See

discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/298141173

Urethral discharge

Article · April 2007

CITATIONS READS

0 200

2 authors:

Nand Lal Sharma Vikram Mahajan

Dr Rajendra Prasad Government Medical C… 186 PUBLICATIONS 1,554 CITATIONS
334 PUBLICATIONS 1,357 CITATIONS
SEE PROFILE

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

It is not from any project View project

All content following this page was uploaded by Vikram Mahajan on 17 March 2016.

The user has requested enhancement of the downloaded file.

III JIMSA April - August 2007 Vol. 20 0.2

URETHRAL DISCHARGE
N.L. Sharma, V.K. Mahajan
Department of Dermatology Indira Gandhi Medical College Shimla-l Zl Oill FlP, india

Abstract: Urethral discharge is a common sexually transmitted infection among patients of 20-24 years of age and comprises
about 15-20% of patients attending STD clinics in India. It results from urethritis and can be due to Neisseria gonorrhoeae
(gonococcal urethritis), Chlamydia trachomatis or non-chlamydial infections (non-gonococcal urethritis). Associated symptoms
include dysuria, increased urinary frequency and meatal pruritis or redness. In gonococcal urethritis profuse purulent
urethral discharge is usually associated with severe symptoms. As the infection resolves the discharge becomes scanty and
mucopurulent or mucoid. Complications of posterior urethritis, seminal vasculitis, prostatitis, epididymitis, urethral strictures
or sterility can occur in untreated patients. Symptoms of chlamydial urethritis are less severe and mucoid or mucopurulent
urethral discharge is usually scanty. Epididymitis or Reiter's disease may occur as its complications. Non-chlamydial urethritis
is often chronic and may be due to Ureaplasma urealyticum or Mycoplasma genitalium.
Diagnosis of urethral discharge is mainly clinical. Demonstration of intracellular diplococci (N. gonorrheae) in Gram-
stained smears of exudates will be diagnostic for gonococcal urethritis while presence of >5 pus cells/oil immersion field or
>10 pus cells/high field in smears from first voided urine indicate non-gonococcal urethritis. Diagnosis by culture of causative
organisms or molecular techniques is more specific hut has the' disadvantage of limited availability. NACO recommends
syndromic approach for diagnosis and treatment in general practice. The drugs used for outdoor/uncomplicated cases are
cefixime, azithromycin or ceftriaxone in gonococcal urethritis and azithromycin, doxycyclin or erythromycin in non-gonococcal
urethritis. Patient education regarding safe sexual practices, early diagnosis and treatment, and partner management are
important preventive measures. .

that globally there are about 62 million new cases of gonorrhea

INTRODUCTION
and 27 million of them occur in South and Southeast Asia alone.
Urethral discharge is one of the common symptoms of sexually Similarly, there are 92 million new cases of chlamydial infections
transmitted diseases. It results from urethritis or inflammation of globally, and South and Southeast Asia accounts for 43 million of
urethra and may be purulent, mucoid or mucopurulent depending them.
upon the cause. It constitutes 15-20 % of patients attending STO
clinics in India', Traditionally it is classified into two broad types:-
CLINICAL SPECTRUM
(I) Gonococcal Urethritis (GU) - due to Neisseria gonorrhoeae;(2) Urethral discharge is often associated with symptoms like:
on-Gonococcal urethritis (NGU) (a.) Burning on passing urine (dysuria); (b.)increased frequency
The non-gonococcal urthritis is further divided into: particularly at night or (c.) meatal pruritis and redness
(a) chlamydialurethritis and (b) non-chlamydial non-gonococcal Gonococcal Urethritis: It takes 2-5 days from infection to
urethritis (NCNGU). appearance of symptoms. Symptoms of urethritis and purulent
discharge peak within two weeks without treatment. Urethral
ETIOLOGY OF NGU (Table 1)
discharge occurs in 95% of rnerr' which is purulent in 75 %, white
TabLe/: The etiological agents" of NGU or cloudy in 10 % and clear in 5 %. When infection begins to
resolve, the character of discharge changes from purulent to.
ChlamydlC/ trachomatls 1540%
mucopurulent and then to mucoid. Without treatment the infection
Ureaplasma urealyticum 10-40%
can ascend upwards and continue for many months. This may
Trichomonas vaginalis 5-15% then produce posterior urethritis, seminal vesiculitis, prostatitis or
Herpes Simplex Virus Unknown epididymitis. Urethral strictures and infertility may occur as IOJig
Candida albicans <5% term sequalae. In less than I % cases, the infection may also
Mycoplasma genitalium .15-25% become blood borne (disseminated gonococcal infection) and may
Other bacteria <5% result in gonococcal arthritis or septicemia ..
ChlamydiaI Urethritis: Genitourinary infection is caused by O-K
Non-infectious causes ?
serovars of Chyamydia trachomatis. A substantial number of these
Unknown 20-30%
patients are asymptomatic. Incubation period varies from 7 to 14
EPIDIMIOLOGY days. Symptoms include discharge and dysuria. On examination
GU is more common than NGU in developing countries, while it is mucoid or mucopurulent urethral discharge is usual. It can. produce
vice versa in the developed world. In U.S college campuses, more ascending infection producing epididymitis' (<3 %) or may result
in Reiter's syndrome (1-2%). Chlamydial urethritis may occur in
than 85% of urethritis is nongonococcal. However, the peak age
women having. chlamydial cervicitis. Although mostly
for both NGU and GU is similar i.e. 20-24 years. WHO estimated3
asymptomatic, but may produce dysuria-pyuria syndrome
Correspondence: Prof. N.L. Sharm~ mimicking cystitis manifesting clinically as dysuria and
e-maiL: [email protected] frequency.
JIMSA April - August 2007 Vol. 20 No.2
III
Chronic Non-CWamydial NGU : It is chronic urethritis', not related • Gonococcal culture from urethral exudate has additional
to gonococcal or chlamydial infection. Probably these cases are advantage of antimicrobial sensitivity testing.
caused by other pathogens like Ureaplasma urealyticum or • For DNA probe hybridisation and other non-urine based tests,
Mycoplasma genitalium. In majority of these cases the cause is urethral swab must be inserted 2-3 cm for optimal results.
not established. Ureaplasma urealyticum has been implicated as • For urine based nucleic acid amplification tests first I()'15 ml of
a cause for the first episode of acute NCNGU. urine should be collected.
Table 2 shows important clinical differences of GU and NGU • Tests for mycoplasma and ureaplasma are not currently FDA-
~IFeature NGU
approved and their usefulness is unproven.
GU
• Routine tests for trichomonas, herpes or other bacterial
Incubation period 7·)4 days 2·8 days
etiologies are not recommended in the initial evaluation of
Onset Gradual Abrupt urethritis.
Dysuria Mild Severe
SYNDROMIC MANAGEMENT FOR
Asymptomatic >10% <3%
URETIIRALDISCHARGE
Type of discharge Mucoid Purulent
In the syndromic approach, the symptoms are recognized and
Quantity of discharge Less/scanty More/profuse evaluated using flow chart devised by WHO. Treatment is then
given for all the etiological agents of that symptom.
DIAGNOSIS OF URETHRAL DISCHARGE Row chart for urethral discharge:
Patient complains of urethral
FOr optimal results, examination of first voided urine is ideal. discharge I painful urination

