Urethritis

1. URETHRITIS Dr. Shilpa Soni MGMCH

2. medial horizontal gp of superficial inguinal LN Inferior vena cava

3. Superficial Inguinal LN - Penile skin - Scrotal skin - Vulva - Vagina, lower third - Uterus, lower part - isthmus of fallopian tube Deep inguinal LN Anterior male urethra & glans penis Sacral LN Vulva Cervix

4. Iliac LN Posterior urethra Vulva Upper third & middle third vagina Cervix Prostate Pre & para aortic group of LN Testes & epididymis Uterus, upper part Ovaries Fallopian tubes Cervix

5. Urethritis Inflammation of the urethra. Discharge +/- dysuria or may be asymptomatic.

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

7. Non Infectious Causes - Trauma - Urethral stricture. - Catheterization. - Chemical irritants. - Dehydration.

8. Gonococcal Urethritis N gonorrhoea – gram negative, non motile, non spore forming diplococci . Oxidase positive Ferments glucose PPNG – penicillinase produc - - ing N. gonorrhoea: cefotaxime , ceftriaxone , ciprofloxacin, tetrac - - ycline can be used.

9. N gonorrhoea – present predominantly intracellularly in the polymorphonuclear leucocytes (PMN). Penetrates columnar epithelium.

10. Structure – - capsule – polyphosphate trilaminar membrane – outer membrane – type 1 protein ( por ) - A & B - type 2 protein( Opa pro) - RMP protein - peptidoglycan – muramic acid & N-acetyl glucosamine. - cytoplasmic membrane – penicillin binding proteins. - Pili - filaments

11. Strains - Pathogenic strains – N. gonorrhoea - N. meningitidis - Non pathogenic strains – N. catarrhalis - N. pharyngis sicca - N. lactamica - N. subflava

12. Clinical features : Affects urethra in both sexes. Transmission – sexual contact Incubation period – 2-5 days Intense burning sensation. Fever & malaise.

13. In men anterior urethritis is more common. Discharge – profuse, purulent & yellowish green. 15% males – mild or asymptomatic.

14. Complications – Posterior urethritis Epididymitis Acute or chronic prostatitis Untreated – periurethral abscess & watercan perineum.

15. 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

16. Proctitis through autoinoculation from cervical discharge or as a result of direct contact from an infected partner’s penile secretions.

17. Complications in females- PID Tubo ovarian abscess Subsequent ectopic pregnancies Chronic pelvic pain Infertility Fitz-Hugh-Curtis syndrome – inflammation of liver capsule associated with genitourinary tract infection. Present in upto ¼ of women with PID caused either by N. gonorrhoea or C. trachomatis .

18. Complications common to both sexes - - Disseminated gonococcal infection (DGI) - Acute arthritis-dermatitis syndrome – acute arthritis, tenosynovitis , dermatitis or combination of these findings. Gonococcal arthritis Meningitis Endocarditis

19. Laboratory diagnosis – Microscopy – gram staining gram negative diplococci

20. Culture – thayer martin medium - chacko nayer medium - martin lewis media - new york city media

21. PCR DNA hybridisation ELISA The complement fixation Latex agglutination immunofluoroscence & anti surface pili assays Radioimmunossay Immunoblotting

22. 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.

23. 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 .

24. Non gonococcal urethritis

25. 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

26. 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.

27. 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.

28. In men- Sites of infection are – urethra. - epididymis . - systemic. Clinical syndrome – urethritis , post gonococcal urethritis & Reiter’s disease.

29. Urethritis – Dysuria with mild to moderate whitish or clear urethral discharge. On examination – focal urethral tenderness - meatal or penile lesions may mimic herpetic urethritis .

30. Epididymitis – recurrent infections Unilateral scrotal pain, Swelling & Tenderness. Fever Urethritis may often be assymptomatic & evident only as urethral inflammation.

31. Prostatitis – Ususaly asymptomatic or may Presents with discomfort on passing urine & vague pain in perineum, groins, thighs, penis, suprapubic region or back. Painful ejaculation.

32. Proctitis – repetitive anal intercourse or by lymphatic spread from posterior urethra. Rectal pain Discharge - mucopurrulent Bleeding

33. 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.

