by Major M. P. Vora. M.B.B.S., D.V.D. Bombay
(An All-India Monthly Journal of Medicine & Surgery)
Volume No. 13, Number. 4 of July 1963.
Page No. 109 to 111.
Non-gonococcal urethritis is not something new. It has long been known. During the last few years its incidence has shown an increase. Hence it deserves the attention of the medical practitioner.
Non-gonococcal urethritis is not a syndrome or a well- defined disease. A number of pathological conditions of different and frequently obscure origin are grouped under this heading. It means an urethral inflammation independent of the presence of Neiserian gonococci. It is met within both sexes. It is of the utmost importance, however, to eliminate by careful examinations any possibility of lurking or chronic gonococcal infection in every case.
Venereal urethritis is frequently related to sexual contact. Non-gonococcal urethritis may be transmitted by sexual relations. Examples of several males being infected by the same woman are not lacking. Urethritis may be due to various causes such as indirect trauma, direct trauma like faulty instrumentation or passing of urinary stone, chemicals when employed as preventive or curative, constitutional diseases like excretion of abnormal quantities of urates, phosphates and oxalates, infective diseases like typhoid, mumps or influenza, the infection of the upper urinary tract especially tuberculosis, diseases of the genitalia such as balanitis, balano-posthitis, intraurethral condylomata acuminata, chancroid or chancre, herpes, toxic or allergic causes, certain drugs and foods.
Generally speaking, non-gonococcal urethritis has a longer incubation period than that of gonorrhoea (5 to 30 days) and has slower beginning with less discharge which is often muco-epithelial or muco-purulant. It is less distressing than gonorrhoea and local and general complications are less frequently met with. Though symptoms are less severe than gonorrhoea, it has a prolonged course, is often resistant to therapy and relapses are frequent. It has been classified as acute, subacute and chronic, according to stage present or onset.
It may be “bacterial” (with the exception of N. gonococci) or “abacterial” on the basis of the micro-organisms which can be demonstrated by routine microscopic examinations. The micro-organisms found in the urethral discharges differ from patient to patient and also in the same individual. Very seldom can a single organism be isolated or the same organism be constantly present on repeated examination. In general more than one germ can be isolated. The most frequently encountered microorganisms are staphylococci, streptococci, micrococcus catarrhalis, entrococci, bacillus coli, diphtheroids etc. These germs can give rise to urethritis but it is difficult to demonstrate the exact role played by them in a single case.
Prostatitis, epididymitis, Cowperitis, peri-urethritis, stricture urethra, cystitis, pyelitis, and arthritis are some of the common complications met within the males. In females, associated vaginitis, cervicitis, cystitis, and pyelitis are not uncommon. However, early signs and symptoms are usually scanty and often disregarded in women till the upper uro-genital tract is also involved.
Reiter’s Disease is characterised by subacute abacterial urethritis followed by conjunctivitis and involving several joints. In addition, balano-posthitis, keratodermia of the palms and soles and enteritis are occasionally noted. It has a prolonged course and recurrences are not uncommon. Aetiology and pathology of this condition are not completely understood and are still matters of discussion and speculation. (Indian Proctitioner, May1957).
Besides the above mentioned organisms other parasites can be found in urethral discharges. Larvae of nematode, cestoda, some protozoa, amaebae, lamblia, giardia and trichomonas vaginalis. Recently trichomonas vaginalis has assumed a considerable importance, as the agent for non-gonococcal urethritis in sexual partners. It is responsible for 10% to 15% of the patients suffering from urethritis. Mycetes especially candida albicans, monilia and yeast are occasionally found in urethral discharges especially in diabetic patients. They are also associated with other micro-organisms.
A number of cases of non-gonococcal urethritis still defeat our efforts to isolate a causative agent. Consequently these cases have been often considered to be of viral aetiology. Viral urethritis due to the virus of lymphogranuloma venereum, mumps and herpes is occasionally found. Urethritis due to pleuro-pneumonia- like organisms or L-forms is also met with. The urethral discharge shows cytoplasmic inclusion bodies. Hence it is often referred to as inclusion urethritis.
The problem of the post gonococcal or residual urethritis which generally follows the penicillin treatment of a case of gonorrhoea, is not uncommon. There is persistant scanty discharge especially in the morning and some discomfort at micturation. Repeated examinations of smears do not reveal the presence of gonococci. Probably other organisms in addition to gonococci may play a role. It should be remembered that when gonococcal infection lasts for a long time, it generally masks the other factors which being resistant to penicillin, maintain the infection after the gonococci have disappeared. At times the prolonged use of antibiotics may be responsible for urethritis, when they are employed in the treatment of gonorrhoea or some other disease. They may act by destroying useful germs thus favouring the transformation of saprophytes into pathogenic micro-organisms. This type of super-infection during antibiotic therapy was reported by the writer (Indian Journal of Medical Sciences. Vol4, No.2, Feb 1950 pp.5456). Among these saprophytes are candida albicans, germ-negative bacilli, and mixed bacterial flora. Avitaminosis may be induced favouring lowered body defences and increased susceptibility to non-gonococcal urethritis. The role of vitamin A and vitamin B2 is well known in genito-urinary symptomatology.
In spite of recent work, the aetiology and pathogenesis of non-gonococcal urethritis remain still obscure and confounding in many cases. In consequence different drugs have been tried for the treatment with varying results.
Treatment of non-gonococcal urethritis as a rule be based on the basis of the infective agent. Hence it is important that the routine microscopic examination of the urethral discharges, other appropriate investigations and also antibiograms should be done as a guide for the treatment. The wide-spread belief that non-gonococcal urethritis may be due to an infection has been mainly responsible for the use of antibiotics in the treatment of the disease. When one is unable to find an infective agent, antibiotics like tetracycline or especially spiramycine (Rovamycine M&B) are employed for the treatment. Penicillin, though widely used by the general practitioner on account of its action on gonococci, has generally no effect on non-gonococcal urethritis. At present, frequently used are the following broad-spectrum antibiotics: chloramphenicol, tetracycline, oxyteracycline, spiramycine, carbomycine and nitrofurantoin. However, sulphanilamides are fairly effective if used early and in sufficient doses and over an adequate period; hence they deserve preliminary trial before expensive antibiotic therapy is tried. Besides, the importance of local therapy consisting of urethro-vesical irrigations cannot be minimised. It is especially recommended when other means fail. Potassium permanganate I in 8000 and oxycynide of mercury I in 5000 to 8000, if used wisely are very useful in dealing with resistant cases. It is especially recommended when other meansfail. At times a combination of sulpha drugs and broad-spectrum antibiotic or fever therapy intravenous T.A.B. vaccine is helpful. Urethral instillations and bougies have been recommended. Conexine (‘Roquexine’) and silver salt jelly (‘Urosalv’) are locally employed. In some cases, fulguration or diathermy, though an urethroscope, has been employed.
However, this problem needs further investigations and research on account of its high incidence, lack of constant results of the treatment and its social importance.