NON-GONOCOCCAL URETHRAL DISCHARGES 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 12 of December 1957; Pages: 676-682
The complaint of “urethral discharge” by the male is a symptom often of obscure origin; it is distressing to the patient and constitutes a l clinical problem. Inflammatory conditions of the lower urinary tract are at times associated with this complaint which is difficult to ignore, and bring the patient quickly to the practitioner. The complaint is so common that only those who keep accurate records with appreciate its frequency. In the writer’s experience it is often mentioned by a large number of patients as a complaint, although not necessarily the primary one. It has to be remembered that all patients who come with this complaint are not necessarily the victims of gonorrhoea which is all easy to assume. On the contrary, most of them often mean thereby something else such as very highly acid or alkaline urine, cystitis, calculus, pollutions, impotency, sterility, and so forth. Whenever such a complaint is heard, it is reasonable to hold a high index of suspicion and to think of gonorrhoea. But this presumption has to be confirmed in every case, at times, by repeated examinations of smears and cultures.
Diagnosis must come first before specific treatment is instituted. One can only deplore the medical approach which regards this complaint as gonorrhoea and an infection for a prescription of sulpha drugs, a few shots of penicillin or some expensive capsules of miracle drugs. One rarely comes across a patient who has previously had a careful office examination to determine the presence of pyuria, its source and the cause. In consequence one often finds such patients treated in vain on assumption and have, to their detriment, been subjected to prolonged and repeated courses of products of modern pharmacy, when there is, at times nothing in the history or physical examination to indicate a disease. One does not imply that one must await the results of time-consuming laboratory findings, but one would certainly like to stress the importance of the intelligent evaluation of the site of infection, the type of organism, use of safe non-toxic drugs for a few days to test therapeutic response and reference to the specialist of a resistant or relapsing case. In every case of urethral discharge, it is of primary importance to exclude the possibility of gonococcal infection and this need not delay an early institution of treatment. Unless the discharge shows typical gonococci, the case must not be diagnosed as of gonorrhoea. With this view in mind, the importance of distinction between gonococcal and non-gonococcal discharges will be apparent.
The causes of urethral discharge are so varied and of such common occurrence as to bring these patients within the scope of nearly all who practice medicine, although more frequently the general practitioner, the venereologist, the sexologist, the urologist or the psychiatrist is the one concerned. Each of them, however, tries to see different aspects of the problem or to approach it from a different and prejudicial standpoint. Broadly speaking, the urethral discharges may be divided into certain groups:-
Various chemicals, according to the wisdom of the patient are frequently used for prophylaxis against venereal diseases or for prevention of conception. In case they are too strong, they leave signs of damage on the glans penis and at the external urinary meatus. Urethritis is accompanied by thin urethral discharge, local discomfort, redness, swelling, and dysuria. The lessons may get secondarily infected. The discharge is watery and contains few pus cells and relatively large number of epithelial cells. One has also to think of the possibility of a deliberate self infliction to avoid duty. Irritant plant juice, acid, tooth-paste and condensed milk are injected into the urethra to simulate gonorrhoea. The writer had occasionally seen such practices among the soldiers while serving in the Indian Army during the Second World War. The excoriation at the external meatus, the paucity of pus cells in the smears and thin discharge should arouse suspicion of the cause. To confirm this, use of litmus paper to find out the reaction, microscopic examination of the smear, test for albumin and intelligent evaluation of the available data are suggested as of help.
A urethral discharge may follow urethral trauma from a passage of foreign body into the urethra. Careless handling of urethral sounds, urethroscope or cystoscope may damage the urethral mucosa and give rise to the complaint of urethral discharge.
Certain functional disorders such as Phosphaturia and Oxaluria are sometimes associated with urethritis and urethral discharge. Such conditions follow the ingestion of certain foods or drugs.
Phosphates are common in alkaline urines. They are suspected when a symptomless deposit is noticed, which can be readily dissolved by addition of acetic acid to the urine. In a severe case, pain, frequency and discharge may be complained of. Mental disturbances and worries frequently predispose to Phosphaturia. At times the phosphatic deposit is squeezed out by the patient at the end of micturition. Microscopic examination is conclusive. Phosphates are found in three forms - (a) triple phosphates of ammonia and magnesium as ‘roof top’ or ‘coffin lid’ crystals or in feathery star - or leaf-like forms, (b) neutral phosphates as fine pointed or wedge-shaped prisms arranged in stellar pattern and (c) the more common amorphous phosphates of calcium in numerous colourless granules.
