1. URETHRITIS
DR JHABAR SINGH
CHAUDHARY

2. Urethritis - inflammation of urethra
which is multifactorial condition and
characterised by dysuria with/without
urethral discharge or may be asymptomatic.
Types- 1.Gonococcal urethritis-pathogen
is gonococci 2. Non gonococcal
urethritis –identified pathogen otherthan
gonococci
3.Non specific urethritis-unidentified
pathogen.

3. Causes of Urethritis
• Neisseria gonorrhoeae
• Chlamydia trachomatis
.Mycoplasma genitalium
• Trichomonas vaginalis
others
ureaplasma urealyticum
N. Meningitidis
Candida albicans.

4. • Herpes simplex viruses
• Adenovirus
• Haemophilus spp.
• Bacteroides ureolyticus
• Exposure to bac. Vaginosis
• Reactive arthritis/Reiter’s syndrome
• Urethral stricture
• Catheterization
• SJS
• Chemicals
• Tumors & condom allergy.

5. Gonorrhea

6. Gonorrhea
I. Epidemiology
II. Pathogenesis
III. Clinical manifestations
IV. Diagnosis
V. Patient management

7. Epidemiology
• Gonos(seed)+rhoea(flow) mean abnormal flow
of semen.
• Only Natural reservoir-human
• Infection almost always contracted during sexual
activity
• All age groups are susceptible(age 15-35yrs are
more susceptible)

8. Risk Factors
• Multiple or new sex partners .
• Urban residence in areas with disease prevalence
• Adolescents, females particularly
• Lower socio-economic status
• Exchange of sex for drugs or money
• African Americans

9. Transmission
• Transmitted by:
– Male to female via semen
– Female to male urethra
– Rectal intercourse
– Fellatio (pharyngeal infection)
– Perinatal transmission (infected mother to infant)
• Gonorrhea is associated with increased
transmission and susceptibility to HIV infection

10. Etiopathogenesis
• G-ve reniform(kidney bean shaped)
diplococci,0.6-0.8um
• 2-10% CO2, 7.2-7.6 Ph, 35-37°C temp.
• Surface hairlike pili & lipo-
oligosaccharide(LOS) acts as virulent factor
• 1. Adherence – Pili & Opa for initial
adhesion in additive fashion(increasing
force & freq. of adhesion of other
gonococci).

11. • 2. Invasion- after adhesion organism
enfolded by pseudopods and endocytosed by
epi. Cells transported to base of cell by
exocytosis - divide and multiply
• 3. Tissue damage -Epithelial cell damage is
mediated by release of
enzymes(phospholipase,peptidase)& TNF
( production is stimulated by LOS &
peptidoglycan).
• Neutrophilic response l/t microabscess
formation followed by exudation of purulent

12. CLINICAL FEATURES
Male
• Symptoms
– Typically purulent or mucopurulent urethral
discharge
– Often accompanied by dysuria
– Discharge may be clear or cloudy
• Asymptomatic in 10% of cases
• Incubation period: usually 1-14 days for
symptomatic disease, but may be longer

13. Complications
LOCAL:-epididymitis,seminal vesiculitis,
proctitis,anorectal(passive rectal intercourse) &
pharyngeal colonisation(fellatio),
para frenal(tysons glands), paraurethral
glands(Littre’s gland), cowper’s
glands(bulbourethral gland),
periurethral abscess(watercan perineum)
SYSTEMIC:-disseminated gonococcal
infection,perihepatitis,endocarditis,meningitis,art

14. CLINICAL FEATURE -
Female
• 50% minimally affected/asymptomatic
• Endo cervix-m.c. site of infection
• urethritis-mucopurulent dis.,vaginal
pruritus&dysuria.

15. Cervicitis
• Non-specific symptoms: abnormal vaginal
discharge, intermenstrual bleeding, dysuria,
lower abdominal pain, or dyspareunia
• Clinical findings: mucopurulent or purulent
cervical discharge, easily induced cervical
bleeding
• 50% of women with clinical cervicitis have no
symptoms

16. Complication in female
• Accessory gland infection
– Bartholin’s glands
– Skene’s glands(paraurethral gland)
• Pelvic Inflammatory Disease (PID)
– May be asymptomatic
– May present with lower abdominal pain, discharge,
dyspareunia, irregular menstrual bleeding and fever
• Fitz-Hugh-Curtis Syndrome(perihepatitis)
• Acute vulvovaginitis-in prepubescent female
• Ophthalmia neonatorum in newborn-acute purulent conjuctivitis
appears 2-5 days after infection from infected mother.

17. DIAGNOSIS
.Clinical diagnosis-thick,creamy,sticky discharge is
diagnostic.
.Definitive diagnosis by Gram stain or culture.
.Direct microscopy of Gram stained smear –sens.
80-95%,sp 95-99%.
• Culture(Modified Thayer Martin media) -gold
std test –senstivity-80-95%.
• Non culture tech.- NAAT-sens. 92-96%, sp. 94-
99%.

18. Gram’s stain
• Smear - air dry - heat and fix - crystal
violet solution for 1 mint and rinse - Gram’s
iodine for 1 mint and rinse - decolorised with
acetone for 10-20 sec. and rinse - counterstan
with safranin for 1 mint and rinse & examine
under oil immersion 100x lens.
. .

19. Gonorrhea Gram Stain
PMNL with G-ve kidney shaped
extra/intracellular diplococci

20. Gonorrhea Treatment
Uncomlicated infection of cervix, urethra&
rectum-
Ceftriaxone 125 mg IM single dose OR
Cefixime 400 mg PO single dose OR
Ciprofloxacin 500 mg PO single dose OR
Ofloxacin 400 mg PO single dose OR
Levofloxacin 250 mg PO single dose

21. Uncomplicated infection
Pharynx
Ceftriaxone 125 mg IM single dose OR
Ciprofloxacin 500 mg PO single dose
Gonococcal conjunctivitis(adult)
Ceftriaxone 1 g i/m single dose
Saline lavage once.

