ACUTE FRESH GONORRHOEA IN MALE
Major. M. P.Vora, M.B.B.S., D.V.D., Hon. Sr. Venereologist
St. George’s Hospital, Bombay
Current medical Practice
A Monthly Journal devoted to Modern Medicine & Surgery
Volume 1; Number 9 of September 1957; Pages: 526-534
Acute fresh gonorrhoea is a disease caused by gonococcus and usually presents an infective discharge from the genitals and dysuria. The diagnosis must be based on the identification of the organism. This is frequently done by means of smears and cultures taken from the urethra. Smears generally appear to work satisfactorily in practice, but both the methods are required for accurate diagnosis. It is a waste to make either smear of cultures from the subpreputial discharge.
Neiser (1879) first described the gonococcus as a Gram-negative intracellular diplococcus. It is present in gonorrhoeal pus and occurs in groups within leucocytes. It resembles a pair of kidneys or beans placed together with their concave borders in opposition. It stains with aniline dyes but is decolorized with Gram’s method. It is a very delicate organism and is quickly destroyed by drying, heat or disinfectants.
Gonorrhoea is primarily a disease of susceptible mucous membrane lined by columnar, cubical or immature epithelium. The urethra, different glands and their ducts lying in the neighbourhood of the urogenital tract, are easily vulnerable to the infection. In the male Tyson’s glands, paraurethral ducts, litter’s glands, Cowper’s glands, the prostate, seminal vesicles, epididymis, the trigone of the bladder, conjunctiva and the rectum are the chief sites likely to fall victims to the infectious activity.
In the adult nearly all cases of acute gonorrhoea are contracted during sexual intercourse with the infected partner. Proctitis usually follows homosexual practices. Accidental infection of the eyes may result due to contamination.
In most cases the diagnosis is established by means of urethral smears and identification of typical Gram-negative intracellular diplococci in them. This is generally enough for ordinary purposes and should be followed in all cases however obvious they may seem. Serological test for syphilis should not be omitted. In the acute stage, the organism can easily and readily be seen in stained smears. A differential Gram’s stain must be used as a routine; use of a single stain is improper and unreliable. When infection is of long standing, the gonococcus is isolated with increasing difficulty and repeated smears and cultures are necessary for confirmation. Smears should be examined immediately and the treatment started without any delay. It is rather uncommon for the male to harbour active gonococci for a long period without physical signs. Smears taken from subpreputial discharges are grossly contaminated and hence valueless. Smears should be made by a cool, flamed platinum loop and spread uniformly on a clean slide. Good smears are valuable in assessing the activity of the infection by noting the number of pus cells per microscopic field. The smear is then fixed by passing the slide rapidly through fire, the care being taken not to overdo the heating. It is stained by Gram’s stain according to the accepted procedures. Gram’s stain is the most reliable routine measure.
Culture of the gonococci is sometimes essential and can be done with the co-operation of an experienced bacteriologist. A culture plate is suitable for the spread of discharge. Culture requires a suitable medium such as Loffler’s serum agar, agar smeared with human or rabbit’s blood, optimum temperature of 34 o to 38 o C and frequent transplanting. The colonies appear after 24 hours’ incubation as translucent grayish, whitish specks in which gonococci can be demonstrated. Identification of gonococcal cultures from other varieties of germs is facilitated by the oxidase reaction i.e. by the addition of 1% solution of dimethyl-para-phenyline-diamine to the plate. Gonococcus is likely to be confused with the other Neisseria like germs i.e., meningococcus, micrococcus catarrhalis, N. flava and N. sicca but the source from where the specimen is taken, intracellular character, morphology and sugar fermentation reactions, etc., help to differentiate it from others. Gonococcus ferments and produces acid in glucose but not in maltose or saccharose media in which phenol red is used as an indicator.
Gonococcal Complement Fixation Test (G.C.F.T.) or Gonococcal Deviation Test (G.D.T.) is done on the same principles as the Wassermann test for syphilis. The test is often negative in a fresh untreated case of gonorrhoea. It becomes positive some 3 to 4 weeks after the infection. Hence it is of no use from the point of diagnosis in the early stage of the disease. It is of some value in complicated gonorrhoea.
