URETHRAL DISCHARGE
URETHRAL DISCHARGE: Excerpt from Differential Diagnosis in Primary Care
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.
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
-
CBC (systemic infection)
- Sedimentation rate (collagen disease, systemic gonorrhea)
- Venereal disease research laboratory (VDRL) test (chancre)
- Frei test (lymphogranuloma venereum)
- Urine culture and sensitivity (cystitis)
- Chancroid skin test (chancroid)
- Human leukocyte antigen (HLA)-B27 antigen (Reiter syndrome)
- Smears for cytology (carcinoma)
- Cystoscopy (bladder neck obstruction, neoplasm)
- Intravenous pyelogram (IVP) and cystogram (malformation,
obstructive uropathy, neoplasm)
Pictures
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins MD, FACP
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
More About Penile candidiasis
More Medical Textbooks Online about Penile candidiasis
Review other book chapters online related to Penile candidiasis:
Medical Books Excerpts
- Candidiasis
- "Professional Guide to Diseases (Eighth Edition)" (2005)
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- Urethral Discharge
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
» Next page: Candidiasis (The 5-Minute Pediatric Consult)
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