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Approach to urethral discharge
- 1. Approach to Urethral Discharge Presenter - Dr Mamta
- 2. Introduction • Prevalence (India) – 15-20% of patients attending STD clinic • Due to irritation or inflammation of urethra • Most commonly due to STIs
- 3. Approach to Urethral Discharge Identification of Cause and associated complications Treatment of cause and complications Follow Up and Test of Cure
- 4. Etiology Sexually Transmitted Infections Gonococcal Urethritis ( Neisseria gonorrhoeae) Non Gonococcal Urethritis • C. trachomatis • M. genitalium • U. urealyticum • T. vaginalis • Others
- 5. Total incidence of urethritis was 10.94% of the all STI patients • Gonococcal urethritis : 5.97% • Nongonococcal urethritis : 4.97%
- 6. Clinical and bacteriological study of urethral discharge CM Gupta, S Sanghi, SK Sayal, AL Das, GK Prasad Department of Dermatology & Venereology, Armed Forces Medical College, Pune Incidence of gonococcal urethritis : 65% Non gonococcal Urethritis : 35% Common organisms causing NGU were • chlamydia (28%) • ureaplasma (11%) • mycoplasma (11%)
- 7. Non Sexually Transmitted Diseases Infections Anatomic abnormalities Congenital abnormalities Iatrogenic Chemical irritation Tumors Foreign bodies Unknown Cystitis Prostatitis
- 8. Non Sexually Transmitted Diseases Infections Anatomic abnormalities Congenital abnormalities Iatrogenic Chemical irritation Tumors Foreign bodies Unknown Urethral Stricture Phimosis
- 9. Non Sexually Transmitted Diseases Infections Anatomic abnormalities Congenital abnormalities Iatrogenic Chemical irritation Tumors Foreign bodies Unknown • Catheterization • Instrumentation • Other procedures
- 10. Non Sexually Transmitted Diseases Infections Anatomic abnormalities Congenital abnormalities Iatrogenic Chemical irritation Tumors Foreign bodies Unknown • Applying liquids such as tea tree oil, antiseptic or disinfectant or using medicated or highly perfumed shower gels can cause inflammation • Lubricants
- 11. Non Sexually Transmitted Diseases Infections Anatomic abnormalities Congenital abnormalities Iatrogenic Chemical irritation Tumors Foreign bodies Unknown
- 12. Non Sexually Transmitted Diseases Infections Anatomic abnormalities Congenital abnormalities Iatrogenic Chemical irritation Tumors Foreign bodies Unknown
- 13. Non Sexually Transmitted Diseases Infections Anatomic abnormalities Congenital abnormalities Iatrogenic Chemical irritation Tumors Foreign bodies Unknown Non Specific Urethritis
- 15. History Examination Laboratory Investigations Sexual / Exposure History Sexual behaviour Condom usage Number of partners Recent contacts Orifices used
- 16. P.c.- Dr Somesh Colour Quantity Consistency Frequency & Relationship to micturition
- 17. History Examination Laboratory Investigations Dysuria with itching and burning around the meatus • Urinary hesitancy, • Urgency, • Frequency • Fever and lower abdominal pain Urethritis due to STDs Urinary Tract Infection
- 18. History Examination Laboratory Investigations Reiter’s Syndrome Skin Lesions Circinate Balanitis Uveitis Arthritis
- 19. History Examination Laboratory Investigations Urethral Neoplasm Painless Urethral Discharge Initially opaque and gray Later – yellowish and blood tinged Dysuria Anuria
- 20. History Examination Laboratory Investigations Gonococcal Urethritis Non – Gonococcal Urethritis Discharge Profuse, purulent and yellowish Scanty, mucoid or mucopurulent Dysuria Intense burning sensation ‘Smarting’ (sharp stinging pain) feeling in urethra on passing urine Incubation Period 2-5 days 2-3 weeks Constitutional Symptoms Present Absent
- 22. History Examination Laboratory Investigations Penis Colour Quantity Consistency
