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Urethritis

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  • 1. Dr. Shilpa Soni MGMCH
  • 2.  medial horizontal gp of Inferior vena superficial cava inguinal LN
  • 3.  Superficial Inguinal LN - Penile skin - Scrotal skin  Deep inguinal LN - Anterior male urethra & glans penis - Vulva - Vagina, lower third - Uterus, lower part - isthmus of fallopian tube  Sacral LN - Vulva - Cervix
  • 4.  Iliac LN  Pre & para aortic group of LN - Posterior urethra - Testes & epididymis - Vulva - Uterus, upper part - Upper third & middle third vagina - Ovaries - Cervix - Fallopian tubes - Prostate - Cervix
  • 5. Urethritis Inflammation of the urethra. Discharge +/- dysuria or may be asymptomatic.
  • 6. Causes of urethritis  Infectious causes- - Gonococcal – Neisseria gonorrhoea (50-90%) - Non gonococcal – - Chlamydia trachomatis. (20-50%) - Ureaplasma urealyticum. (20-80%) - Mycoplasma genitalium. (10-30%) - Trichomonas vaginalis. (1-70%) - Yeast. - HSV.
  • 7.  Non Infectious Causes - Trauma - Urethral stricture. - Catheterization. - Chemical irritants. - Dehydration.
  • 8. Gonococcal Urethritis 1. N gonorrhoea – gram negative, non motile, non spore forming diplococci. 2. Oxidase positive 3. Ferments glucose 4. PPNG – penicillinase produc- - ing N. gonorrhoea: cefotaxime, ceftriaxone, ciprofloxacin, tetrac-ycline can be used.
  • 9.  N gonorrhoea – present predominantly intracellularly in the polymorphonuclear leucocytes (PMN).  Penetrates columnar epithelium.
  • 10.  Structure – - capsule – polyphosphate - trilaminar membrane – outer membrane – type 1 protein (por) - A &B - type 2 protein(Opa pro) - RMP protein - peptidoglycan – muramic acid & N-acetyl glucosamine. - cytoplasmic membrane – penicillin binding proteins. - Pili - filaments
  • 11.  Strains - Pathogenic strains – N. gonorrhoea - N. meningitidis - Non pathogenic strains – N. catarrhalis - N. pharyngis sicca - N. lactamica - N. subflava
  • 12. Clinical features :  Affects urethra in both sexes.  Transmission – sexual contact  Incubation period – 2-5 days  Intense burning sensation.  Fever & malaise.
  • 13.  In men anterior urethritis is more common.  Discharge – profuse, purulent & yellowish green.  15% males – mild or asymptomatic.
  • 14.  Complications – - Posterior urethritis - Epididymitis - Acute or chronic prostatitis - Untreated – periurethral abscess & watercan perineum.
  • 15.  In females – 90% infection  50% of infected females are asymptomatic.  Primary site - endocervical canal  Symptoms of urethritis includes - Discharge - scanty, mucopurulent cervical discharge. - Vaginal pruritus - Dysuria
  • 16.  Proctitis through autoinoculation from cervical discharge or as a result of direct contact from an infected partner’s penile secretions.
  • 17.   Complications in femalesPID Tubo ovarian abscess Subsequent ectopic pregnancies Chronic pelvic pain Infertility Fitz-Hugh-Curtis syndrome – inflammation of liver capsule associated with genitourinary tract infection. Present in upto ¼ of women with PID caused either by N. gonorrhoea or C. trachomatis.
  • 18.  Complications common to both sexes - - Disseminated gonococcal infection (DGI) - Acute arthritis-dermatitis syndrome – acute arthritis, tenosynovitis, dermatitis or combination of these findings. - Gonococcal arthritis - Meningitis - Endocarditis
  • 19.  Laboratory diagnosis – - Microscopy – gram staining - gram negative diplococci
  • 20.  Culture – thayer martin medium - chacko nayer medium - martin lewis media - new york city media
  • 21.  PCR  DNA hybridisation  ELISA  The complement fixation  Latex agglutination immunofluoroscence & anti surface pili assays  Radioimmunossay  Immunoblotting
  • 22.  - Treatment – uncomplicated gonorrhoea Cefixime 400 mg stat or Ceftriaxone 125 mg stat IM or Ciprofloxacin 500 mg stat or Ofloxacin 400 mg stat or Levofloxacin 250 mg stat + If chlamydia infection is not ruled out - Azithromycin 1 gm stat or - Doxycycline 100 gm BD for 7 days.
  • 23.  Treatment – DGI - Ceftriaxone 1 gm IM or IV every 24 hrs or - Cefotaxime 1 gm IV every 8 hrly or - Ciprofloxacin 400 gm IV every 12 hrs or - Ofloxacin 400 gm IV every 12 hrs or - Levofloxacin 250 gm IV daily. or - Spectinomycin 2 gm IV every 12 hrly.
