by Dr. M. P. Vora
The Bombay Hospital Journal
(A Medical Research Centre Publication.)
Volume No. 14, Number. 4 of October 1972.
Page No. 65/231 to 69/235.
The incidence of non- gonococcal urethritis (N.G.U) of venereal origin has been on the increase during the last few years. This is probably due to improved methods of investigations and diagnosis and greater awareness of the subject. The residual non-gonococcal urethritis following the treatment of an acute attack of gonorrhoea is also of frequent occurrence.
This was once considered to be chronic gonorrhoea due to gonococci lurking in the deeper tissues and was subjected to various treatments. Many clinicians rarely thought of mixed primary infection of the urethra, resistance of the organism, personal sensitivity or host factor which could lead to persistence of urethritis or relapse. No doubt, a few clinicians were aware that gonorrhoea was not the only cause of urethral discharge. However, the majority was inclined to label them as chronic gonorrhoea and treat them with poor results.
Primary mixed infection of the urethra of venereal origin is a real entity. When this is treated with penicillin, gonococci disappear from the urethral discharge; however, the discharge continues on account of additional bacterial or virus infection, which is unaffected by penicillin. The incidence of post-gonococcal urethritis (P.G.U) is higher when penicillin used than when sulpha drugs with antifolic agent are given. This may be due to insufficient time to resolve inflammatory changes following the use of penicillin and broader spectrum of activity of sulpha drugs than that of penicillin.
The close association of bacteria other than gonococci, T.vaginalis, monilia, mycoplasma, and Chlamydia with N.G.U. and N.S.U. (non- specific urethritis) their intimate relation with clinical course of the disease, their response to treatment and their re-appearance from the wife or contact- all these facts go to suggest that either bacteria or mycoplasma or Chlamydia play an important role in the etiology of N.G.U. and N.S.U. of venereal origin.
However, it is extremely difficult to fix responsibility on a particular etiologic factor. There are numerous difficulties in actually determining the significance of organisms that are detected in smears and cultures. It is quite possible that they may be saprophytes or pathogenic or that the normally harmless flora is being turned hostile under changed local conditions. Abacterial urethritis accounts for above 80percent and bacterial urethritis for 20percent of cases of non-gonococcal urethritis of venereal origin. From the point of prognosis, the latter condition is comparatively easily amenable to treatment and less likely to relapse than the former one.
RESIDUAL NON-GONOCOCCAL URETHRITIS
This may be due to:
Unavoidable causes -
Uncleared foci in the Paraurethral ducts, Littre’s gland, Cowper’s gland, prostate and the posterior urethra are the commonest cause of persistent urethritis. Primary mixed infection of the urethra leads to P.G.U. The difference in the rate of P.G.U. following the use of sulpha drugs and penicillin has already been referred. One has to think of various possibilities such as an additional etiologic factor, the presence of intra-urethral warts, pre-existing lesions of the upper urinary tract or symptomless prostatitis of non-specific origin. Some of these cases may be due to bacteria other than gonococci, or virus infection. Staphylococci, streptococci, B.coli, and viruses are resistant to penicillin therapy. It is, therefore, very important to examine the case carefully, when the urethral discharge persists in spite of normal therapy. When the urine contains pus cells and the whole urethra is perfectly normal in appearance and texture, one has to think of and explore the possibility of a lesion of the upper urinary tract. Urinary calculus, tuberculosis, growth, disease of the bladder or kidney or focal infection etc. have to be considered. At times, stricture of the urethra undetectable by the passage of a bougie but seen by the urethroscope, should not be easily dismissed.
Among the avoidable causes for the persistence of urethral discharge may be one of the following. Fault in taking medicine such as inadequate or irregular medication, improper sterilization of instruments or urinary meatus, early instrumentation of the urethra and early employment of tests and cure can be given. Utmost care must be taken to guard against introducing infection into the urethra.
(a) A course of tetracycline 500mg. B.D. for 7 days.
(b) Local measures such as urethrovesical irrigations with oxycyanide of mercury 1 in 5,000 at 110° F.
PRIMARY BACTERIAL URETHRITIS OF VENEREAL ORIGIN
This may occur with or without previous history of gonorrhoea. It may be due to one or more organisms. Common of organisms are, Staphylococcus albus or aureus, Streptococcus haemolyticus or faecalis, Bacillus proteus or coli, H.influenza, pneumococci, diphtheroids, cornybacterium vaginalis, bacteria of Neisserian group other than gonococcus such as N. catarrhalis, N. pharyngitis sicca, N. Pharyngitis flava, etc can be responsible for urethritis. Incubation period varies from 4 to 10days.
Signs and symptoms:
There is burning and smarting pain in urethra, specially while passing urine. There is inflamed meatus and turbid urine. Urethroscopy may reveal soft infiltrations and sclerotic spots- crescentic or annular- on the roof and lateral walls of urethra. Complications are usually the same as in a case of gonorrhoea.