22. Gonnorrhea - Special Considerations
• Allergy, intolerance or adverse reaction
– Use Spectinomycin 2g i/m stat
Pregnancy
– No quinolones
• Management of sex partner
• All sex partners in last 60 days should be treated
for both gonorrhea & chlamydia.

23. Prophylaxis & t/t of Gonorrhea in
Infants
• Ceftriaxone 25-50 mg/kg IV or IM single dose,
not to exceed 125 mg.
• Topical antibiotics alone is inadequate &
unnecessary with systemic therapy.

24. • Disseminated gonococcal infection
• Recommended regimen:
• Ceftriaxone, 1 g im or iv q24h
• Alternative regimens: • Cefotaxime, 1 g iv
q8h or
• Ceftizoxime, 1 g iv q8h or
• Ciprofloxacin, 400 mg iv q12h[*] or
• Ofloxacin, 400 mg iv q12h[*] or
• Levofloxacin, 250 mg iv qd[*] or
• Spectinomycin, 2 g im q12h

25. • Contd..
• Preceding regimen should be contd for 24-48
hrs after improvement begins ,following
regimen to complete for 1 week therapy.
• Cefixime, 400 mg po bd or
Ciprofloxacin, 500 mg po bd or
• Ofloxacin, 400 mg po bd or
• Levoflox 400 mg po od daily.
• Gonococcal meningitis/endocarditis
• Ceftriaxone 1-2g i/v 12 hrly -10-14 days/4 wk

26. Chlamydia trachomatis

27. • Serovars D-K a/w genital infection/urethritis
• Gram –ve obligate bacterium(energy requiring
parasite),have CW,CM,DNA&RNA.
• LIFE CYCLE-unique biphasic
• Metabolically inert infectious EB has rigid cell
wall attacks col. Epi. Cells.
• After entering host cell EB becomes RB which
is metabolically active.
• RB divide by binary fission until an intracellular
inclusion is formed .
• EB released from this inclusion after host cell
lysis.

28. Chlamydia Life Cycle(48-72hr)

29. Clinical features
In women-symptomatic 30%
Endocervix is m.c site
Some women develope
urethritis –odourless,
mucoid dis.
Pruritus +/-
Dysuria without freq./
Urgency.

30. • In men-symptomatic 75%
• Mucoid/mucopurulent dis.
• May complicate as epididym
• -itis ,prostitis,vas deferentitis,
Proctitis.
.

31. Laboratory Tests for Chlamydia
• Gram stain –PMNL >5/hpf with no
demonstrable organism.
• Tissue culture–on Mc Coy cells.
– Specificity approaching 100%
– Sensitivity ranges from 60% to 90%
– Role in medicolegal cases.
– Non-amplified tests
• Nucleic Acid Hybridization (NA Probe), e.g. Gen-Probe
Pace-2
– sensitivities ranging from 75% to 100%; specificities greater than
95%
– detects chlamydial ribosomal RNA
– able to detect gonorrhea and chlamydia from one swab .
• Enzyme Immunoassay (EIA), e.g. Chlamydiazyme
– sensitivity and specificity of 85% and 97% respectively .

32. Contd….
• DNA amplification assays (NAAT)
– polymerase chain reaction (PCR)
– ligase chain reaction (LCR)
– Cofirmatory test.
• Sensitivities with PCR and LCR 95% and 85-98%
respectively; specificity approaches 100%
• LCR ability to detect chlamydia in first void urine
• DFA Test –sensitivity 75-85%,sp 98-99%.

33. Chlamydia Treatment
• Recommended:
– Azithromycin 1 g PO single dose( toc)(preg) OR
– Doxycycline 100 mg PO BID x 7 days
• Alternative:
– Erythromyin base 500 mg PO QID x 7 days( preg)
– Ofloxacin 300 mg PO BID x 7 days OR
– Levofloxacin 500 mg PO QD x 7 days OR
– Amoxycillin 500 mg PO TDS x 7 days.( preg)

34. Chlamydia Treatment in Infants
• Neonatal ocular prophylaxis does not prevent
perinatal transmission of chlamydia
• Erythromycin base 50 mg/kg/d PO divided into
4 doses daily for 14 days.

35. Mycoplasma genitalium
• Atleast 13 spp are common commensals of
human urogenital tract
• Transmitted efficiently by sexual contact
• T/t - Azithro 1gm PO stat (DOC).

36. TRICHOMONAS VAGINALIS
• Common cause of STD in women
• 20% of men with NGU are infected with T .
vaginalis
• Coinfection with gonococci is common.
• Important cause of persistent/recurrent
urethritis
• PCR Assay is more sensitive than culture.

37. Trichomoniasis Treatment
• Recommended:
– Metronidazole 2 g po single dose OR
– Tinidazole 2 g po single dose
• Alternative:
– Metronidazole 500 mg po BID x 7 days
• Advise to abstain from alcohol during and up to
24 hours after completion of metronidazole and
72 hours after completion of tinidazole.

38. Trichomoniasis Treatment - Special
Considerations
• Allergy, intolerance or adverse reaction
– Metronidazole desensitization(start with .04mg PO
doubling dose every 15 min upto 250mg).
• Pregnancy
– Counsel on risk & benefits of treatment
– Metronidazole 2 gm single dose (Category B)
– Abstain from breastfeeding for 24 hours after last
dose

39. Trichomoniasis Treatment - Special
Considerations

40. Thank you