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
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
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.