Physical examination :
A careful local and general physical examination should never be neglected. By careful examination only can other causes of the same symptoms be excluded and the true nature of the infection determined. Detailed history should be taken and inquiry should be made about:
A thorough physical examination in every case, however desirable, is not always possible in a busy clinic. However, every care must be taken to see that venereal diseases in all forms are diagnosed or excluded. A careful examination of the genitalis, the glans penis, urethral opening, prepuce, shaft of the penis, skin of the perineal region and the body, lymph nodes especially inguinal, cervical and supratrochlear, testis epididymis, spermatic cord, etc. should be made. The external urethral opening is cleaned, inspected and smears are made from the discharge milked out from the urethra. If no obvious discharge is present, patient should be given a clean slide and advised to collect a specimen himself in the morning before he has passed urine. A sample of blood is taken for serologic test for syphilis as a routine in all cases. Any form of trauma to the urethra or to its neighbouring glands must be carefully avoided in the presence of an acute infection. Rectal examination of the prostate or Cowper’s glands and the instrumentation of the urethra either to feel it or to exclude a urethral stricture, therefore, must not be preformed.
The most common manifestation of acute fresh gonorrhoea in the male is an acute urethritis. Occasionally acute proctitis may be encountered in homosexuals. The incubation period of gonococcal urethritis varies from 2 to 7 days, the extremes being 2 to 14 days.
Signs and Symptoms:
The most striking feature is the presence of purulent urethral discharge, at times symptomless, but often accompanied by burning and smarting on micturition. At the beginning the discharge is thin and watery but soon takes on frank purulent character. The lips of the urinary meatus become red, swollen and everted. The urine may become hazy due to the presence of pus. At the onset, the infection is mainly confined to the anterior urethra. When it extends back to the posterior urethra, the symptoms become more marked with pain, burning, urgency, nocturnal frequency and frank haematuria at times. The infection may be associated with chordee or nocturnal priapism with increased sexual desire. The inguinal lymph nodes may be slightly enlarged and tender. The rough idea of the extent of the spread of infection may be inferred from the duration of infection, nature of symptoms and Thompson’s Two Glass Test. If the urethritis is present for more than seven days or if there is exaggeration of symptoms or if the two glass test shows haze of pus in both glasses, it may be assumed that the posterior urethra is involved. In the era of powerful drugs it is, now, not very important to ascertain whether the infection has reached to the posterior urethra or not. Actually it is quite possible that the infection of the posterior urethra may occur in cases in which it appears clinically limited to the anterior urethra.
Thompson’s Two Glass Test - is designed to distinguish between anterior and posterior urethritis. The patient is asked to urinate in two glasses i.e., first 4 to 8 oz. in the first glass and the similar quantity into the second glass. If only the first glass contains haze, the infection is mainly confined to the anterior urethra; while the haze in both glasses indicates involvement of both the anterior and the posterior urethrae. The test is simple and useful but has certain fallacies. To obviate these defects three glass test is devised. It must be remembered that apparent urinary turbidity may result from phosphates and carbonates; the routine addition of few drops of dil. Acetic acid to the sample of urine will clear such a source of error.
An acute purulent urethritis following sexual exposure leads to immediate suspicion of probable gonococcal infection. Gonorrhoea does not account for all the cases of urethral discharges and other possible causes must therefore be considered in those cases in which gonococcus is not demonstrated or where signs and symptoms are atypical or when the possibility of gonorrhoea is denied by the patient. Causes of urethral discharge fall into several well-defined groups and inability to demonstrate the gonococcus may indicate the need for reviewing the case and making other appropriate investigations, to find the cause. It should, however, be borne in mind that the gonococcus might be overlooked in the initial smear and if doubt exists, repeated smears and cultures should betaken. Also residual focus of old gonococcal infection such as prostatitis or stricture urethra must be carefully excluded especially where there is a previous history of gonorrhoea. The causes of urethral discharge may be considered under the following heads:
Pleuro-pneumonia-like L organisms are often found in non-gonococcal urethral discharges. They occupy an intermediate place between the bacteria and the virus. They are filterable and yet can be cultivated on non-lining media and form small colonies with a framework of fine filaments in which clusters of vesicles containing tiny granules can be seen. When these grains are stained with Giemsa stain, they look like ovoid spheroid reckettsia-like bodies with ring forms in the cytoplasm of epithelial cells. Incubation period is longer i.e. 5 to 30 days; the discharge is thinner, mucopurulent, free from gonococci and full of epithelial cells. Urethroscopy reveals ‘sago grain’ appearance of the urethral mucosa.
Reiter’s Disease : A symptomatic triad of urethritis, polyarthritis and conjunctivitis is occasionally met with. The discharge fails to show gonococci. Relapses are common. Etiopathology of this condition is largely a matter of discussion.
