Dr.

Shilpa Soni
MGMCH
 medial horizontal gp of
superficial
Inferior vena
cava
inguinal LN
 Superficial Inguinal LN Deep inguinal LN

- Penile skin
- Anterior male urethra & glans
- Scrotal skin
penis
- Vulva
Sacral LN
- Vagina, lower third

- Uterus, lower part - Vulva

- isthmus of fallopian tube

- Cervix
 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
Urethritis

Inflammation of the urethra.

Discharge +/- dysuria or may be

asymptomatic.
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.
 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. Ferments glucose
4. PPNG penicillinase produc-
- ing N. gonorrhoea: cefotaxime,
ceftriaxone, ciprofloxacin, tetrac-
-ycline can be used.
 N gonorrhoea present predominantly intracellularly
in the polymorphonuclear leucocytes (PMN).
Penetrates columnar epithelium.
 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
 Strains

- Pathogenic strains N. gonorrhoea

- N. meningitidis
- Non pathogenic strains N. catarrhalis
- N. pharyngis sicca
- N. lactamica
- N. subflava
Clinical features :
Affects urethra in both sexes.

Transmission sexual contact

Incubation period 2-5 days

Intense burning sensation.

Fever & malaise.

 In men anterior urethritis is more common.
Discharge profuse, purulent & yellowish
green.
15% males mild or asymptomatic.
 Complications

- Posterior urethritis

- Epididymitis

- Acute or chronic prostatitis

- Untreated periurethral abscess & watercan

perineum.
 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
 Proctitis through autoinoculation from cervical
discharge or as a result of direct contact from an
infected partners penile secretions.
 Complications in 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.
Present in upto of women with PID caused either by
N. gonorrhoea or C. trachomatis.
 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
 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 assays
Radioimmunossay
Immunoblotting
 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.
 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.

Non
gonococcal
urethritis
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
 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.
 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.

 In men-

- Sites of infection are urethra.

- epididymis.

- systemic.

- Clinical syndrome urethritis, post gonococcal

urethritis & Reiters disease.

 Urethritis

- Dysuria with mild to moderate whitish or clear

urethral discharge.

- On examination focal urethral tenderness

- meatal or penile lesions may mimic

herpetic urethritis.
 Epididymitis recurrent infections

- Unilateral scrotal pain, Swelling & Tenderness.

- Fever

- Urethritis may often be assymptomatic & evident only

as urethral inflammation.
 Prostatitis

- Ususaly asymptomatic or may

- Presents with discomfort on passing urine & vague

pain in perineum, groins, thighs, penis, suprapubic
region or back.

- Painful ejaculation.
 Proctitis repetitive anal intercourse or by lymphatic
spread from posterior urethra.

- Rectal pain

- Discharge - mucopurrulent

- Bleeding
 Reiters 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.
 Organisms associated with Reiters syndrome are

- N. gonorrhoea

- C. trachomatis

- U. urealyticum

- Salmonella

- Shigella

- Campylobacter

Treatment antibiotics, NSAIDS, sulfasalazine, corticosteroids &

immunosupressants.
 In women
- Cevicitis mucopurulent cervical discharge
- cervical erythema & edema with an area of
ectopy
- spontaneous or easily induced cervical
bleeding
- Urethritis dysuria
- frequency
- pyuria
- Bartholoinitis
- Endometritis abnormal vaginal bleeding
- menorrhagia
- metrorrhagia
- PID lower abdominal pain
- adenexal tenderness on pelvic examination
- MPC often present
- Perihepatitis (Fitz-Hugh-Curtis Syndrome)
 Lab diagnosis
Clinical syndrome Clinical criteria Presumptive Diagnostic
- male criteria criteria

NGU Dysuria, urethral Gram stian - > 5 Positive culture

discharge PMNL/hpf
Pyuria on first void
urine
Acute epididymitis Fever, epididymal Positive culture or
or testicular pain, non culture test on
evidence of NGU - do - epididymal
Epididymal aspirate.
tenderness or mass.
Clinical Clinical criteria Presumptive Diagnostic
syndrome criteria criteria

Mucopurulent Mucopurulent Cervical gram Positive culture or

cervicitis cervicitis discharge staining > 30 non culture test.
Cervical ectopy & PMNL/hpf in non
edema, menstruating
spontaneous or women
easily induced
cervical bleeding
Acute urethral Dysuria, frequency Pyuria
syndrome syndrome > 7 days No bacteria - do -
of symptom
PID Lower abdominal Cervical Positive culture or
pain, adenexal gramstaining non culture test
tenderness on positive for (cervix first void
pelvic examination gonococcus, urine,
evidence of MPC endometritis on endometrium,
often present endometrial tubal)
biopsy
 Antigen detection DFA

- enzyme linked immunosorbant

assay
- monoclonal or polyclonal Ab
against chlamydial
lipopolysacharide (LPS) or MOMP
 Nucleic acid hybridization

- rRNA by hybridization with DNA probe.

- PAGE 2 assay by Genprobe

PCR

Serology complement fixation test or

microimmunofluorescence
 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
Chlamydial infection in pregnancy
In antenatal period -

1. Spontaneous abortion

2. Neonatal conjunctivitis

3. Low birth baby

4. Prematurity & preterm delivery

 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
Clinical features intense redness & swelling of
conjunctiva
- profuse purulent discharge
Complication corneal perforation
- scarring
- blindness
Treatment Infection during Neonatal Infantile
pregnancy chlamydial pneumonia
conjunctivitis
Recommended Erythromycin 500 Syp erythromycin Syp erythromycin
regimine mg QID for 7 days 50 mg /kg /day in 50 mg/ kg/ day
or 4 divided doses for orally in 4 divided
Amoxycillin 500 14 days doses for 14 days
mg TDS for 7 days
or
Azithromycin 1 gm
stat.
Alternative Erythromycin base Trimethoprim
regimine 500 mg QID for 7 40mg with
days or 250 mg sulfamethoxazole
QID for 14 days 200 mg orally BD
or for 14 days.
Erythromycin
ethylsuccinate 800
mg QID for 7 days
or 400 mg QID for
14 days.
Ureoplasma urealyticum
Causes non specific urethritis.

Transmitted by sexual contact.

In males causes urethritis, proctitis & Reiters syndrome

In females causes acute salphingitis, PID, cervicitis &

vaginitis.

- Also been associated with infertility, abortions, postpartum

fever & low birth baby.
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

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 which prevents the

bacterial invasion in the urothelium.

Herpes genitalis
HSV 1 & HSV 2
Incubation period 5-14 days
Symptoms painful lesions
- Fever, headache, myalgias & malaise
- Grouped vesicles pustules ulcers.
Diagnosis- tzancks 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
 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.

Syndromic approach
Urethral Discharge
History / Examine
Milk urethra

Discharge present No other STI? No ECCV

Yes Yes
Treat for Gonorrhoea & Use appropriate flow chart
Chlamydia &
trichomoniasis

ECCV, Partner treatment, Follow up

 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
 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
 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

Thank you