Treatment - The patient should be reassured that there is nothing seriously wrong with him. Reaction of the urine should be changed to acid by giving ammonium chloride gr. 10 three times a day for a few days.
Oxalates may sometimes cause a urethral discharge. It usually follows the ingestion of certain foods rich in oxalates such a spinach, rhubarb, tomatoes, beetroot, black currant, berries, beans, tea, coffee and cocoa. Oxalates of calcium give rise to scanty urinary haze which rests like fine powder on a cloud of mucus often called “a powdered wig” deposit. Urine is acid in reaction. The crystals are soluble in strong hydrochloric acid and recrystallise on addition of ammonia, but are insoluble in acetic acid. Microscopically, they appear as transparent octahedral “envelope crystals” or small squares crossed by two intersecting diagonals or “dumb bell” forms. They have no pathological significance. Their presence in fresh urine, together with renal or cystic irritation should arouse suspicion of a calculus. The treatment consists of excluding foods containing oxalates.
Sodium, potassium or ammonium urates give rise to thick urinary deposit. When first passed, urine is usually clear and forms a “brick red” amorphous deposit as it cools. On heating, the precipitate disappears. It also disappears on addition of caustic potash. It is common in highly concentrated urine. It has no clinical significance. Microscopically either amorphous forms or the “hedge-hog” crystals of sodium urates or globular crystals of ammonium urates are seen. They are readily soluble in caustic soda solution. The condition often physiological and no particular treatment is indicated.
Uric acid crystals
“Red sand” or “gravel” appears as reddish brown crystals. The most common forms are “whetstones”, rosette-like clusters of prisms and rhombic plates. They are soluble in hydroxide solution but not in hydrochloric or acetic acid. A deposit of uric acid crystals has no significance unless it occurs before or very soon after the urine is passed, when it suggests a stone in the kidney or bladder, especially if red blood cells are also present in the urine.
Allergic urethral discharges
Occasionally a urethral discharge of an allergic nature may follow in susceptible person the ingestion of certain food. Brinjal, asparagus, spinach, rhubarb and strawberries are often causative factors. History of previous attacks under similar conditions should give a clue. Attacks of urticaria, asthma or other allergic disturbances are suggestive of diagnosis. Treatment consists of an avoidance of the existing cause.
PHYSIOLOGICAL URETHRAL DISCHARGES
Prostatorrhoea - An escape of prostatovesicular fluid from the external urinary meatus independent of orgasm. Its escape is noticed when the patient strains at stools or at urination. It is clear, slightly sticky glycerine-like whitish discharge. It is merely an excess of secretion expressed by the pressure of hard stools on the prostate and the vesicles. Normally it does not contain pus cells unless there is inflammation. Such a discharge occurring markedly after an act of defaecation is occasionally noticed both in married and unmarried men.
Urethrorrhoea - An escape of normal urethral secretion from the external urinary meatus without coitus being indulged in. It is simply an excess of secretion from the accessory sexual glands in the urethra like Cowper’s or Littre´’s. Its occurrence in some quantity at times of sexual excitement and before ejaculation is absolutely a normal event. It is perfectly clear viscid fluid mucus, free of pus cells. It is frequently mistaken for gonorrhoea by the laity. It is common in young unmarried men.
Pollutions 2 . - or ‘wet dreams’ are sometimes the cause of a complaint of urethral discharge in a young adult who has reached sexual maturity. They are involuntary emissions of seminal fluid occurring in the normal male from the time of puberty onwards and unassociated with the act of coitus. Their occasional occurrence especially in the unmarried male is a perfectly normal event. They may be physiological or pathological. In the later case, they result from non-physiological stimulation so frequently as to disturb the normal health and sexual life of the man. The sufferer is highly strung, emotional and psychopathic. Unless they are pathological they need no treatment.
Spermatorrhoea - Oozing of semen without erection and unaccompanied by the usual phenomenon of ejaculation. The patient is constantly in a state of erethism. It is a very rare condition. The discharge consists of semen from the seminal vesicles and contains sperms in large numbers. A weak wave of contraction usually passes over the whole genital tract.