The diagnosis of gonorrhoea having been confirmed, the treatment should be instituted at once. This verification of diagnosis need not entail any delay in starting treatment. The placing of ‘symptomatic therapy’ before the ‘treatment of specific disorders’, however well meant, is to be highly deprecated. Early stage is the most hopeful time to commence treatment, and greatly improves the prognosis. The disease is easily curable with the modern powerful drugs but it is often overlooked that the cessation of signs and symptoms does not necessarily indicate cure in the true sense, and that surveillance and repeated tests over a period of at least three months are necessary to establish the presumption. Many tragedies could be avoided by observing this important fact. The patient should be advised about:-
Absolute rest in bed is advisable during the acute stage. Alcoholic drinks, spices, cycling, weight-lifting and sexual excitement should be prohibited. Bowels should be regular. Bland fluids by mouth should be encouraged. An alkaline diuretic mixture with tincture belladonna should be prescribed as a routine. Drainage of the urethra should be helped and not interfered with. From this point it is good to support the penis so as to obliterate the penoscrotal angle.
With the introduction of potent drugs in the treatment of gonorrhoea, the local therapy has somewhat relegated in the background. Local therapy consists of various procedures such as anterior urethral irrigations, urethrovesical lavage, prostatic massage, urethral dilatations, urethral instillations and operative measures. As regards the first two procedures, there is at present considerable divergence of opinion among the specialists about their advisability and utility in the acute fresh case. It is better to institute it only when the acute stage has passed and the infection has come under control, i.e. after 2 or 3 days of medication and to continue it for about 10 to 15 days. Other procedures have usually no place in the treatment of an early case of acute fresh attack. They have proved very useful and must-be procedures in all late (Posterior urethritis) subacute, chronic and complicated cases. The older the infection proportionately the greater is the importance of local therapy. In acute gonococcal proctitis, it is necessary, in addition of the specific drugs, to give for about 12/15 days, daily rectal irrigations of warm potassium permanganate solution 1 in 8000. Irrigation of the urethra is carried by gravity method. The douche can with its attachments be placed 2 or 3 feet above the patient’s pelvis. The antiseptics most commonly used are potassium permanganate or oxycynide of mercury 1 in 8000 at 105 oF. The anterior urethra is washed and cleaned by repeatedly distending and emptying of the canal. About a pint of solution is needed. Urethrovesical irrigations are given in cases of posterior urethritis. They need considerable experience and depend on the patient’s ability to relax his sphincters so as to allow the fluid to pass into the bladder. No attempt must be made to force the fluid in, for it often leads to complications. When the bladder gets full, the patient is asked to void the fluid as if in a natural act of micturition. This is repeated a couple of times with another pint of solution. During these procedures, great care must be taken to observe proper sepsis. It is good practice to use goggles to protect one’s eyes.
The introduction of sulpha drugs and penicillin in the treatment of gonorrhoea has brought about a great revolution. These drugs rapidly control the infectivity; shorten the course of the disease and reduce the chances of complications. The success in the treatment however, depends on the observance of certain basic factors with regard to their use:-
Treatment of acute fresh gonorrhoea is usually by sulpha drug or penicillin. The latter should not be given as a routine if there is any suspicion of concomitant syphilis. Sulphanilamides should be preferred to penicillin for the treatment of gonorrhoea under the following circumstances:-
Sulphanilamides : They are remarkably rapid and effective in the treatment of gonorrhoea. Though they are not as effective as penicillin for gonorrhoea, they have many advantages over penicillin.
Of recent years there has occurred a gradual decline in their efficiency but it is solely due to improper medication in subcuartive doses either for prophylaxis or treatment. However, the success rate comes to the tune of 80 to 85 percent. Their mode of action is not thoroughly understood, but it is believed that they exert bacteriostatic and bacteriolytic influence on the organisms and thus render them susceptible to the body defense mechanism. The urethral discharge ceases, burning disappears, and urine becomes free from organisms and pus cells in three to five days. A short intensive course is better than a mild prolonged one. Administration of small doses at regular intervals encourages drug-resistance, while prolonged administration increases the risk of blood dyscrasias like agranulocytosis, anaemia and purpura. If no improvement is obtained within the first 3 or 4 days, none may be later noticed however prolonged the administration might be. The maximum dose in 24 hours for an adult is 5 to 6 gms. and the total dose should not exceed 25 to 30 gms., administered over the period of 5 to 6 days. Usually it is better to give 6gms on the first day and 5 gms. daily for another 4 days. The daily dose should be evenly spread throughout the day and a tumbler of water is given with each dose. For younger patients the dose is proportionately smaller. During this therapy it is necessary to see that the patient takes adequate fluids i.e. ten pints a day. This simple precaution is found in the long run a very useful measure in avoiding serious complications such as anuria or haematuria. Urine should be inspected daily. Usually no serious toxic reactions are met with in 5 to 6 days’ therapy. If the patient fails to respond, another member of the sulpha group should be prescribed after a week’s interval. Along with this, a course of 3 to 5 intravenous injections of T.A.B. vaccine (25-300 million organisms) on alternate days is recommended. In addition local treatment consisting of daily urethrovesical irrigations and weekly prostatic massage and urethral dilatation for about 6 to 8 weeks should be prescribed.