Altematively, waiting for 3 hours after last voided urine and milking
of urethra may increase the yield of discharge. Samples for smears! Examine - Discharge confirmed ].
cultures are taken from the discharge.
Gram stained smears :- These show gram negative intra cellular
Treat for gonorrhoea and
diplococci in GU. In case of NGU, plenty of polymorphonuclear chlamydia

leucocytes are seen, and diplococci are absent. Presence of >5

WBCsloil immersion field in urethral smears and > I0 WBCslhigh Educate. counsel and promote
condom
power field, in smears from first voided urine indicates diagnosis of
urethritis". NACO RECOMMENDED TREATMENT
Culture:- It is the most specific investigation; direct plating on
In syndromic approach both GU and NGU are treated
selective media is preferable but if it is not possible; Stuart's simultaneously.
transport medium may be used. Gonorrhoea Uncomplicated gonococcal infection: (i) Cefixine
Table 3 shows sensitivities' of smear/culture: 400mg orally as a single dose, or (ii) Azithromycin 2 g orally as
Site Gram stain Gram stain Culture sensitivity
a single dose, or Ceftriaxone 250 mg 1M as single injection
Complicated and disseminated infection(If infection goes beyond
sensitivity % specificity % %
anterior urethra): Ceftriaxone 1 gm 1M or IV once daily for 7
Urethra of 95 95 96·)00 days Cefixime 400gm twice daily orally for 7 days or Non-
symptomatic males
Gonococcal injection. Azithromycin 1 gm orally in a single dose,
or Doxycycline 100 mg orally twice daily for 7 days, or
Urethra of 60 95 96·)00
Erythromycin base/stearate 500mg 4 times a day for 7 days
asymptomatic males Regimen in Pregnancy
Erythromycin basel stearate 500mg orally 4 times a day for 7
Leucocyte esterase test: It is less sensitive than microscopy of days N.B: For ureaplasma infection, Spectinomycin and
first voided urine sediment but easier to perform. Streptomycin are effective.
Non culture tests:- Rely on detection of bacterial products in Prevention:- Early diagnosis, prompt treatment, and partner
patients' samples, this may be either: (I.) Non amplified tests: a) management are the most important aspects. As the patient at this
Antigen detection methods (Enzyme Immunoassay, Direct time is most receptive, counseling, for avoidance of promiscuity,
Flourescent antibody test) b) Nucleic acid hybridization, or sticking to one partner, use of condom and completing the treatment
(2.) Amplified tests: Nucleic acid amplification tests (PCR, should be emphasized. .
Transcription mediated amplification, Strand displacement
RECOMMENDED READING
amplification) are highly specific, but technically demanding.
I. Kanwar A J. Clinical Approach 10 Vaginal/Urethral discharge. In:. Sexually Trans-
Serology: Rarely of value mined Diseases and AIDS. Edited by Sharma VK, Viva Books Private Lid, New Delhi,
2003, I' .468 .
Rapid tests: Not adequately evaluated; have low sensitivity. 2. Core Training Programs: STD clinical Trainings: Urethritis, NNPTC, CDC
Website http://depts.washinglOll.eduln'llptclindex,html. Editor Baur HM, 2005
• Confirmatory tests for chlamydia trachomatis and gonococci, 3. Global Prevalence and Incidence of selected curable Sexually Transmitted Infec-
performed at the time of empirical treatment are important to tions - Overview and Estimates, WHO Publication 2001, pp 10-/5.
4. Hackett G, Penile discharge. www.netdoctor.co.uk/. 2005
identify a specific etiology which may improve compliance 5. Majumdar S, Saha Cc. Chlamydia infections and non-gonococcal urethritis ill Sexu-
ally Transmitted Diseases and AIDS. Edited by Sharma VK, Viva Books Private Ltd,
and facilitate partner management. New Delhi. 2003, PI' 232·246.

View publication stats