All the patients who are the subjects of physiological discharges or who have difficulties of sexual adjustment should be carefully examined to exclude any pathological lesion and should be told not to worry about the discharges. They should be reassured thet they have no serious illness and the discharges will have no bad effect on their well-being. They should be told to relax properly and to have vigorous exercise daily. By discussion, reassurance and advice, their tension and anxiety could be relieved.
INTRAURETHRAL SORES AND TUMOURS
As the cause of urethral discharges - The presence of an intraurethral chancre, a secondary syphilitic papule, chancroid, primary lesion of lymphopathia venereum or granuloma inguinale, herpes, intraurethral warts, etc. may be responsible for a complaint of a urethral discharge. At times the discharge may be profuse and give rise to pain and frequency.
Primary syphilis - If a chancre is situated in the urethra, there will be induration at the site and enlargement of the inguinal lymph nodes so typical of early syphilis; separation of the lips of the meatus will usually reveal its presence in the terminal part of the urethra. The glans penis is swollen, oedematous and indurated. The discharge is serosanguine and shows Treponema pallidum on dark-ground examination. Use of the urethroscope may be made to have a proper view of deeper lesions. The chancre can be palpated over the straight metal sound passed into the urethra. Eve if no sore is visible but there is profuse watery discharge associated with enlarged, shotty but not tender inguinal glans, a gland puncture should be done and a search for Treponema pallidum made. It is frequently successful. A secondary syphilitic papule in the urethra will be often associated with typical secondary symptoms and serological positivity.
Chancroid - This lesion is diagnosed only after exclusion of syphilis. It is painful and may cause a smarting of the urethra and painful inguinal adenitis. It may lead to narrowing of the urethra. Treatment of both the chancroid and chancre is the same when they occur elsewhere. But when such a lesion is suspected, a straight sound should be passed within two weeks of treatment, in order to prevent urethral stricture. In every case of suspected chancroid, smear for Haemophilus ducreyi. Ito-Reen-steirna Test, dark-field illumination for the exclusion of spirochaetes and blood serological examinations should not be omitted.
Warts - occasionally, intraurethral warts are found just within the meatus. They may occur alone or in association with other warty growths on the genitals. There may be pre-existing irritating discharge which in the presence of warm, moist locality leads to warty growths. Such warts may give rise to profuse urethral discharge. If they are situated at the end of the canal, they can be seen by opening the lips of the urethra, but deep inside, warts can only be seen on urethroscopy. They are removed by cautery under local anaesthesia; and the predisposing cause of irritating discharge should be removed.
Urethral stricture - This is often responsible for persitent mild urethral discharge. Usually these patients have a history of previous gonorrhoea or urethral trauma. This can be confirmed by passing a sound into the urethra and by urethroscopy.
Intraurethral foreign body - urethral calculus, a sinus or an abscess in this situation may give rise to urethritis and urethral discharge. Diagnosis may be confirmed by urethroscopy, chemical and microscopical examination of the urine, and radiological examination.
This often leads to urethra discharge. Urethritis may be complicated by cystitis so also it is by no means uncommon for cystitis to be the primary cause of urethritis and urethral discharge. The discharge is usually slight and thin in nature and often associated with bladder symptoms such as frequency, urgency, dysuria and infected or even blood-stained urine. Cystitis may be due to defects in emptying the bladder either due to nervous lesion of the spinal cord, tabes dorsalis or to obstruction caused by an enlarged prostate, stricture of the urethra or a bladder stone. Bilharziasis, foreign body, papilloma, malignant growth or tuberculosis of kidney, prostate or epididymis may be the cause of cystitis.
The symptoms of cystitis are due to bladder irritation and are represented by frequency, urgency and intense dysuria. There is a constant desire to urinate (strangury) and a constant dread of going so owing to the pain felt during the act. The urine is alkaline directly it is passed and is heavily loaded with hazy, ropy pus and mucus and may contain red blood cells or even blood threads. There may be frank recurring haematuria, especially in cases of papilloma, Schistosomiasis, renal or vesicular stone, tuberculosis and malignancy. In such cases x-ray, urography and cystoscopy should always be done. Stone in the bladder causes aggravation of the symptoms on exercise and gives rise to pain and haematuria at the end of micturition and pain at the tip of the penis. Tuberculosis either of the kidney, prostate or epididymis should be excluded by thorough clinical and bacteriological examination. Primary infections of the bladder due to bacillus coli or Abacterial pyuria have been at times the cause of cystitis. Any case of cystitis which does not resolve in about two weeks should be reassessed and full clinical, bacteriological and radiological, examinations undertaken.