The drugs now chiefly used are sulphathiozole, sulphadiazine and gantrisin. There is little difference in their effectiveness. Being less toxic and possessed of high therapeutic potency, they are the drugs of choice. They should receive first trial in all cases of acute gonorrhoea especially associated with penile sores, so that the results of dark-field illuminations for Tr.pallidum may not be interfered with. For an average ambulant patient, dose of 5 gms. daily for 5 days adequate; an initial dose of 2g. may be considered according to the urgency. The tablets should be given at regular intervals (at 6, 10, 2, 6, 10) with a tumbler of water.
In treating gonorrhoea with penicillin, there is a danger of masking syphilis or modifying its course if a double infection has been contracted at or about the same time. The relatively small dose given to cure gonorrhoea, may be sufficient to mask or modify the approach of syphilis for some months and is likely to hasten the late dangerous sequelae. Hence this drug should not be used as a routine in the treatment of gonorrhoea, especially where there are penile sores under investigations. The writer has seen with dismay two cases of aneurysms developed within two years of treatment of gonorrhoea with penicillin. They seem to be examples of concomitant syphilis in which la dangerous sequelae were hastened by the relatively small dose of penicillin used for gonorrhoea; for, the possibility of old syphilitic infection in them, was reasonably excluded by carefully taken oral and circumstantial evidence. When penicillin is used for acute fresh gonorrhoea, the total dose of penicillin should not ordinarily exceed 400,000 to 600,000 units; but if for any reason it is considered desirable to increase beyond that limit, a strong case can be made for continuing the administration of penicillin for at least 8 to 20 days thus completing a minimal curative course of 4.8 to 6 mega units for early syphilis and following the case as a routine for both gonorrhoea and syphilis. The significance of fever early in the course of penicillin therapy either for gonorrhoea or any other condition should make one suspect the possibility of dual infection and one must look carefully for further developments.
Penicillin is available at present in many forms. Crystalline sodium or potassium penicillin G in aqueous solution is given in 40,000 to 50,000 units intramuscularly at 3 hour intervals till at least 5 to 6 doses are completed i.e. the total dose of 300,000 units is quite sufficient for an average case, and maintains an effective blood level for 15 to 18 hours. Several delayed absorption preparations are now available, which can do away with frequent injections and save attendant inconvenience both to the patient and the doctor. Only a single injection can maintain a prolonged and effective blood concentration extending for 18 to 72 hours. Procain penicillin G 300,000 units fortified with crystalline sodium penicillin G 100,000 units are quite satisfactory. Aqueous solution can easily be made, passes with ease through an average size needle, attains a high peak of concentration in a short time, and maintains effective blood level for the desired period of 18 hours. Benzathine penicillin or Diamine penicillin (‘Penidure’ - Wyeths) and Benethamine penicillin (‘Benapen’ - Glaxo) are new additions which give considerably higher blood levels for more prolonged periods than that of procain penicillin and definitely reduce the possible danger of inducing penicillin sensitivity or resistance which is often associated with other types of penicillin. A single doe of 300,000 units proves effective for a case.
Penicillin has a dramatic action on gonococci generally and on sulphanilamides-resistant strains of gonococci specially. However, a few disadvantages referred to above have even to this day left the primary place of sulpha drugs in the treatment of gonorrhoea. Oral route for penicillin is not advisable for reasons of indiscriminate use, which may lead to subcuartive doses and induce carrier stage. A penicillin-treated case should be given, apart from usual surveillance and tests to show that gonorrhoea is really cured, an additional three months’ period of observation to ensure that the development of concomitant syphilis has not been masked or retarded. An overall period of six months is recommended and serum tests for syphilis insisted on.
Streptomycine is effective in gonorrhoea. Two gms. in a day is usually more than enough for an acute fresh case. There is not so much risk of masking syphilis as in the case of penicillin. It is effective against the secondary organisms which sometimes associate with acute gonorrhoea.
Auriomycin, Chloromycitin, Terramycin and Tetracycline are all quite effective in gonorrhoea. An average dose of 2-3 gms. daily for 1 to 2 days is suggested, for an acute fresh case. But these costly drugs should be used only when ordinary cheap remedies have proved ineffective. Toxic reactions to these drugs are not uncommon.