- 23. Milking of Urethra From the base of the penis to the glans by grasping the penis firmly between the thumb and forefinger Thumb pressing on the ventral surface and then moving the hand distally, compressing the urethra
- 25. Balanoposthitis
- 26. History Examination Laboratory Investigations Scrotum epididymitis
- 27. History Examination Laboratory Investigations Anorectal Examination Erythema of the anal mucosa with mucoid or purulent exudates and friability of the mucosa Anorectal Gonorrhea and Chlamydia
- 28. History Examination Laboratory Investigations Per Abdomen • Abdominal guarding and rebound tenderness – peritonitis - severe PID • Inguinal lymphadenopathy - HSV urethritis and GU
- 29. History Examination Laboratory Investigations Oral Cavity
- 30. History Examination Laboratory Investigations Oral Cavity
- 31. History Examination Laboratory Investigations Specimen collection , transport and processing Specimens easily obtained Noninvasive procedure Stable at ambient temperatures No complex handling or processing Characteristics of an Ideal Laboratory Test:
- 32. History Examination Laboratory Investigations Specimen collection , transport and processing Specimens easily obtained Noninvasive procedure Stable at ambient temperatures No complex handling or processing Testing Sensitive and specific Simple to perform and reproducible Inexpensive Rapid results Reagents easily obtained and stored Little or no equipment required Characteristics of an Ideal Laboratory Test:
- 33. History Examination Laboratory Investigations Specimen collection , transport and processing Specimens easily obtained Noninvasive procedure Stable at ambient temperatures No complex handling or processing Testing Sensitive and specific Simple to perform and reproducible Inexpensive Rapid results Reagents easily obtained and stored Little or no equipment required Interpretation Objective Differentiates past and current infection Characteristics of an Ideal Laboratory Test:
- 34. History Examination Laboratory Investigations Sample collection
- 35. History Examination Laboratory Investigations Urethral Swab Retract prepuce Tip of meatus cleaned with normal saline Pus is directly collected on the sterile swab if discharge is present
- 36. History Examination Laboratory Investigations If No Discharge Milking of urethra Still No Discharge
- 38. Other samples : First Void Urine Sample Rectal Swab Pharyngeal Swab
- 39. Investigations
- 40. Gram Stain Detection of gram negative diplococci inside PMNL is diagnostic Presence of greater than or equal to 2 WBCs per oil immersion field in the absence of gram negative Gonococcal Urethritis NGU
- 41. In men with symptomatic urethritis, the sensitivity of urethral smear is 90-95% and specificity is 95-100%
- 42. Urine sediment Gram stain : Microscopic examination of first- void urine sediment demonstrating more than or equal to 10 WBC per high-power field is diagnostic of NGU Urinary leukocyte esterase test Screening test for chlamydial and GC infections in asymptomatic men Serologic test for syphilis (VDRL), blood test for human immunodeficiency virus (HIV) and hepatitis B virus (HBV) infections
- 43. Further testing is not routinely done and should be carried out only if there is a recurrent or persistent urethritis even after treatment for GU and Chlamydia
- 44. Culture of Urethral Discharge UD wet preparation Antigen detection (specimen – UD) Serology: (specimen – Blood) For detection of organism specific antibodies Nucleic acid amplification tests (NAATs) (specimen – UD) Urine analysis (routine/microscopy) and midstream urine cultures Anorectal mucus discharge Gram stain Diagnostic imaging.
