0
Dr. Shilpa Soni
MGMCH
 medial horizontal gp of
Inferior vena
superficial
cava
inguinal LN
 Superficial Inguinal LN

- Penile skin

- Scrotal skin

 Deep inguinal LN
- Anterior male urethra & glans

penis

- Vul...
 Iliac LN

 Pre & para aortic group of LN

- Posterior urethra

- Testes & epididymis

- Vulva

- Uterus, upper part

- ...
Urethritis
Inflammation of the urethra.

Discharge +/- dysuria or may be
asymptomatic.
Causes of urethritis
 Infectious causes-

- Gonococcal – Neisseria gonorrhoea (50-90%)
- Non gonococcal –
- Chlamydia tra...
 Non Infectious Causes

- Trauma
- Urethral stricture.
- Catheterization.
- Chemical irritants.
- Dehydration.
Gonococcal Urethritis
1.

N gonorrhoea – gram negative, non motile, non spore
forming diplococci.

2.

Oxidase positive

3...
 N gonorrhoea – present predominantly intracellularly

in the polymorphonuclear leucocytes (PMN).
 Penetrates columnar e...
 Structure –

- capsule – polyphosphate
- trilaminar membrane
– outer membrane – type 1 protein (por) - A
&B
- type 2 pro...
 Strains

- Pathogenic strains – N. gonorrhoea
- N. meningitidis
- Non pathogenic strains – N. catarrhalis
- N. pharyngis...
Clinical features :
 Affects urethra in both sexes.
 Transmission – sexual contact

 Incubation period – 2-5 days
 Int...
 In men anterior urethritis is more common.

 Discharge – profuse, purulent & yellowish

green.
 15% males – mild or as...


Complications –

- Posterior urethritis
- Epididymitis
- Acute or chronic prostatitis
- Untreated – periurethral absces...
 In females – 90% infection
 50% of infected females are

asymptomatic.
 Primary site - endocervical canal
 Symptoms o...
 Proctitis through autoinoculation from cervical

discharge or as a result of direct contact from an
infected partner’s p...



Complications in femalesPID
Tubo ovarian abscess
Subsequent ectopic pregnancies
Chronic pelvic pain
Infertility
Fitz-...
 Complications common to both sexes -

- Disseminated gonococcal infection (DGI)
- Acute arthritis-dermatitis syndrome – ...
 Laboratory diagnosis –
- Microscopy – gram staining
- gram negative

diplococci
 Culture – thayer martin medium

- chacko nayer medium
- martin lewis media
- new york city media
 PCR
 DNA hybridisation
 ELISA
 The complement fixation

 Latex agglutination immunofluoroscence & anti

surface pili...

-

Treatment – uncomplicated gonorrhoea
Cefixime 400 mg stat or
Ceftriaxone 125 mg stat IM or
Ciprofloxacin 500 mg stat ...
 Treatment – DGI
- Ceftriaxone 1 gm IM or IV every 24 hrs or
- Cefotaxime 1 gm IV every 8 hrly or

- Ciprofloxacin 400 gm...
Non
gonococcal
urethritis
CHLAMYDIA TRACHOMATIS
 C. trachomatis – gram negative obligate intracellular micro

organism that preferentially infect s...
 Two functional & morphological forms- Elementary body – infectious but metabolically inert.
- Reticulate body – metaboli...
 Clinical features –
- Incubation period – 1 - 3 weeks.
- Low grade urethritis with scanty or moderate mucoid

or mucopur...
 In men- Sites of infection are – urethra.

