Urethritis is an inflammation of the walls of the urethra (urethra). Signs are pain, pain and burning when urinating, pathological discharge from the urethra, the nature of which depends on the causative agent of the disease. In complicated cases, the inflammatory process also passes to neighboring pelvic organs: prostate, bladder and scrotum organs. Another consequence of urethritis is a narrowing (stricture) of the urethra or its complete adhesion. An important point in the diagnosis of urethritis is to determine its etiology. For this purpose, a bacteriological examination of urine and a smear from the urethra is carried out. Treatment of urethritis is carried out in accordance with its cause (antibiotics, metronidazole, antimycotic drugs), with the development of the adhesive process, urethral augmentation is indicated.
Meaning
Urethritis is an inflammation of the urethra wall. It usually has an infectious nature. Extremely rarely develops without the presence of an infectious agent (radiation, toxic, allergic urethritis). Sometimes the cause of the disease is an injury during a diagnostic or therapeutic procedure (catheterization of the bladder in men, administration of drugs, etc.).
Infectious urethritis is divided into two large groups: specific and nonspecific. A specific inflammatory process in the urethra is caused by pathogens of sexually transmitted diseases (Gonococcus, trichomonas, chlamydia, ureoplasma, mycoplasma). The cause of the development of nonspecific inflammation of the urethra becomes conditionally pathogenic flora (Staphylococcus, streptococcus, fungi, proteus, E. coli).
Primary and secondary urethritis are isolated. With primary inflammation of the urethra, the infection penetrates directly into the urethra, most often during sexual contact with a partner who has a sexually transmitted disease. Secondary urethritis occurs when an infection spreads from an inflammatory focus located in another organ (from the pelvic organs, seminal vesicles, bladder, prostate gland).
Bacterial urethritis
The cause of the development of nonspecific inflammation of the urethra is conditionally pathogenic flora. Microorganisms enter the urethra during prolonged catheterization of the bladder in women and men, transurethral endoscopic manipulation or sexual contact with a casual partner.
Primary bacterial urethritis
There are acute and chronic bacterial urethritis. The course of acute nonspecific inflammatory process differs from the clinical picture of gonorrheal urethritis. The duration of the incubation period may be different. Local signs of inflammation are not so pronounced. It is characterized by pain during urination, itching, burning, purulent or mucopurulent discharge, slight swelling of the urethral mucosa and tissues surrounding the external opening of the urethra.
It must be remembered that on the basis of the clinical picture and the nature of the discharge, it is impossible to carry out differential diagnosis of bacterial and gonorrheal urethritis. The diagnosis is made only upon receipt of laboratory data confirming the absence of gonococci: bacposev for the presence of gonorrhea, PCR diagnostics, etc.
Chronic inflammation of the urethra is usually asymptomatic. There is a slight itching and burning sensation when urinating, scanty mucous discharge and high resistance to therapy. A short and wide urethra in girls and women allows infection to freely enter the bladder, causing cystitis, which is diagnosed during ultrasound of the bladder. In men, chronic urethritis in some cases is complicated by colliculitis (inflammation of the seminal tubercle). The seminal tubercle is the place of exit of the excretory ducts of the prostate and the vas deferens. Its inflammation can lead to hemospermia and ejaculation disorders.
Secondary bacterial urethritis
The infectious agent enters the urethra from the local focus of infection (in the pelvic organs, bladder, prostate, seminal vesicles) or with an infectious disease (sore throat, pneumonia). Secondary nonspecific urethritis is characterized by a long latent course. Patients complain of mild soreness during urination, scanty discharge from the urethra of a mucopurulent nature, more pronounced in the morning. In children, pain when urinating is often absent. Examination reveals hyperemia and gluing of the sponges of the external opening of the urethra.
When conducting a two- or three-cup sample, the first portion of urine is cloudy, contains a large number of leukocytes. In the second portion, the number of white blood cells decreases, and in the third, as a rule, corresponds to the norm. For a preliminary determination of the nature of the microflora, a bacterioscopic examination of the discharge from the urethra is carried out. To clarify the type of infectious agent and its sensitivity to antibacterial drugs, seeding of the discharge or flushing from the urethra is performed.