Diagnosis depends on the exclusion of gonorrhoea and confirming the possible etiology by examination of smears and cultures of urethral discharge. Blood V.D.R.L. should not be omitted at the beginning and at the end. The prognosis of these cases is much more favourable than that of bacterial urethritis.
It would depend on etiology and sensitivity of the organism. It is usually based on the same pattern as in the case of P.G.U.
This may be either inflammatory or non inflammatory. It results from faulty treatment, excessive local therapy, strong or hot solutions for irrigations, instrumentation of the urethra etc., and leading to damage of the mucous membrane. The urethral discharge is milky in colour and contains large number of epithelial cells, monocytes, and a few pus-cells. A secondary infection may be super-added. Infection with Trichomonas vaginalis, viruses, bacterial or fungi is not uncommon. Urine contains epithelial cells and threads in varying sizes and light in weight. Urethral mucosa may show leucoplekic spots or infiltrations of the bulbous part. There is usually no pain or smarting while passing urine.
Suspend instrumentation of urethra. Oil santali flavum m xv t.d.s. is given by mouth. In some cases, normal saline can be used for irrigation. If there is secondary infection, appropriate remedy has to be used to control the infection.
Urethritis due to the virus of inclusion conjunctivitis and PPLO, organism is common affection of the male urethra and the cervix in the female. It may be acquired venereally or through contamination. Swimming pools may be a source. The virus of Chlamydozoon occulo-genitalis of L.V. may be at times responsible. Elementary bodies and inclusion bodies are detected in Geimsa stained smear specimens of urethral discharge. Complications involving the prostate, Bartholin’s gland and the cervix may be met with.
Broad spectrum antibiotics such as methacyclin (Rondomycin), Erythromycin or tetracycline HCL 500mg. b.d. for 7 to 10 days orally may be prescribed. Urethrovecicle irrigation with oxycyanide of mercury 1 in 5000 work well. If the posterior urethra is involved, weekly urethral dilatations and prostatic massage may have to be instituted for 8 to 10 weeks.
ABACTERIAL URETHRITS OF VENEREAL ORIGIN (N.S.U.)
It may be primary acute or primary sub-acute type. The incubation period is fairly long and relapses are common. In the acute variety, there is severe pain and smarting during micturition. Smears of the mucopurulent urethral discharge show a large number of pus-cells but no organism. Complications such as posterior urethritis, prostatitis, epididymitis, arthritis, iritis etc are common.
In the primary sub acute abacterial urethritis, the incubation period may be as long as 30 to 50 days. Signs and symptoms are generally mild. There is usually mucopurulent discharge which contains pus cells and epithelial cells but no organisms on repeated examinations. Culture may show a growth of ‘L’ organism. Urethroscopy reveals characteristic mucosal picture. There are “sago” granules, wedge-shaped excre-scences, lying superficial to the mucous membrane without the involvement of the subepithelial connective tissue. In short, trachoma-like picture is common. The course of disease is intractable and recurrence is common. Complications such as stricture urethra, arthritis, iritis, conjunctivitis, prostatitis, epidymitis are known to occur.
Virus infection due to ‘L’ organism, ‘TRIC’ agent, ‘T’ strain mycoplasma or Chalamydia.
Sulpha drugs and penicillin are of no use in this condition. Urethral burning can be relived by giving oil of sandalwood minimum 15 in a capsule three times a day. Broad spectrum antibiotics such as spiramycin (Rovamycin) or tetracycline HCL 500mg may be prescribed for 7 to 10 days. Urethrovesical irrigations with oxycyanide of mercury 1 in 5000 daily, dilatation and prostatic massage once a week for 8 weeks, and fever therapy with T.A.B. vaccine intravenously are likely to be successful.
It is a clinical symptom of abacterial urethritis of venereal origin and consists of conjunctivitis, poly-arthritis, balanitis, and keratodermi with blood borne complications. An identical syndrome associated with dysentery and having the primary focus of infection in the bowel is met with. Syndrome may be complete or partial and is often associated with pyrexia. The disease is uncommon in females. It usually follows an attack of gonorrhoea. Incubation period is from 10 to 30 days.
Signs and symptoms:
With an acute attack, there is profuse urethral discharge, clear and tenacious in character, redness of the meatus, conjunctivitis, shifting arthritis, pyuria or even haematuria and fever. In the course of the disease painful heel due to periosteitis of os calcis, ankylosing spondylitis, chronic arthritis of the sacroiliac joint and attacks of uveitis are noted. Urethroscopy reveals a typical “cobble stone” or trachoma-like picture. Wedge-shaped lesions lie superficial to the mucosa of the anterior urethra. There is no involvement of the sub-epithelial connective tissue.
