This document discusses urethritis and balanoposthitis. It begins by defining urethritis as inflammation of the urethra and describing the different types of urethritis including gonococcal and non-gonococcal causes. It then focuses on gonococcal urethritis caused by Neisseria gonorrhoeae. It describes the clinical features, investigations, management, and complications of gonococcal and chlamydial urethritis. The document then defines balanoposthitis as inflammation of the glans penis and prepuce. It discusses the various etiologies, clinical features, investigations, and management of balanoposthitis.

1. INTRODUCTION
 Chief presenting complaints
Ulcers
Discharge
Lymphadenopathy

2. Discharge
Male
Subpreputial
Female
VaginalCervicalUrethralUrethral

3. URETHRITIS
FG OFFR ADITYA PASUMARTHY
INTERN

4. Discharge - male
 Urethral
 Physiological-
 Prostaturia
 Spermaturia
 Phosphaturia
 Pathological
 Gonococcal
 Non gonococcal
 Sub prepuceal
 Physiological - Smegma
 Pathological – multiple etiologies

5. URETHRITIS
Inflammation of the urethra
Discharge
+/- dysuria or may be asymptomatic.

6. TYPES
 BROADLY CLASSIFIED AS
- Gonococcal –
- Neisseria gonorrhoea (50-90%)
- Non gonococcal –
- Chlamydia trachomatis
- Ureaplasma urealyticum
- Mycoplasma genitalium
- Trichomonas vaginalis
- Yeast
- HSV
 Non Infectious Causes
- Trauma
- Urethral stricture.
- Catheterization.
- Chemical irritants.
- Dehydration.

7. GONOCOCCAL URETHRITIS
 N gonorrhoea – present predominantly intracellularly in the
polymorphonuclear leucocytes (PMN).
 Penetrates columnar epithelium.

8. CLINICAL FEATURES
Clinical features :
 Affects urethra in both sexes.
 Transmission – sexual contact
 Incubation period – 2-5 days

9. SYMPTOMS
 MALE-
 Discharge – profuse, purulent &
yellowish green
 Intense burning sensation
 Fever & malaise
 15% males – mild or asymptomatic
 SITE-In men anterior urethritis is more
common.
 FEMALE-
 -Discharge - scanty, mucopurulent
cervical discharge
- Vaginal pruritus
- Dysuria
 -50% of infected females are
asymptomatic
Primary site - endocervical canal

10. COMPLICATIONS
 MALES
- Posterior urethritis
- Epididymitis
- Acute or chronic prostatitis
- Untreated – periurethral abscess &
watercan perineum.
 FEMALES
- PID
- Tubo ovarian abscess
- Subsequent ectopic pregnancies
- Chronic pelvic pain
- Infertility
 Fitz-Hugh-Curtis syndrome –
inflammation of liver capsule
associated with genitourinary tract
infection.

11.  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

12. INVESTIGATIONS
 Laboratory diagnosis –
- Microscopy – gram staining
- gram negative diplococci
 Culture
 – thayer martin medium
- chacko nayer medium
- martin lewis media
- new york city media
 OTHERS
 PCR
 DNA hybridisation
 ELISA
 The complement fixation
 Latex agglutination
immunofluoroscence & anti surface
pili assays
 Radioimmunossay
 Immunoblotting

13. MANAGEMENT
 Treatment – uncomplicated gonorrhoea
- Ceftriaxone 250 mg stat IM or
- +
If chlamydia infection is not ruled out
- Azithromycin 1 gm stat or
- Doxycycline 100 gm BD for 7 days.

14. NON GONOCOCCAL
URETHRITIS

15. CHLAMYDIAL URETHRITIS
 C. trachomatis – gram negative obligate intracellular micro
organism that preferentially infect squamo-coloumnar
epithelium.

16. 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.

17.  URETHRITIS
 EPIDIDYMITIS
 PROSTATITIS

18. REITERS SYNDROME
 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.

19.  WOMEN- URETHRITIS
 CERVICITIS
 ENDOMETRITIS
 PID
 FITZ CURTIS HUGH SYNDROME

20. Chlamydial infection in pregnancy
 In antenatal period -
1. Spontaneous abortion
2. Neonatal conjunctivitis
3. Low birth baby
4. Prematurity & preterm delivery

21.  Postnatal infection
1. Neonatal conjunctivitis
2. Ophthalmia neonatorum
3. Pneumonia
4. Chronic lung or eye disease

22. TREATMENT
 Azithromycin 1 gm stat
 Doxycycline 100 mg bd 7 days

23. Chlamydial infection in pregnancy
 In antenatal period -
1. Spontaneous abortion
2. Neonatal conjunctivitis
3. Low birth baby
4. Prematurity & preterm delivery

24.  Postnatal infection
1. Neonatal conjunctivitis
2. Ophthalmia neonatorum
3. Pneumonia
4. Chronic lung or eye disease

25. 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.