Treatment
Modern urology has effective methods of therapy for nonspecific urethritis. Treatment tactics are determined depending on the type of pathogen, the severity of symptoms, the presence or absence of complications. The combination of urethritis with cystitis is an indication for complex therapy. With a chronic nonspecific process, the intake of antibacterial drugs is supplemented by instillation of solutions of collargol and silver nitrate into the urethra, measures are taken to normalize immunity. The result of therapy for secondary urethritis is largely determined by the effectiveness of treatment of the underlying disease (urethral stricture, vesiculitis, prostatitis).
Gonorrheal urethritis
As a rule, it develops as a result of sexual intercourse with an infected partner, less often by indirect contact through towels, sponges, underwear, chamber pots. The cause of infection in children may be cohabitation with an adult patient, use of a shared toilet.
Symptoms
The first symptoms of the disease appear 3-7 days after infection. In some cases, it is possible to increase the incubation period to 2-3 weeks. Depending on the duration of the infection, acute gonorrhea is distinguished (the duration of the disease is less than 2 months) and chronic gonorrhea (the duration of the disease is more than 2 months).
Acute gonorrheal urethritis usually begins suddenly. There are abundant yellowish-gray purulent creamy discharge from the urethra, pain, burning and pain when urinating. When the inflammatory process is localized in the anterior urethra, the patient’s condition is satisfactory. The spread of inflammation to the posterior urethra is accompanied by hyperthermia up to 38-39 ° C and general signs of intoxication. Pain during urination becomes more pronounced.
Chronic gonorrheal urethritis develops:
- in patients with untreated or incompletely cured acute inflammation of the urethra of gonococcal etiology;
- in patients with weakened immunity;
- when involved in the inflammatory process of the prostate and the posterior part of the urethra.
The chronic inflammatory process is characterized by a weak severity of symptoms. Patients are concerned about itching and a slight burning sensation in the urethra. The onset of urination is accompanied by indistinct tingling pains. Discharge from the urethra is scanty, mucopurulent, mainly in the morning. Smear examination indicates the presence of gonococci and secondary microflora.
In chronic gonorrheal urethritis, the ducts of the paraurethral glands are often involved in the process. Inflammation complicates the outflow, leading to blockage of ducts, the development of infiltrates, abscesses and closed cavities. The general condition of the patient worsens, sharp pain during urination is characteristic.
Diagnosis
Microscopy of secretions from the urethra is performed. The diagnosis is confirmed in the presence of gonococci (Neisseria gonorrhoeae) – gram-negative bean-shaped aerobic diplococci. The standard study consists of two stages, includes staining by the Gram method and diamond green (or methylene blue).
Differential diagnosis
Diagnosis usually does not cause difficulties due to the presence of characteristic symptoms (pain during urination, purulent discharge from the urethra). A differential diagnosis of gonorrheal urethritis and inflammation of the urethra of another etiology (trichomonas, non-specific urethritis, etc.) is carried out. The diagnostic criterion is the results of a bacterioscopic examination. Anamnesis reveals the presence of sexual contacts with patients with gonorrhea.
Treatment
Treatment of gonorrheal urethritis is carried out by venereologists. Recently, there has been an increasing resistance of gonorrhea pathogens to penicillin. The greatest effectiveness is noted when taking cephalosporins and fluoroquinolones. The patient is recommended to drink copious amounts. Alcohol, fatty and spicy foods are excluded from the diet.
Chronic gonorrheal urethritis is an indication for combination therapy. The patient is prescribed antibacterial drugs and local treatment. With the growth of granulation tissue and cellular infiltration (soft infiltration), instillations of solutions of collargol and silver nitrate are carried out into the urethra. With the predominance of scar-sclerotic processes (solid infiltrate) the urethra is boosted with metal booges. Pronounced granulations are cauterized once a week with a 10-20% solution of silver nitrate through a urethroscope.
Criteria of cure
7-10 days after the end of treatment, a bacterioscopic examination of the urethra is performed. If gonococci are not detected, a combined provocation is performed: biological (pyrogenal or gonovaccine intramuscularly) and chemical (injection of 0.5 r of silver nitrate into the urethra). Mechanical (anterior urethroscopy or the introduction of booge into the urethra), thermal (heating by inductothermal current) and alimentary (alcohol and fatty foods) provocation is also used.
Then, every day for three days, the secret of the prostate gland, urine filaments and swabs from the urethra are examined. In the absence of leukocytes and gonococci, the provocation is repeated after 1 month. After another month, a third, final control study is conducted. If there are no clinical manifestations, and gonococci are not detected during sowing and bacterioscopy, the patient is removed from the register. Acquired immunity in gonorrhea is not formed. A person who has had gonorrheal urethritis in the past may become infected again.