34. Organisms associated with Reiter’s syndrome are N. gonorrhoea C. trachomatis U. urealyticum Salmonella Shigella Campylobacter Treatment – antibiotics, NSAIDS, sulfasalazine , corticosteroids & immunosupressants .

35. In women – Cevicitis – mucopurulent cervical discharge - cervical erythema & edema with an area of ectopy - spontaneous or easily induced cervical bleeding Urethritis – dysuria - frequency - pyuria

36. Bartholoinitis Endometritis – abnormal vaginal bleeding - menorrhagia - metrorrhagia PID – lower abdominal pain - adenexal tenderness on pelvic examination - MPC often present - Perihepatitis (Fitz-Hugh-Curtis Syndrome)

37. Lab diagnosis Clinical syndrome - male Clinical criteria Presumptive criteria Diagnostic criteria NGU Dysuria , urethral discharge Gram stian - > 5 PMNL/ hpf Pyuria on first void urine Positive culture Acute epididymitis Fever, epididymal or testicular pain, evidence of NGU Epididymal tenderness or mass. - do - Positive culture or non culture test on epididymal aspirate.

38. Clinical syndrome Clinical criteria Presumptive criteria Diagnostic criteria Mucopurulent cervicitis Mucopurulent cervicitis discharge Cervical ectopy & edema , spontaneous or easily induced cervical bleeding Cervical gram staining > 30 PMNL/ hpf in non menstruating women Positive culture or non culture test. Acute urethral syndrome Dysuria , frequency syndrome > 7 days of symptom Pyuria No bacteria - do - PID Lower abdominal pain, adenexal tenderness on pelvic examination evidence of MPC often present Cervical gramstaining positive for gonococcus, endometritis on endometrial biopsy Positive culture or non culture test (cervix first void urine, endometrium , tubal)

39. Antigen detection – DFA - enzyme linked immunosorbant assay - monoclonal or polyclonal Ab against chlamydial lipopolysacharide (LPS) or MOMP

40. Nucleic acid hybridization rRNA by hybridization with DNA probe. PAGE 2 assay by Genprobe PCR Serology – complement fixation test or microimmunofluorescence

41. 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

42. Chlamydial infection in pregnancy In antenatal period - Spontaneous abortion Neonatal conjunctivitis Low birth baby Prematurity & preterm delivery

43. Postnatal infection Neonatal conjunctivitis Ophthalmia neonatorum Pneumonia Chronic lung or eye disease

44. 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

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

46. 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.

47. 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

48. Bacterial vaginosis G. vaginalis & M. hominis Vaginal discharge Ecaluation of sex partner is also necessary.

49. Traetment of NGU Tab Azithromycin 1 gm stat or Tab Doxycycline 100 gm BD for 10 daysA

50. Complications of urethritis Chronic recurrent UTIs Trigonitis in females Stricture urethra

51. 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 .

52. 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

53. 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.

54. Syndromic approach

55. Urethral Discharge History / Examine Milk urethra Discharge present Treat for Gonorrhoea & Chlamydia & trichomoniasis Yes No other STI? No Yes Use appropriate flow chart ECCV ECCV, Partner treatment, Follow up

56. Treat patient for both Gonorrhoea and Chlamydia infection. The Regime: Azithromycin 1G orally as a single dose (to treat chlamydial infection) PLUS Cefexime 400 mg orally, single dose under supervision (to treat gonococcal infection) Kit one Gray Treatment of Urethral Discharge

57. Treat patient for both Gonorrhoea and Chlamydia infection. The Regime: Azithromycin 1G orally as a single dose (to treat chlamydial infection) PLUS Cefexime 400 mg orally, single dose under supervision (to treat gonococcal infection) Kit one Gray Treatment of VD- Cervicitis

58. Recommended regimen Scenidazole 2 G orally, single dose, under supervision ( to treat trichomoniasis and bacterial vaginosis). Plus Fluconazole 150 mg orally, single dose (to treat candidiasis). NOTE: Patients taking Metronidazole or Tinidazole should be cautioned to avoid taking alcohol while on these drugs up to 24-48 hrs . Kit one Gray Treatment for Vaginal Discharge Vaginitis. Kit two Green

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