Abacterial pyuria - This cystitis often associated with urethritis in which the above mentioned causes have been carefully excluded. It is recognised that a primary focus of infection may be followed by changes in other organs at a distance from the original focus of infection. The focus of infection does not require being very active in order to produce remote effects. The urogenital tract is liable to suffer from toxins or bacteria disseminated from the focus situated anywhere in the body. When the focus of infection is very active, the relationship between the primary infection and its subsidiary expression is readily recognised, and the two together form the symptom-complex. But in chronic infections the relationship between the focal infection and the symptoms depending upon it, is often difficult to determine. The focal infection, therefore, seems to be linked up occasionally with the problem of pyuria.
The writer has come across cases of symptomless pyuria associated with oral sepsis, pyorrhea and dental caries. With the aggravation of the oral condition, the number of pus cells in the urine seemed to increase. When the oral condition was treated, the pyuria automatically disappeared. These cases, if there is previous history of exposure to infection, are likely to be mistaken for chronic gonorrhoea unless proper care is exercised. Spirochaetes of dental origin have been reported to cause cystitis. In such a case administration of 4 to 6 I.V. injections of neoarsphenamine or mapharside at four-day intervals is suggested. However, it should be resorted to only after the confirmation of spirochaetes by dark-field examination and the failure of usual and ordinary remedies such as alkalis, sulpha drugs and streptomycin.
All forms of cystitis may be complicated by epididymitis and in all such cases gonorrhoea must first be excluded by negative smears, cultures and complement fixation tests.
NON GONOCOCAL URETHRITIS
Bacterial urethritis - Gonococcal - If any doubt exists, repeated examination of smears and cultures should be made, for gonococci might be overlooked in the initial examination in a chronic or inadequately treated case of gonorrhoea. Residual foci of old gonococcal infection should be carefully excluded which may be responsible for a thin early morning drop of urethral discharge (gleet) in which pus cells are present but gonococci are scanty and recovered with great difficulty. Special care is essential in case of a chronic scanty urethral discharge with a previous history of gonorrhoea. Repeated urethral smears, prostatic smears, massage of the urethra over a sound, urethroscopy, and passage of a curved sound to exclude stricture and finally complement fixation test have to be done before gonorrhoea can be finally excluded.
Other Bacteria - Streptococci, staphylococci, pneumococci, diphtheroid bacilli and bacillus coli are all occasionally associated with urethritis. In such cases there is a purulent or mucopurulent urethral discharge full of secondary organisms. Treatment consists of urethral irrigations and the use of sulpha drugs or streptopenicillin or one of the broad-spectrum antibiotics, depending on the susceptibility of the organisms.
Urethritis has been observed in mumps, scarlet fever, typhoid fever, influenza and bacillary dysentery. Occasionally non-syphilitic spirochaetes may be detected on dark-field examination of the urethral discharge or prostatic fluid. In spirochaetal urethritis 4 to 6 injections of mapharside once or twice a week are suggested. Urethritis following antibiotic therapy for the cure of other diseases has been recorded by the writer 1. This superinfection during the antibiotic therapy, even though rare, is not uncommon.
Abacterial urethritis - Protozoa - Trichomonas can occasionally be recovered from urethral discharges, the preputial sac and the prostatic fluid. Trichomonas vaginalis infestation is not uncommon, both in the female and the male, giving rise to urethral discharge and non-specific urethritis. The trichomonas urethral discharge is usually thick, homogeneous, creamy or milky, and profuse. On dark-field examination of a droop of the discharge mixed with saline will reveal trichomonas in active forms.
Treatment - Heavy doses of alkalis by mouth, urethral irrigations with soda bicarb gr 60 per pint, a course of mepacrine or atebrine 0.1 gm t.d.s. for 6 to 8 days. Stovarsol jelly may be injected into the urethra for some days. A few injections of mapharside may be given. Trichorad (Ward Blenkinsopp & Co.) 100 mg t.d.s. after food for 10 to 14 days has also given good results.
Urethritis due to Giardia lamblia and E.histolytica has been reported.
Metazoa - Ova and larvae of the helminthes are occasionally found in urethral discharges especially in the tropics. The most common is S.haematobium. Miracil D. (Bayer) 20 mg per kg per day in two divided doses for 6 days is reported to give good results in Schistosomiasis.