- 45. Point Of Care Test
- 46. INTRODUCTION Definition Analytical testing performed at sites outside the traditional laboratory environment usually at or near the site of patients care. Quality POCT-A Joint commission handbook LAB POCT
- 47. POCT Conventional Gram staining KOH mount Wet mount RPR Dark ground microscopy Newer Immunochromatography optical immunoassay, latex agglutination
- 48. Test Reference Standard Samples Sensitivity % Specificity % BioStar OIA GC test Culture 326 60 90 PATH GC-Check NAAT 1084 70 97 OneStep Culture 1050 98 98
- 49. Test Reference Standard Samples Sensitivity, % Specificity,% BioStar OIA Chlamydia test Culture NAAT 306 78 97 Clearview Chlamydia NAAT (PCR) 1495 30 99 Quick vue NAAT 100 65 100 CRT(Chlamydia rapid test) NAAT 686 84 99
- 50. Test Reference Standard Samples Sensitivity % Specificity % XenoStrip-Tv Culture 60 90 92.5 Miller, et al (2003) OSOM TV Trichomonas Rapid Test wet mount, culture, and NAAT Wet mount 330 1009 90 95 100 Huppert,et.al. (2007) 100 Campbell, etal. (2008)
- 51. Tests Costs(INR) Clearview chlamydia 285 Standard SD Bioline Syphilis 45 Syphicheck-WB 30 SD Bioline-HIV1/2 50 Comb Aids 40 Signal HIV 70 Point of care tests being used in India currently AIIMS
- 52. The Clearview Chlamydia Based on Immunochromatography Antigen- lipopolysaccharide 30 minutes to complete Kit storage- 2 to 8 degrees Cost-Rs285/test(used in India) Sensitivity(32%), Specificity(99%)
- 53. How to use the Clearview Chlamydia test • Mix the sample for 10 minutes at 30 deg.with sodium azide • Add 5 drops of sample to the Sample Window on absorbent pad • Read the result at fifteen minutes, • checking both the Result and Control Windows.
- 54. Barriers to POC tests • Cost and technology • Multiple-step procedures • Difficulty in reading and interpreting the test results • Patients and Clinicians may both prefer traditional methods
- 55. 4 Glass Test
- 57. • Samples are cultured • If one specimen grows far more bacteria than the others, it is felt that the infection has been localized to the urethra, bladder, or prostate, depending on which specimen grows bacteria
- 58. Tests Done In AIIMS (Dept of Microbiology) N.gonorrhoeae C.trachomatis Mycoplasma T.vaginallis Microscopy Antigen Detection Culture Wet Mount Culture NAAT NAAT Culture NAAT
- 59. Treatment
- 60. Syndromic Management • World Health Organization (WHO) has recommended a syndromic approach to patient management, where laboratory diagnosis is not feasible • Patient is treated for all the possible causes of that syndrome
- 61. Syndromic Management : Advantages & Disadvantages Advantages Disadvantages Problem oriented Over-diagnosis and over treatment resulting in: • Increased cost • Increased side effects • Potential for increased resistance Highly sensitive Does not miss mixed infections Treatment given at first visit Avoids expensive lab tests Cannot be used for aymptomatic patients Can be implemented at PHC level
- 62. NACO 2014 Guidelines Cefixime 400mg Azithromycin 1 gm Doxycycline 100mg BD X 7days Follow Up After 7 days If symptoms persist Treat for T. vaginalis
- 63. Partner Management • All sexual partners of patients whose last sexual contact with the patient was within 60 days before onset of symptoms or diagnosis of infection in the patient • Female partners treated on same lines after ruling out pregnancy and history of allergies. • Sexual abstinence
- 64. Sexually Transmitted Diseases Treatment Guidelines, 2015 (Centre for Disease Control and Prevention) Recommended Regimen Alternative Regimen Ceftriaxone 250mg IM Single dose PLUS Azithromycin 1gm orally in a single dose If ceftriaxone is not available: Cefixime 400mg orally in a single dose PLUS Azithromycin 1 gm orally in a single dose Gonorrhea
- 65. Recommended Regimens Alternative Regimens Azithromycin 1 gm orally in a single dose OR Doxycycline 100mg orally BD X 7 days Erythromycin base 500mg QID X 7days OR Erythromycin ethylsuccinate 800mg orally QID X 7 days OR Levofloxacin 500mg OD X 7 days OR Ofloxacin 300mg BD X 7 days Chlamydia
- 66. Recommended Regimen Alternative Regimen Metronidazole 2 gm orally in a single dose OR Tinidazole 2 gn orally in a single dose Metronidazole 500mg BD X 7 days Trichomonas vaginalis
- 67. Recommended Regimens Acyclovir 400mg orally TDS X 7-10 days OR Acyclovir 200 mg orally 5 times/day X 7-10 days OR Valacyclovir 1 gm orally BD X 7-10 days OR Famciclovir 250mg orally TDS X 7-10 days
- 68. Drug Resistance How big is the problem??
