Inflammations of the urethra

Inflammatory conditions of the urethra include:

   meatal ulcer;

   urethritis:

    gonoccoccal urethritis;

    nonspecific urethritis;

    Reiter’s syndrome.

Ulceration of the urethral meatus

Meatal ulcer is quite common in circumcised boys. It may occur soon after the operation or may be delayed for up to 2 years from circumcision. Lack of protection by the prepuce seems to be the excitatory cause with friction from clothing and ammoniacal dermatitis as contributory factors. The ulcer forms a scab which blocks the meatus and the child can only pass urine by bursting the scab. This hurts so the boy screams and a tiny amount of blood may be passed as well. The process causes fibrosis which can result in an acquired pinhole meatus.

Treatment

Local measures to soften the scab and alkalinise the urine are often curative. A few need meatotomy.

Gonorrhoeal urethritis

Gonorrhoea is a sexually transmitted disease caused by Neisseria gonorrhoeae (gonococcus), a Gram-negative kidney-shaped diplococcus that infects the anterior urethra in the male, the urethra and cervix in females, and the oropharynx, rectum and anal canal in both sexes, but especially men

Gonorrhoea in men usually declares itself by urethral discomfort and urethral discharge up to 10 days after exposure. There is often scalding dysuria. In some there may be no symptoms other than slight discharge.

Investigations. Pus and gonococci are present in the Gram-stained urethral smear. The passage of pus in the first part of the urinary stream can be demonstrated as haziness in the first glass of a two-glass test. Treatment should not wait upon the results of urethral culture when the clinical picture and urethral smear are typical.

Complications are uncommon in the UK and are all prevented by effective treatment. Local complications include posterior urethritis, prostatitis — acute or chronic, acute epididymo-orchitis, periurethral abscess and urethral stricture. Gonococcal arthritis, iridocyclitis, septicaemia and endocarditis are even more unusual.

Treatment is by antibiotics, usually penicillin. The effective concentra­tion may be increased by probenecid and high doses may be needed for resistant strains. Completely resistant beta lactamase-producing strains, rare in the UK, will not respond to penicillin whatever the dose. Patients with these organisms and those allergic to penicillin must be treated with second-line drugs such as kanamycin.

Contact tracing is important in controlling the spread of the disease.

Gonorrhoea in women affects primarily the urethra and cervix, and is often symptomless. It can never be diagnosed on clinical grounds alone. Almost three-quarters of all female cases attend initially as a result of contact tracing. Symptoms which are present in 50 per cent or less often consist of a mild dysuria or slight urethral discharge which can go unnoticed by the patient. If Skene’s tubules are emptied by milking the urethra against the posterior pubic ramus, a bead of pus may appear at the urethral meatus. There may be some reddening or erosion of the cervix with a mucopurulent cervical plug but copious vaginal discharge is more likely to be due to concomitant trichomonal vaginitis.

Complications. Gonococcal proctitis occurs in at least 60—70 per cent of cases and is usually symptomless. Ten per cent suffer from salpingitis which, if bilateral, may lead to infertility.

Gonorrhoea in the newborn is now rare. It used to be an important cause of blindness.

Nonspecific urethritis (syn. nongonococcal urethritis)

This is a form of urethritis which is diagnosed by exclusion when gonorrhoea and other known infections have been excluded. At present some 40 per cent of cases are due to Chlamydia trachomatis and some are shown to be caused by Urea plasma urealytica. The causative agent in up to 50 per cent is unknown.

Clinical features. Dysuria and a mucopurulent urethral discharge appear up to 6 weeks after sexual intercourse. The urine is usually grossly clear but may contain ‘threads’ or pus cells. Epididymitis is not uncommon and urethral stricture rarely results. In women the condition presents as a form of urethrotrigonitis and may be very resistant to diagnosis.

Treatment with oxytetracycline or doxycycline is usually effective, although relapse is common especially in men in whom the prostate may act as a reservoir of infection. It is important to treat both partners as re­infection is probable if this is not done.

Reiter’s disease

Reiter’s disease (syn. sexually acquired reactive arthritis) is usually Sexually transmitted in the UK but abroad it is more commonly dysenteric in origin. Subacute urethritis 4—6 weeks after contact is associated with a clear, viscid discharge which is free from organisms.

A few days later, conjunctivitis, unilateral then bilateral, occurs in 50 per cent. In more severe cases there is anterior uveitis. Usually in 10 days to 2 weeks arthritis supervenes but it is not an invariable feature of the condition. Another concurrent manifestation is keratoderma blennorrhagicum, consisting of nodules, vesicles and pustules frequently found on the sole of the foot (Fig. 67.8).

Differential diagnosis. This is principally from gonorrhoea, which must be excluded by blood culture. In Reiter’s disease, the urethritis and arthritis are milder and the incubation period is longer than gonorrhoea.

Prognosis. The urethritis and conjunctivitis frequently subside in a few weeks but the arthritis may persist for months. Severe anterior uveitis and frequently recurrent attacks suggest a bad outlook.

Treatment. The ophthalmic complications are treated with eye baths and shades. Mydriatics and topical steroids are indicated for iritis. Other symptoms may prove difficult to control and severe cases should be under the care of a specialist in genitourinary medicine.