Yeast - Monilial infection of the urethra has been shown by means of smears and cultures. Fungoid urethritis is often seen in diabetics. Fungi seldom attack a healthy urethra. In most cases Mycotic urethritis follows urethral trauma either by faulty instrumentation or foreign body introduced. Local treatment with irrigations plus Mycostatin tablets (Squibb) 500,000 units t.d.s. orally for 6 - 10 days may be prescribed.
Virus - Urethritis due to virus infection is a definite clinical entity and is not uncommon. This is often called Welsch urethritis. This is diagnosed when the above-mentioned causes of non-gonococcal urethritis have been carefully ruled out. Its origin is as yet unknown but a virus is considered to be the most probable cause for Cytoplasmic inclusion bodies have been demonstrated within the epithelial cells on microscopic examination of the discharges.
Pleuro-pneumonia-like ‘L’ Organisms - are often found in non-gonococcal discharges and occasionally in association with gonorrhoea. They may be responsible for urethral discharges. They have been found in anal discharges of passive agents or homosexuals who had given Abacterial urethritis to their mates. They occupy an intermediate place between the bacteria and the viruses. The incubation period varies from 5 to 30 days. Symptoms depend on extend of the urethra involved. In the early stage it causes urethritis and severe pain during micturition. In case of posterior urethritis, frequency, urgency and dysuria are marked. Complications like prostatitis, epididymitis and arthritis have been noted. The discharge is thin mucopurulent but not so homogeneous as in the case of gonorrhoea. The discharge contains a number of pus cells, relatively greater number of epithelial cells but no visible micro-organisms. At times, the ‘L’ bodies may be detected. In confirming the diagnosis, it is essential to exclude gonorrhoea, to do dark-field examination to exclude trichomonas or spirochaetes and to exclude other bacteria. Urethroscopy reveals ‘sago-grain’ appearance of the urethral mucosa in the earlier stages and “cobble-stone” appearance in the later stages.
Treatment - Penicillin has no effect on Abacterial urethritis in general. Sulphanilamides are satisfactory. A course of sulphathiozole or sulphadiazine 4 to 5 gm daily for 6 to 7 days is advised. The effect is not dramatic and some watery discharge may persist for a few days. To minimize this discharge daily urethral irrigation with potassium permanganate or oxycyanide of mercury, 1 in 8000 should be carried out as a routine. 10 to 15 minims of sandalwood oil orally relieves pain. Streptomycin gm 2 daily for 4 to 6 days, and fever therapy with T.A.B. vaccine intravenously has been tried with encouraging results. Local treatment such as prostatic massage or urethral dilatation may be required in some cases. All cases should have the same type of surveillance as in the case of gonorrhoea.
Reiter’s Disease 3 - This is a symptomatic triad consisting of polyarthritis, urethritis and conjunctivitis. Occasionally keratosis may be associated. The aetiology and pathology are still unknown. A virus is generally accepted as the cause and Cytoplasmic inclusion bodies have been found in the discharges from the conjunctiva and the urethra. The first sign is a non-gonococcal urethritis which fails to respond or relapses after an initial treatment. At the same time or soon after, there develops conjunctivitis of both eyes.. In a few days or weeks the joints are involved. There are various degrees of severity of this condition. Fever, fleeting and relapsing nature of joint pains, sterile nature of urethral and conjunctival discharges and negative gonococcal complement fixation test are usually constant features of the disease.
Treatment - Penicillin has no effect. Sulphanilamides are usually of little use. Streptomycin and fever therapy are the methods of choice. Excellent results have been reported with the use of hypertherm, but where this facility is not available, artificial fever therapy with intravenous T.A.B. vaccine for 3 to 6 injections is also found to be valuable. Streptomycin two gm per day for 5 to 7 days is suggested. The joint pains may be relieved by applications of Scott’s dressings to the affected joints, which should not be immobilized for the fear of becoming stiff. Passive and active movements should be encouraged from the beginning. In very resistant cases gold salts, e.g. myocrisin starting with 0.01 gm may be tried at weekly intervals. Total of 0.2 gm is suggested. Lately, steroid compounds, prednisone and prednisolone have been used with encouraging results. Generally speaking the prognosis of Abacterial urethritis is less favourable than that in the bacterial urethritis. All patients should be placed under the full surveillance as in the case of gonorrhoea.