- 69. 127 Tests included Conclusion : High resistance to penicillin, cephalosporin and tetracyclin Ceftriaxone and Spectinomycin treatment remained effective
- 70. Clinical and bacteriological study of urethral discharge CM Gupta, S Sanghi, SK Sayal, AL Das, GK Prasad Department of Dermatology & Venereology, Armed Forces Medical College, Pune Neisseria gonorrhoea was resistant to Penicillin (38%), Ciprofloxacin (67%) Norfloxacin (6%)
- 71. Results Cure rates : 97% for azithromycin,98% for doxycycline Adverse events : 25% with azithromycin,23% with doxycycline Azithromycin and doxycycline are equally efficacious in achieving microbial cure and have similar tolerability
- 72. Updated in 2014 Reported an overall efficacy of 97.4 % for doxycycline and 94.3 % for azithromycin (efficacy difference of 2.6 %; 95 % CI: 0.5 %, 4.7 %) Should we be alarmed ???
- 73. • To date, no prospective clinical studies have focused on the potential role of antibiotic resistance as a cause for chlamydia treatment failure • Chlamydia antimicrobial sensitivity testing is challenging
- 74. Follow Up & Test of Cure N.gonorrheoae Test of cure is not needed for persons who receive a diagnosis of uncomplicated Urogenital or rectal gonorrhoea and treated with any of the recommended or alternative regimens Pharyngeal Gonorrhea patient treated with an alternative regimen should return 14 days after treatment for TOC If symptoms persist after treatment : Culture + Antimicrobial susceptibility
- 75. C.Trachomatis TOC not advised if treated with recommended or alternative regimen Patients should be retested after 3 months
- 76. Dhat Syndrome
- 77. • Vague somatic symptoms of fatigue, weakness, anxiety, loss of appetite and guilt • Attributed to semen loss through nocturnal emissions, urine and masturbation • Though there is no evidence of loss of semen
- 78. Epidemiology • More prevalent in the Indian subcontinent • Historical evidences - similar kinds of syndromes were prevalent in Europe, USA and Australia in the 19th century
- 79. • 3 categories : 1. Dhat alone : Patients attribute their symptoms to semen loss; presenting symptoms hypochondriacal, depressive or anxiety symptoms 2. Dhat with comorbid depression and anxiety : Dhat is seen as an accompanying symptom 3. Dhat with sexual dysfunction
- 80. • Most commonly reported psychiatric disorders in the patients of Dhat syndrome: Erectile dysfunction (22-62%) Premature ejaculation (22-44%) Depressive neurosis (40-42%) Anxiety neurosis (21-38%) Somatoform/hypochondriasis (32-40%)
- 81. • Commonest associated psychiatric illness ; • Neurotic depression (39%) • Anxiety neurosis (21%) • 31% did not receive a psychiatric diagnosis
- 82. After random allocation into groups, four types of treatment were given: • Anti-anxiety drug • Antidepressant • Placebo • Counselling Best response was seen with the anti-anxiety and antidepressant drugs Twenty-one patients dropped out of treatment
- 83. • Treatment Emphatic listening Non-confrontational approach Reassurance and correction of erroneous beliefs Drugs- placebo, antianxiety and antidepressant drugs
- 84. Thank You
Editor's Notes
- CT accounts for 15-40% of cases,m.g 15-25% while the prevalence of t.v varies substantially from one region to another as well as within specific subpopulations
- Conducted in gujarat To determine the prevalence, clinical profile, and the pattern of STIs in males. A retrospective study of male cases attending STI clinic between January 2008 and December 2009 was carried out
- A clinicobacteriological study of 52 patients with urethritis was carried out. All the patients were evaluated clinically and bacteriologically at the beginning and end of the treatment.