It is considered that the syndrome is due to infection with a virus, P.P.L. organism or inclusion bodies and has venereal origin through normal or abnormal sexual activity like fellatio, cunnilingus or sodomy.
Irrigations, sulpha drugs, streptomycin, spiramycin, etc have been used with good results. T.A.B. vaccine or milk injections are also used.
The Stevans-Johnson-Syndrome, Bechcet’s syndrome, typhoid, rheumatism, bacillary dysentery and gonococcal arthritis.
URETHRITIS DUE TO LOCAL CAUSES OR DISEASES
Intraurethral warts, meatal ulceration, inflammation of ducts of paraurethral glands, intra-urethral chancre, herpes, chancroid primary lesion of lymphogranuloma venereum, balanitis, graneloma inguinale endourethral lesions etc.
Presence of venereal warts especially in association with N.G.U. should always arouse strong suspicion of intraurethral warts and demand a careful examination of the urethral meatus and the anterior urethra.
Treatment will depend on the cause.
It may be primary or secondary, spreading from the kidney or the prostate. It is usually the posterior urethra which is first involved and shows infiltrations on the floor, seen as pearly white bodies. These lesions pass through three stages i.e. granulation, ulceration, and casciation. The anterior urethra is last to get affected. Primary tuberculosis of the glands penis and the meatus is common in children.
Fistulae, stricture, abscess.
Signs and symptoms:
Pain and frequency of micturition of several months’ duration may be the only complaint. Urethral discharge is muco-purulent or haemorrhagic. Periurethral induration may be palpable in some cases.
Diagnosis rests on finding tubercle bacilli in the urine and the urethral discharge. Tubercular nodules or lesions may be present in other organs in the vicinity. In all cases of apparently abacterial urethritis, one must examine the urine at least three times before one could rule out this possibility.
DIVERTICULA OF THE URETHRA
Diverticula or pouches in the urethral wall are likely to mislead one to a wrong diagnosis of urethral stricture. This condition often causes persistence of urethritis in spite of treatment. There is no difficulty in the flow of urine. Only urethroscopic examination can reveal its existence.
URETHRITIS AS THE RESULT OF DESCENDING INFECTION
Infection of the kidney, bladder or prostate is likely to give rise to persistent urethritis and urethral discharge.
URETHRITIS DUE TO INGESTION OF CERTAIN FOODS OR DRUGS
Asparagus, strawberries, beetroot, pepper, radish, cocoa and drugs like iodides, phenolphthallin is known to cause urethral discharge.
MYCOTIC OR FUNGAL URETHRITIS
Cases have been recorded of mycotic urethritis of venereal origin with a complication, posterior urethritis in which glossy white fungoid patches were detected. Mycotic urethritis is on the increase. Free use of antibiotics, contraceptive pills, pregnancy and nutritional disturbances may be responsible for this. Common fungi are Candida albicans yeast and rhinosporodia. Microscopic examination shows spores and mycelia. Culture on Stuart’s Sabouraundi’s and Feinberg-Whittington media will be conclusive.
Mycostatin 500,000 units (one tablet) three times a day orally. This provides specific therapy and helps to restore normal conditions. Besides, urethral instillations of mycostatin 1000 units per ml or 12.5 to 25mg amphotericin in 5 ml aqua sterile and 2.5 ml of 5% dextrose solution are recommended. The urethral opening should be sealed for 15 minutes following installations.
CONDITIONS STIMULATING NON-GONOCOCCAL URETHRITIS
Preputial discharge due to various causes, balanitis urinary deposits of phosphates, oxalates, urates, and uric acid crystals may stimulate urethritis.
Urethrorrhoea- A prolonged sexual excitement leads to increased secretion of urethral glands. The discharge is clear, viscid and contains mostly epithelial cells and a few leucocytes. Urine is clear. It often precedes actual ejaculation of semen.
Prostatorrhoea- An escape of prostatic fluid at the time of straining for stool and at the end of urination. The discharge is milky and contains no pus cells.
Pollutions- or wet dreams- involuntary discharge of the seminal fluid during early morning when the bladder or rectum is full.
Spermatorrhoea- Discharge of seminal fluid without any desire or erection. It is not a common condition. The discharge contains sperms, pseudo-threads, sago bodies, amorphous debris- all of which disappears on addition of acetic acid. The incidence of these conditions is very much higher than is generally supposed. In all these cases, bacteriological examination must be made before the diagnosis.
It will be seen that the problem of non-gonococcal urethritis is difficult and complicated. Any attempt to treat the condition by “trial and error” is not only doomed to failure but also results in waste of time and money and adds to the sufferings. Every patient needs a careful examination laboratory investigations and a thorough study. Drugs must be carefully selected and administered in adequate dosage over a sufficient period. In some cases, local therapeutic measures such as urethral irrigations, dilatations and prostatic massage have to be employed in addition to chemotherapy.