Forecast
With proper, timely treatment of fresh gonorrheal urethritis, the prognosis is favorable. With the transition of the process to a chronic form and the development of complications, the prognosis worsens. Gonococcal endotoxin has a sclerosing effect on the tissues of the urethra, which can lead to the formation of strictures (usually multiple) in the anterior part of the urethra. Frequent complications of chronic inflammation of the urethra in gonorrhea are vasiculitis, epididymitis, chronic prostatitis. The outcome of prostatitis may be impotence, the outcome of epididymitis – infertility as a result of cicatricial narrowing of the vas deferens.
Trichomonas urethritis
Symptoms and diagnosis
Symptoms of trichomonas urethritis appear 5-15 days after infection. Characterized by mild itching, moderate whitish foamy discharge from the urethra. The diagnosis is confirmed by the detection of Trichomonas (Trichomonas vaginalis) in native and colored preparations. Examine the discharge of the urethra, urethral scraping or centrifugate of the freshly released first portion of urine. In native preparations, the movements of the flagella of the trichomonads are clearly visible.
Often, when examining a native drug (especially in men), mobile trichomonads cannot be detected. It is possible to increase the reliability of the study using additional methods (microscopy of stained smears, examination of crops).
Treatment
Specific antitrichomonas drugs are used, the most effective of which are metronidazole, ornidazole and tinidazole. The treatment regimen depends on the patient’s condition, the severity of symptoms, the presence of complications and concomitant sexually transmitted infections. Self-medication is unacceptable, since it can contribute to the transition of an acute process into a chronic one.
In order to prevent re-infection, the patient’s permanent sexual partner is treated at the same time. During therapy and for one to two months after its completion, the patient is recommended to drink copious amounts, exclude spicy food and alcohol from the diet. In case of resistant chronic inflammation, both general and local therapy is prescribed. Within 5-6 days, the patient is instilled with a 1% trichomonacide solution lasting 10-15 minutes.
In some cases, trichomoniasis in men is asymptomatic or accompanied by extremely poor symptoms. Patients are often unaware of their disease, and spread the infection among their sexual partners. In 15-20% of cases with chronic trichomonas urethritis, prostatitis develops, which worsens the patient’s condition and makes it difficult to cure.
Chlamydial urethritis
A number of serotypes of Chlamydia trachomatis act as an infectious agent. Chlamydia are located intracellularly, which is typical for viruses, but the presence of certain signs (DNA, RNA, ribosomes, cell wall) makes it possible to classify these microgranisms as bacteria. It affects the epithelial cells of the urethra, cervix, vagina and conjunctiva. Sexually transmitted.
Chlamydial urethritis usually proceeds sluggishly, with little symptoms. The inflammatory process in the urethra in some cases is accompanied by joint damage and conjunctivitis (urethro-oculo-synovial syndrome, Reiter’s disease). The diagnostic criterion is the presence of semilunar intracellular inclusions in the stained scrape from the urethra.
Treatment. Problems in the treatment of chlamydia are associated with insufficient permeability of cell membranes for most antibiotics. Repeated manifestations after the treatment courses are characteristic. To increase the effectiveness, broad-spectrum antibiotics are combined with corticosteroid drugs (dexamethasone, prednisone). The maximum dose of prednisone is 40 mg / day, the course of treatment is 2-3 weeks. During the course of therapy, the dose of hormones is gradually reduced to complete withdrawal.
Candidamycotic urethritis
Yeast-like fungi act as the causative agent. Inflammation of the urethra of fungal etiology is rare, it is usually a complication after long-term treatment with antibacterial drugs. Sometimes it develops after sexual contact with a woman who suffers from candidamycotic vulvovaginitis. The risk of infection increases if there is a history of inflammatory diseases or damage to the urethra.
Candidamycotic urethritis is characterized by erased symptoms. Patients complain of slight burning sensation, mild itching, whitish scanty discharge from the urethra. Microscopy in the acute process reveals a large number of yeast-like fungi. In chronic inflammation, mycelium filaments predominate in the sample. Therapy consists in the abolition of antibacterial drugs and the appointment of antifungal agents (nystatin, terbinafine, fluconazole).