- epididymis.
- systemic.
- Clinical syndrome – urethritis, post gonococcal

...
 Urethritis –
- Dysuria with mild to moderate whitish or clear

urethral discharge.
- On examination – focal urethral ten...
 Epididymitis – recurrent infections
- Unilateral scrotal pain, Swelling & Tenderness.
- Fever
- Urethritis may often be ...
 Prostatitis –
- Ususaly asymptomatic or may
- Presents with discomfort on passing urine & vague

pain in perineum, groin...
 Proctitis – repetitive anal intercourse or by lymphatic

spread from posterior urethra.
- Rectal pain
- Discharge - muco...
 Reiter’s syndrome – urethritis

- conjuctivitis
- arthritis
- characteristic mucocutaneous lesions as well
as psoriasis ...
 Organisms associated with Reiter’s syndrome are
- N. gonorrhoea
- C. trachomatis
- U. urealyticum

- Salmonella
- Shigel...
 In women –
- Cevicitis – mucopurulent cervical discharge

- cervical erythema & edema with an area of
ectopy
- spontaneo...
- Bartholoinitis
- Endometritis – abnormal vaginal bleeding

- menorrhagia
- metrorrhagia
- PID – lower abdominal pain
- a...
 Lab diagnosis
Clinical syndrome Clinical criteria
- male

Presumptive
criteria

Diagnostic
criteria

NGU

Dysuria, ureth...
Clinical
syndrome

Clinical criteria

Presumptive
criteria

Diagnostic
criteria

Mucopurulent
cervicitis

Mucopurulent
cer...
 Antigen detection – DFA

- enzyme linked immunosorbant
assay

- monoclonal or polyclonal Ab
against chlamydial
lipopolys...
 Nucleic acid hybridization
- rRNA by hybridization with DNA probe.
- PAGE 2 assay by Genprobe
 PCR
 Serology – complem...
 Treatment

- Recommended
Doxycycline 100 mg BD for 47 days or
Azithromycin 1 gm stat
- Alternative
Amoxycillin 500 mg TD...
Chlamydial infection in pregnancy


In antenatal period -

1.

Spontaneous abortion

2. Neonatal conjunctivitis
3. Low bi...
 Postnatal infection
1.

Neonatal conjunctivitis

2. Ophthalmia neonatorum
3. Pneumonia
4. Chronic lung or eye disease
Neonatal conjuctivitis
 Commonlly starts within 21 days of birth.
 Accounts for 5-15% of conjunctivitis in new borns
 C...
Treatment

Infection during
pregnancy

Neonatal
chlamydial
conjunctivitis

Infantile
pneumonia

Recommended
regimine

Eryt...
Ureoplasma urealyticum
 Causes non specific urethritis.
 Transmitted by sexual contact.
 In males causes – urethritis, ...
Mycoplasma genitalium
 Accounts for 29% of sexually transmitted urethritis
 More common organism in C. trachomatis negat...
Bacterial vaginosis
 G. vaginalis & M. hominis
 Vaginal discharge
 Ecaluation of sex partner is also necessary.
Traetment of NGU
 Tab Azithromycin 1 gm stat

or
Tab Doxycycline 100 gm BD for 10 daysA
Complications of urethritis
 Chronic recurrent UTIs
 Trigonitis in females
 Stricture urethra
Newer modality in Treatment of
recurrent urethritis
 Tab TRACFREE – 600 mg BD for 3 months

- CRANE BERRY fruit extract w...
Herpes genitalis





HSV 1 & HSV 2
Incubation period 5-14 days
Symptoms – painful lesions
Fever, headache, myalgias &...
 Recurrent episodes –

- Acyclovir 400 mg TDS for 5 days or 800 mg BD for 5
days or 800 mg TDS for 2 days.
- Famcyclovir ...
Syndromic approach
Urethral Discharge
History / Examine
Milk urethra

Discharge present

No

Yes
Treat for Gonorrhoea &
Chlamydia &
trichomon...
Treatment of Urethral Discharge
Treat patient for both Gonorrhoea
and Chlamydia infection.
The Regime:
Azithromycin 1G ora...
Treatment of VD- Cervicitis
Treat patient for both Gonorrhoea
and Chlamydia infection.
The Regime:
Azithromycin 1G orally ...
Treatment for Vaginal Discharge
Vaginitis.
Recommended regimen
Scenidazole 2 G orally, single dose, under
supervision ( to...
Thank you
Urethritis
Urethritis
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Transcript of "Urethritis"

