URETHRAL DISCHARGE

A significant purulent urethral discharge invariably signals the diagnosis of gonorrhea and, until a Gram stain is done, little consideration is given to the other causes of a nonbloody urethral discharge. However, one should also consider other etiologic agents (Staphylococcus, Escherichia coli, herpes, mima polymorpha, and, particularly, Chlamydia trachomatis). Furthermore, the anatomy of the urogenital tree should be visualized so that inflammation of all the components can be carefully considered in the resistant case.

URETHRAL DISCHARGE

Beginning with the prepuce, the physician should consider balanitis of either infectious or autoimmune origin (e.g., Reiter disease). An ulcer from lues, chancroid, or lymphogranuloma inguinale or venereum must be looked for. The urethra suggests the urethritis of gonorrhea, Chlamydia, and numerous other organisms, whereas autoimmune disorders like Reiter disease precipitate a nonspecific urethritis and nonbloody discharge. Again, chancres, chanchroids, and herpes may involve the anterior urethra. Trichomonas organisms rarely produce a discharge in the male. In the female, the Skene glands may be infected by gonorrhea or other organisms. A urethral caruncle can easily be recognized as a small, cherry-red mass at the urethral orifice.

Further up, the prostate is encountered and acute and chronic prostatitis and prostatic abscess are immediately suggested. Inflammation of Cowper glands or of the seminal vesicles should be remembered as a possible cause of a discharge in resistant cases. In the female, urethrovaginal fistula (most frequently from surgery or cervical carcinoma) should be considered.

As elsewhere, a purulent discharge does not necessarily signify inflammation alone. There may be a foreign body, a papilloma, and occasionally a carcinoma that precipitates a superimposed infection.

Approach to the Diagnosis

The association of other symptoms and signs is helpful in narrowing the list of possibilities. The discharge of acute urethritis is usually associated with severe pain on micturation whereas the discharge of prostatitis is often not. The discharge of chronic prostatitis is usually painless and occurs most frequently on arising. Urethral caruncles, papillomas, and carcinomas frequently have a bloody discharge, at least intermittently. On examination, the physician can detect induration of a urethral chancre and the erythema of a balanitis is obvious when the prepuce is retracted. The presence of arthritis or conjunctivitis makes Reiter syndrome a distinct possibility, although gonorrhea may do the same. The boggy prostate of prostatitis and the increase of the discharge on massage will assist greatly in this diagnosis.

In the laboratory, a smear and culture are axiomatic in diagnosis, and one must massage the prostate and milk the urethra if little discharge is found on simple inspection. After massaging the prostate, the first portion of a voided specimen should be examined, smeared, and cultured if no discharge is apparent. Culture for Chlamydia if routine cultures are negative. Cystoscopy and cystograms may be necessary, but the indications for these will be at the discretion of the urologist, who should be consulted if routine treatment is ineffective.

Other Useful Tests

1. CBC (systemic infection)
2. Sedimentation rate (collagen disease, systemic gonorrhea)
3. VDRL test (chancre)
4. Frei test (lymphogranuloma venereum)
5. Urine culture and sensitivity (cystitis)
6. Chancroid skin test (chancroid)
7. HLA-B27 antigen (Reiter syndrome)
8. Smears for cytology (carcinoma)
9. Cystoscopy (bladder neck obstruction, neoplasm)
10. IVP and cystogram (malformation, obstructive uropathy, neoplasm)

Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8