  • 24. Non gonococcal urethritis
  • 25. CHLAMYDIA TRACHOMATIS  C. trachomatis – gram negative obligate intracellular micro organism that preferentially infect squamo-coloumnar epithelium.  Based on monoclonal antibody assay – 18 serological variants. - A, B, Ba & C – trachoma. - D-K – genital tract infections. - L1 – L3 – LGV
  • 26.  Two functional & morphological forms- Elementary body – infectious but metabolically inert. - Reticulate body – metabolically active but non infectious.  The intracellular bacteria rapidly modify their membrane bound compartment into chlamydial inclusion to prevent the phagosome lysosome fusion.
  • 27.  Clinical features – - Incubation period – 1 - 3 weeks. - Low grade urethritis with scanty or moderate mucoid or mucopurulent urethral discharge & variable dysuria. - Subclinical urethritis are also common.
  • 28.  In men- Sites of infection are – urethra. - epididymis. - systemic. - Clinical syndrome – urethritis, post gonococcal urethritis & Reiter’s disease.
  • 29.  Urethritis – - Dysuria with mild to moderate whitish or clear urethral discharge. - On examination – focal urethral tenderness - meatal or penile lesions may mimic herpetic urethritis.
  • 30.  Epididymitis – recurrent infections - Unilateral scrotal pain, Swelling & Tenderness. - Fever - Urethritis may often be assymptomatic & evident only as urethral inflammation.
  • 31.  Prostatitis – - Ususaly asymptomatic or may - Presents with discomfort on passing urine & vague pain in perineum, groins, thighs, penis, suprapubic region or back. - Painful ejaculation.
  • 32.  Proctitis – repetitive anal intercourse or by lymphatic spread from posterior urethra. - Rectal pain - Discharge - mucopurrulent - Bleeding
  • 33.  Reiter’s syndrome – urethritis - conjuctivitis - arthritis - characteristic mucocutaneous lesions as well as psoriasis such as circinate balanitis & keratoderma blenorrhagicum. Reactive arthritis is RF seronegative, HLA-B27 linked arthritis often precipitated by genitourinary or gastro intestinal infections usually after 2-3 weks of infection.
  • 34.  Organisms associated with Reiter’s syndrome are - N. gonorrhoea - C. trachomatis - U. urealyticum - Salmonella - Shigella - Campylobacter  Treatment – antibiotics, NSAIDS, sulfasalazine, corticosteroids & immunosupressants.
  • 35.  In women – - Cevicitis – mucopurulent cervical discharge - cervical erythema & edema with an area of ectopy - spontaneous or easily induced cervical bleeding - Urethritis – dysuria - frequency - pyuria
  • 36. - Bartholoinitis - Endometritis – abnormal vaginal bleeding - menorrhagia - metrorrhagia - PID – lower abdominal pain - adenexal tenderness on pelvic examination - MPC often present - Perihepatitis (Fitz-Hugh-Curtis Syndrome)
  • 37.  Lab diagnosis Clinical syndrome Clinical criteria - male Presumptive criteria Diagnostic criteria NGU Dysuria, urethral discharge Gram stian - > 5 PMNL/hpf Pyuria on first void urine Positive culture Acute epididymitis Fever, epididymal or testicular pain, evidence of NGU Epididymal tenderness or mass. - do - Positive culture or non culture test on epididymal aspirate.