This is an important part of treatment itself. When medication is over, subsequent follow-up is necessary in every case to ensure that the gonococcal infection is really eradicated, and the concurrent syphilitic infection is absent. Numbers of tragedies are frequently met with for want of observance of this simple caution. In a sulpha-drug-treated case a period of three months’ observation is recommended, while in a penicillin-treated case a period of six months is advised.
For this purpose, certain tests are performed. Many of the tests, mentioned below as guidance, can easily be done by a general practitioner in his office, while for the difficult ones such as passing of a sound or urethroscopy, he can seek the help of the nearest specialists for carrying them out; for they are not to be done by the inexperienced person. Tests of cure of gonorrhoea are usually spread over the first three months. Provocative or strong procedures such as prostatic massage or urethral instrumentation with the object of revealing any concealed foci of infection should not be undertaken too early, but only last when it is reasonably ascertained that no such foci exist. After the therapy is over, the patient should be seen daily for about 3 to 7 days to find out whether he has reacted satisfactorily. There should be practically no discharge from the urethra, urine should be clear and free from gonococci on microscopic examination. Patient should be told to avoid sexual excitement, alcoholic drinks, to desist from squeezing his penis frequently and to report after a week. At every visit, the patient should be examined carefully for signs of early syphilis. The urethra should be free from any discharge; urine should be clear and reveal no gonococci or pus cells more than five per field on microscopic examination. If discharge persists or smear shows pus cells more than five per microscopic field or gonococci, the treatment should be considered as a failure and retreatment becomes necessary. A drug different from that previously used should be given a trial along with local therapy. If all is well, the patient is advised to attend after a fortnight when the microscopic examination of the fresh sample of urine held for 5 to 6 hours is done and a serologic test for syphilis is taken. The examination must not show gonococci or pus cells exceeding five per field and the serology should be negative. The next fortnightly two examinations should include further searching examinations of urine and one serologic test for the examination of lues. A fortnight later urine may be repeated after a subcutaneous injection of a provocative dose of gonococcal vaccine, 500 million organisms. A week later a prostatic massage is given on a full bladder, prostatic smear is taken and also urine voided subsequently is examined for pus cells and organisms. Culture, if possible, is made at the same time. The nest week full size straight and curved sounds are passed and urethra is gently massaged and palpated over them, smears are taken from urethral secretions and of urine on two successive days and searched for evidence of latent focus. These tests should never be done to soon for fear of driving the latent infection further backwards. All these tests must not reveal either gonococci or pus cells. At the end of three months urethroscopy should be done as a final test of cure for gonorrhoea and a serologic test for syphilis. In penicillin treated cases later observations are directed mainly towards the exclusion of syphilis. When all these tests are satisfactory, then and then only the case can be reasonably considered really cured. If the patient is to resume sexual relations, he should be advised to use a condom for the first two occasions and to have an additional check-up as a special precaution.
For his very valuable help and suggestions, my thanks are due to Dr. B.A. Daruwala, M.B., D.V.D., Hon. Senior Venereal Surgeon, J.J. Hospital, Bombay and Hon. Associate Venereologist and Dermatologist, B. D. Petit, Parsi General Hospital, Bombay. My thanks are also due to Dr. M. S. Trasi, M. B., D.V.D., for his suggestions.
Tabulator showing treatment and surveillance for an acute fresh case of gonorrhoea in the male
1 st - Clinical and bacteriological examination for the diagnosis of
gonorrhoea, urethral smear, and blood for serological examination.
Mist. Alkaline ozi T.D.S Sulphathiozole.
- Tabs. 2, at 4-hour intervals, five times a day, plenty of fluids by
2 nd , 3 rd , 4 th and 5 th day - Drugs as on the first day continued. In addition
irrigation of the urethra daily for about 10 days.
7 th and 8 th day - clinical examination, urine examination.
22 nd - Clinical and urine examination, blood test, microscopic examination
of the urine, smear.
37 th - Clinical examination, urine examination, microscopic examination of
the smear made from centrifugalised sample of urine held over 5 to 6
52 nd - Clinical examination, urine examination, smear of the urine,
examination of blood test for syphilis.
67 th - Clinical examination, urine examination after a provocative dose of
75 th - Prostatic massage on a full bladder, prostatic smear, and inspection of
the urine voided and a smear made from the urine, culture of
82 nd - Clionical examination, full-sized urethral sound is passed, urethra is
palpated urethral secretion taken for examination and urine examined
for G.C. and P.C. on two successive days and searching examination
90 th - Careful clinical examination. Examination of the urine held for 6
hours, Urethroscopy and blood test for syphilis.