- X ray of pelvis showing multiple metallic objects in the anterior and posterior urethra. It is usually seen in children and adolescents
- No cause may be found in one third of patients
- Identification of cause requires a thorough history, meticulous examination along with relevant laboratory investigation
- If there is no spontaneous discharge but the patient complains of it then milking of urethra should be done
- Sharply marginated , light red erosions along with discrete pustules over coronal sulcus
- Look for any scrotal erythema, edema. On palpation there may be tenderness of spermatic cord
- No specific clinical signs are found to be consistently associated with these infections.
- There may be multiple erosions, generalised erythema, acute pharyngitis or tonsillitis with cervical lymphadenopathy
- Wear sterile gloves. Specimen should be collected at least 2 hours after the patient has urinated as voiding decreases the amount of exudate and reduces the chances of detecting the organism
- Intraurethral swab is a sterile thin calcium alginate swab with a flexible wire shaft
- First 10-15ml of early morning urine is collected in a sterile plastic container with a large opening.urine is centrifuged for 10mins.supf part is decanted and sediment is used as specimen.If recent anal intercourse has occurred, a proctoscope is inserted 1st,followed by a swab stic 3 cm into canal rotating it for 10 secs to collect sample from the crypts just inside the anal ring.if orogenital contact with an infected person is suspected,specimen is collected from tonsillar crypts and bed of pharynx
- In presence of only extracellular or atypical gram negative diplococci, the diagnosis of gonorrhoea should be confirmed by culture
- In 1968 two urologists, Meares and Stamey, published a paper about the four glass test for prostatitis for localisation of infection.
- Patients are asked to urinate their first 10 ccs of urine into a sterile cup. Then, they are asked to urinate 10 ccs of urine from their midstream into a sterile cup. Next, their prostate is massaged and expressed prostatic secretions are collected. Finally, another 10 ccs of urine is collected to finish the "four glass collection.
- should be evaluated and treated for UD syndrome. Sexual abstinence should be advised during the course of treatment.
- A clinicobacteriological study of 52 patients with urethritis was carried out. All the patients were evaluated clinically and bacteriologically at the beginning and end of the treatment.
- But in view of growing literature citing increasing reports of repeat positive infections, this meta-analysis was updated in 2014
- suggesting a small, but statistically significant difference in favour of doxycycline. Beacause most of the included studies were not double blinded.double blinding is necessary to ensure r/o reinfection to be similar in both arms as it is likely that one week of doxycycline will deter people from resuming sexual activities while on treatment. most trials were based in high risk populations attending sexual health clinics. These populations are not representative of the majority of those who get chlamydia which is a largely asymptomatic infection.
- Moreover the use of chlamydial NAATs at <3 weeks gives false + due to continued presence of non viable organisms. If retesting is not feasible at 3 months,retest whenever patient returns in next 12 months
- Which changed in response to changes in social and economic factors
- mostly young, recently married, belonging to average or low socioeconomic status (perhaps a student, laborer or farmer by occupation), from rural area and from family with conservative attitudes towards sex
- n a prospective study of 144 consecutive male patients with psychosexual disorders, comprising 93 with Dhat syndrome with or without impotence or premature ejaculation, 21 with premature ejaculation, and 30 suffering only impotence
- n a prospective study of 144 consecutive male patients with psychosexual disorders, comprising 93 with Dhat syndrome with or without impotence or premature ejaculation, 21 with premature ejaculation, and 30 suffering only impotence