  • 38. Clinical syndrome Clinical criteria Presumptive criteria Diagnostic criteria Mucopurulent cervicitis Mucopurulent cervicitis discharge Cervical ectopy & edema, spontaneous or easily induced cervical bleeding Cervical gram staining > 30 PMNL/hpf in non menstruating women Positive culture or non culture test. Acute urethral syndrome Dysuria, frequency Pyuria syndrome > 7 days No bacteria of symptom PID Lower abdominal pain, adenexal tenderness on pelvic examination evidence of MPC often present Cervical gramstaining positive for gonococcus, endometritis on endometrial biopsy - do Positive culture or non culture test (cervix first void urine, endometrium, tubal)
  • 39.  Antigen detection – DFA - enzyme linked immunosorbant assay - monoclonal or polyclonal Ab against chlamydial lipopolysacharide (LPS) or MOMP
  • 40.  Nucleic acid hybridization - rRNA by hybridization with DNA probe. - PAGE 2 assay by Genprobe  PCR  Serology – complement fixation test or microimmunofluorescence
  • 41.  Treatment - Recommended Doxycycline 100 mg BD for 47 days or Azithromycin 1 gm stat - Alternative Amoxycillin 500 mg TDS for 7 days or Erythromycin 500 mg QID for 7 days or Erythromycin ethylsuccinate 800 mg QID for 7 days or Ofloxacin 300 mg BD for 7 days or Tetracycline 500 mg QID for 7 days
  • 42. Chlamydial infection in pregnancy  In antenatal period - 1. Spontaneous abortion 2. Neonatal conjunctivitis 3. Low birth baby 4. Prematurity & preterm delivery
  • 43.  Postnatal infection 1. Neonatal conjunctivitis 2. Ophthalmia neonatorum 3. Pneumonia 4. Chronic lung or eye disease
  • 44. Neonatal conjuctivitis  Commonlly starts within 21 days of birth.  Accounts for 5-15% of conjunctivitis in new borns  Clinical features – intense redness & swelling of conjunctiva - profuse purulent discharge  Complication – corneal perforation - scarring - blindness
  • 45. Treatment Infection during pregnancy Neonatal chlamydial conjunctivitis Infantile pneumonia Recommended regimine Erythromycin 500 mg QID for 7 days or Amoxycillin 500 mg TDS for 7 days or Azithromycin 1 gm stat. Syp erythromycin 50 mg /kg /day in 4 divided doses for 14 days Syp erythromycin 50 mg/ kg/ day orally in 4 divided doses for 14 days Alternative regimine Erythromycin base 500 mg QID for 7 days or 250 mg QID for 14 days or Erythromycin ethylsuccinate 800 mg QID for 7 days or 400 mg QID for 14 days. Trimethoprim 40mg with sulfamethoxazole 200 mg orally BD for 14 days.
  • 46. Ureoplasma urealyticum  Causes non specific urethritis.  Transmitted by sexual contact.  In males causes – urethritis, proctitis & Reiter’s syndrome  In females causes – acute salphingitis, PID, cervicitis & vaginitis. - Also been associated with infertility, abortions, postpartum fever & low birth baby.
  • 47. Mycoplasma genitalium  Accounts for 29% of sexually transmitted urethritis  More common organism in C. trachomatis negative urethritis in 13-45% of cases  Common in recurrent urethritis
  • 48. Bacterial vaginosis  G. vaginalis & M. hominis  Vaginal discharge  Ecaluation of sex partner is also necessary.
  • 49. Traetment of NGU  Tab Azithromycin 1 gm stat or Tab Doxycycline 100 gm BD for 10 daysA
  • 50. Complications of urethritis  Chronic recurrent UTIs  Trigonitis in females  Stricture urethra
  • 51. Newer modality in Treatment of recurrent urethritis  Tab TRACFREE – 600 mg BD for 3 months - CRANE BERRY fruit extract which prevents the bacterial invasion in the urothelium.
  • 52. Herpes genitalis     HSV 1 & HSV 2 Incubation period 5-14 days Symptoms – painful lesions Fever, headache, myalgias & malaise Grouped vesicles pustules ulcers. Diagnosis- tzanck’s smear, histopathology, viral culture,serology & PCR.  Treatment – acyclovir 400 mg TDS for 7-10 days/ valacyclovir 1 gm BD for 7-10 days/ famcyclovir 250 mg BD for 7-10 days
  • 53.  Recurrent episodes – - Acyclovir 400 mg TDS for 5 days or 800 mg BD for 5 days or 800 mg TDS for 2 days. - Famcyclovir 125 mg BD for 5 days or 1000 mg BD for 1 days. - Valacyclovir 1 gm BD for 5 days or 500 mg BD for 3 day.
  • 54. Syndromic approach
  • 55. Urethral Discharge History / Examine Milk urethra Discharge present No Yes Treat for Gonorrhoea & Chlamydia & trichomoniasis ECCV, Partner treatment, Follow up other STI? No Yes Use appropriate flow chart ECCV
  • 56. Treatment of Urethral Discharge Treat patient for both Gonorrhoea and Chlamydia infection. The Regime: Azithromycin 1G orally as a single dose (to treat chlamydial infection) PLUS Cefexime 400 mg orally, single dose under supervision (to treat gonococcal infection) Kit one Gray
  • 57. Treatment of VD- Cervicitis Treat patient for both Gonorrhoea and Chlamydia infection. The Regime: Azithromycin 1G orally as a single dose (to treat chlamydial infection) PLUS Cefexime 400 mg orally, single dose under supervision (to treat gonococcal infection) Kit one Gray
  • 58. Treatment for Vaginal Discharge Vaginitis. Recommended regimen Scenidazole 2 G orally, single dose, under supervision ( to treat trichomoniasis and bacterial vaginosis). Plus Fluconazole 150 mg orally, single dose (to treat candidiasis). NOTE: Patients taking Metronidazole or Tinidazole should be cautioned to avoid taking alcohol while on these drugs up to 24-48 hrs. Kit one Gray Kit two Green
  • 59. Thank you