26. 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

27. BALANOPOSTHITIS

28. DEFINITION
 Gk : ‘Balanos’ - Head of Penis / Glans
Lat : ‘Posthe’ - Foreskin / Prepuce
+ ‘itis’ – inflammation
Defined as the inflammation of the Glans Penis and mucosal surface of the
prepuce, commonly in uncircumcised males, with subpreputial discharge and
phimosis.
2% Incidence

29. ETIOLOGY
 INFECTIVE
 NON INFECTIVE
 IRRITANTS/ALLERGENS
 TRAUMATIC
 FIXED DRUG ERUPTION
 PREMALIGNANT
 CUTANEOUS /MUCOCUTANEOUS
 MISCELLANEOUS

30.  INFECTIVE
Spirochaetal
Treponema Pallidum
T. refrigens / phaegedenis / balanitidis / vincenti
Viral
HSV (20%)
HPV
Mycobacterial
M. tuberculosis
M. leprae

31. OTHER BACTERIA
Gardenella Vaginalis
Streptococcus sp
S. aureus
Calymmatobacterium granulomatis
Neisseria gonorrhoeae
Chlamydia trachomatis
Hemophilus ducreyi
Pseudomonas

32. Protozoal
Trichomonas vaginalis
Entamoeba histolytica
Parasitic
Scabies
Pediculosis
Creeping eruptions / CLM

33.  IRRITANTS / ALLERGENS
 Smegma
Soaps
Urine
Condoms
Spermicides
Podophyllin / Topicals
Lubricants
 TRAUMATIC
MALIGNANT DISEASES
SCC / BCC
MELANOMAS
 FIXED DRUG ERUPTIONS
Tetracyclines / Sulphonamides
Carbamazepines
Dapsone
Salicylates
Erythromycin
Metronidazole
Barbiturates
PREMALIGNANT CONDITIONS
Erythroplasia of Qeuyrat (Bowen’s dis)
Leukoplakia
Extramammary Paget’s

34.  CUTANEOUS / MUCOCUTANEOUS
Pemphigus
DH / EM /SJS/TEN
LP / Psoriasis
Behcet’s Disease
Aphthae
Herpes Zoster
Varicella Zoster
 MISCELLANEOUS
Circinate Balanitis
Zoon’s Balanitis
Balanitis Xerotic Obliterans
FB-induced (Beads / Calculi)
Post Intravesical BCG (Granulomatous
BP)

35. CLINICAL FEATURES
 Papules / Pustules or Vesicles (even Bullae) with Erosions
 Prepucial Edema, Phimosis
 Thick, foul smelling subpreputial discharge
 Pain / Pruritis / Burning Micturition
 Painful LAN
 Extensive Ulceration

36. CLINICAL FEATURES
 Smooth erythematous scaly papules with satellite pustules (Superadded
inf)with peeling of skin +/- Plaques of thrush / Maceration / Erosions
(Candida albicans)

37. CLINICAL FEATURES
 Small Gray-White vesicles on erythematous base +/- Ulceration with
Prostatitis / Urethritis
(Trichomonas Vaginalis)

38. CLINICAL FEATURES
 Superficial Erosions with Purulent Urethral Discharge (Neisseria
Gonorrhoea)

39. CLINICAL FEATURES
 Erosive indurated painless Chancre over Prepuce with Phimosis – Doughy
inflitrate / Nodular Infiltrate / Diffuse Inflitrate)
(Follman’s Balanitis of Syphilis)

40. CLINICAL FEATURES
 Multiple painful shallow non-indurated ulcers with undermined edges over
prepuce / glans +/- Phimosis (Chancroid)

41. CLINICAL FEATURES
 Annular erythematous moist plaques with ulceration healing with fibrosis /
scarring with preceding Oral Ulcers / Ophthalmic inv
(Behcet’s Disease)

42. CLINICAL FEATURES
 Bright red micaceous scaly annular plaques with cutaneous / nail / joint inv
(Penile Psoriasis)

43. CLINICAL FEATURES
 Painless, Serpiginous, geographic dermatitis of Glans (uncirc) and
Hyperkeratotic plaques (Cir) (CIRCINATE BALANITIS of REITER’S DIS)

44. CLINICAL FEATURES
 Chronic inflamm followed by atrophic sclerosis, depigmentation,
induration, phimosis and Urethral Stricture
(Lichen Sclerosus et Atrophicans / BXO)

45. COMPLICATIONS
 Recurrence / Chronicity
 Phimosis / Paraphimosis
 BXO
 Prepucial Adhesions
 Prepucial Perforation
 Phagaedena
 Scarring / pigmentation
 Meatal Sricture
 Lymphedema
 Neoplasm

46.  Detalied History taking / Clinical Examination
 Confirm Diagnosis
KOH MOUNT (CANDIDA)
SUBPREPUTIAL SWAB for Culture (TRICH)
GS / ZN STAIN (MIXED INF)
PUS CULTURE / ABST (MIXED INF)
DGI MICROSCOPY (SPIRO)
TZANCK SMEAR (HSV)
ACETOWHITE TEST (HPV)
URETHRAL SWAB (GONO)
PATCH TESTS (CD)
SKIN BIOPSY

47.  OTHER INVESTIGATIONS
HIV
VDRL / RPR / TPI / FTA-ABS
BS F/PP
URINALYSIS / CULTURE
CBC

48. TREATMENT- GENERAL MEASURES
SUBPREPUCIAL IRRIGATION
NS / KMnO4 (1:10,000) / 1% Boric Acid
1% Lead Acetate / 0.6% MgSO4
CIRCUMCISION (Phimosis / ZB / Chronic / Intractable BP)
TREATMENT OF SEXUAL PARTNER(S)
MANAGEMENT OF SYSTEMIC DISEASE (HIV / DM / PSOR / BEHCET’S)
PERSONAL HYGEINE

49. TREATMENT- SPECIFIC
 ORAL and / or TOPICAL ANTIBIOTICS / ANTIFUNGALS / ANTIVIRALS /
ANTHELMINTHICS
 TOPICAL CORTICOSTEROIDS (PSOR / LP / FDE / ZB / BXO / CD)
 SURGICAL MGMT (MEATOPLASTY-TOMY, DORSAL SLIT, CIRCUMCISION)