillin 500 14 days doses for 14 days
mg TDS for 7 days
or
Azithromycin 1 gm
stat.
Alternative Erythromycin base Trimethoprim
regimine 500 mg QID for 7 40mg with
days or 250 mg sulfamethoxazole
QID for 14 days 200 mg orally BD
or for 14 days.
Erythromycin
ethylsuccinate 800
mg QID for 7 days
or 400 mg QID for
14 days.
Ureoplasma urealyticum
Causes non specific urethritis.

Transmitted by sexual contact.

In males causes – urethritis, proctitis & Reiter’s syndrome

In females causes – acute salphingitis, PID, cervicitis &

vaginitis.

- Also been associated with infertility, abortions,

postpartum fever & low birth baby.
Mycoplasma genitalium
Accounts for 29% of sexually transmitted urethritis

More common organism in C. trachomatis negative

urethritis in 13-45% of cases

Common in recurrent urethritis
Bacterial vaginosis
G. vaginalis & M. hominis

Vaginal discharge

Ecaluation of sex partner is also necessary.

Treatment of NGU
Tab Azithromycin 1 gm stat

or

Tab Doxycycline 100 gm BD for 10 daysA

Complications of urethritis
Chronic recurrent UTIs

Trigonitis in females

Stricture urethra
Newer modality in Treatment of recurrent
urethritis
Tab TRACFREE – 600 mg BD for 3 months

- CRANE BERRY fruit extract which prevents the

bacterial invasion in the urothelium.

Herpes genitalis
HSV 1 & HSV 2
Incubation period 5-14 days
Symptoms – painful lesions
 Fever, headache, myalgias & malaise
 Grouped vesicles pustules ulcers.
Diagnosis- tzanck’s smear, histopathology, viral
culture,serology & PCR.
Treatment – acyclovir 400 mg TDS for 7-10 days/
valacyclovir 1 gm BD for 7-10 days/ famcyclovir 250 mg
BD for 7-10 days
Recurrent episodes –

- Acyclovir 400 mg TDS for 5 days or 800 mg BD for 5

days or 800 mg TDS for 2 days.

- Famcyclovir 125 mg BD for 5 days or 1000 mg BD for 1

days.
- Valacyclovir 1 gm BD for 5 days or 500 mg BD for 3 day.