  1. 1. Dr. Shilpa Soni MGMCH
  2. 2.  medial horizontal gp of Inferior vena superficial cava inguinal LN
  3. 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. 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. 5. Urethritis Inflammation of the urethra. Discharge +/- dysuria or may be asymptomatic.
  6. 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. 7.  Non Infectious Causes - Trauma - Urethral stricture. - Catheterization. - Chemical irritants. - Dehydration.
  8. 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. 9.  N gonorrhoea – present predominantly intracellularly in the polymorphonuclear leucocytes (PMN).  Penetrates columnar epithelium.
  10. 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. 11.  Strains - Pathogenic strains – N. gonorrhoea - N. meningitidis - Non pathogenic strains – N. catarrhalis - N. pharyngis sicca - N. lactamica - N. subflava
  12. 12. Clinical features :  Affects urethra in both sexes.  Transmission – sexual contact  Incubation period – 2-5 days  Intense burning sensation.  Fever & malaise.
  13. 13.  In men anterior urethritis is more common.  Discharge – profuse, purulent & yellowish green.  15% males – mild or asymptomatic.
  14. 14.  Complications – - Posterior urethritis - Epididymitis - Acute or chronic prostatitis - Untreated – periurethral abscess & watercan perineum.
  15. 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. 16.  Proctitis through autoinoculation from cervical discharge or as a result of direct contact from an infected partner’s penile secretions.
  17. 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. 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. 19.  Laboratory diagnosis – - Microscopy – gram staining - gram negative diplococci
  20. 20.  Culture – thayer martin medium - chacko nayer medium - martin lewis media - new york city media
  21. 21.  PCR  DNA hybridisation  ELISA  The complement fixation  Latex agglutination immunofluoroscence & anti surface pili assays  Radioimmunossay  Immunoblotting
  22. 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. 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. 24. Non gonococcal urethritis
  25. 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. 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. 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. 28.  In men- Sites of infection are – urethra. - epididymis. - systemic. - Clinical syndrome – urethritis, post gonococcal urethritis & Reiter’s disease.
  29. 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. 30.  Epididymitis – recurrent infections - Unilateral scrotal pain, Swelling & Tenderness. - Fever - Urethritis may often be assymptomatic & evident only as urethral inflammation.
  31. 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. 32.  Proctitis – repetitive anal intercourse or by lymphatic spread from posterior urethra. - Rectal pain - Discharge - mucopurrulent - Bleeding
  33. 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. 34.  Organisms associated with Reiter’s syndrome are - N. gonorrhoea - C. trachomatis - U. urealyticum - Salmonella - Shigella - Campylobacter  Treatment – antibiotics, NSAIDS, sulfasalazine, corticosteroids & immunosupressants.
  35. 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. 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. 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. 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. 39.  Antigen detection – DFA - enzyme linked immunosorbant assay - monoclonal or polyclonal Ab against chlamydial lipopolysacharide (LPS) or MOMP
  40. 40.  Nucleic acid hybridization - rRNA by hybridization with DNA probe. - PAGE 2 assay by Genprobe  PCR  Serology – complement fixation test or microimmunofluorescence
  41. 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. 42. Chlamydial infection in pregnancy  In antenatal period - 1. Spontaneous abortion 2. Neonatal conjunctivitis 3. Low birth baby 4. Prematurity & preterm delivery
  43. 43.  Postnatal infection 1. Neonatal conjunctivitis 2. Ophthalmia neonatorum 3. Pneumonia 4. Chronic lung or eye disease
  44. 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. 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. 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. 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. 48. Bacterial vaginosis  G. vaginalis & M. hominis  Vaginal discharge  Ecaluation of sex partner is also necessary.
  49. 49. Traetment of NGU  Tab Azithromycin 1 gm stat or Tab Doxycycline 100 gm BD for 10 daysA
  50. 50. Complications of urethritis  Chronic recurrent UTIs  Trigonitis in females  Stricture urethra
  51. 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. 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. 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. 54. Syndromic approach
  55. 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. 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. 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. 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. 59. Thank you
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