Urethral Discharge
George P.N. Samraj
Discharge from the urethra is a common symptom. The characteristics and the cause of urethral discharge (UD) vary widely. Discharge can be profuse or scanty; clear, yellowish, or white; mucopurulent or serous; bloody, watery, or frank pus. UD can be from an acute or chronic condition and patients may or may not have symptoms.
Approach
The causes of UD are summarized as follows:
A. Sexually transmitted diseases
1. Gonococcal (GC)
2. Nongonococcal (NGC):
a. Chlamydia trachomatis
b. Ureaplasma urealyticum
c. Mycoplasma genitalium
d. Other organisms linked to UD:
(1) Bacteria: Gardnerella vaginalis, Escherichia coli, tuberculosis, Corynebacterium species, bacterioides, mycoplasmas
(2) Viruses: herpes simplex virus, adenoviruses, cytomegalovirus, human papilloma virus, and others
(3) Protozoal: Trichomonas vaginalis; approximately 5 million cases occur annually in the United States
(4) Fungal: Candida species
B. Nonsexually transmitted diseases
1. Infections: cystitis, prostatitis
2. Anatomic abnormalities: urethral stricture, phimosis
3. Congenital abnormalities of the urogenital system
4. Iatrogenic: catheterization, instrumentation, and other procedures
5. Chemical irritation from use of douches, lubricants, and other chemicals
6. Tumors and malignant lesions and new growths
7. Foreign bodies: common in children, teenagers
8. Substance abuse: chronic use of amphetamines or other stimulants produces a serous discharge. Caffeine and alcohol are also implicated in UD
9. Miscellaneous factors linked to UD: sexual practices, masturbation, oral sex
10. Unknown: no organisms may be found in up to one-third of patients
History
A detailed medical history is essential for the evaluation of UD. The essential symptoms addressed at the time of interview are (a) dysuria, (b) urethral discharge, (c) itching at the urethra, (d) hematuria, (e) rectal symptoms, (f) contact with infectious agents, and (g) sexual history. The characteristics of UD are noted in relation to color, quantity, odor, consistency, frequency, and relationship to urination. Profuse, yellowish UD occurring 3 to 7 days after sexual exposure is characteristic of GC. GC infection is more common in men than in women. In 1997, 324,901 cases of gonorrhea were reported to the Centers for Disease Control, with a case rate of 122/100,000 (1). Clear to white, scanty, or mucopurulent UD (23% to 55%) that develops gradually at least a week after exposure, with waxing and waning in intensity, suggests chlamydial infection. This is the most common sexually transmitted disease (STD) in the United States, with 3 million new cases occurring annually (2). As many as 85% of women with chlamydial infections and 40% of infected men are asymptomatic (3). Sexual history should include sexual behaviors, condom usage, number of sexual partners, recent sexual contacts, and the orifices used for sexual contacts. Consistent usage of condoms prevents sexually transmitted urethritis. Oral sex increases UD from oral flora infections.
Physical examination
A. Focused physical examination (PE) should include vital signs, and urologic and rectal examination. In men, this should include examination of the penis, perimeatal region (for evidence of erythema), urethral meatus, scrotum, testicles, epididymis, prostate, and perianal and inguinal region. Stains present on the patient’s underwear may indicate the characteristics of the discharge, which is particularly useful in a patient who has urinated shortly before examination. Recent micturition can eliminate much inflammatory discharge. Sometimes it is necessary to examine the patient in the morning before voiding to enhance the diagnosis. Perform a complete gynecologic and urologic examination in women.
B. Abdomen. Completely examine the abdomen to rule out intraabdominal pathology, including masses and inflammation, obstruction, or distention of organs.
C. Additional physical examination should include the skin and other systems, as needed. If a patient is suspected of gonococcal infection, it may be essential to check the patient’s joints, skin, throat, eye and other organs.
Testing
A. UD sample collection. Proper collection and handling of UD sample is essential for the diagnosis. When the discharge is not spontaneous, the urethra should be gently stripped. This is best accomplished by grasping the penis firmly between the thumb and forefinger with the thumb pressing on the ventral surface. Then move the hand distally, compressing the urethra. This maneuver may express a small amount of discharge. The urethral meatus can be gently spread and if no urethral discharge is expressed, a calcium-alginate urethral (or nasopharyngeal) swab should be inserted at least 2 cm into the urethra and the discharge collected. The use of cotton-tipped swabs is contraindicated because their large size makes the insertion extremely uncomfortable and the cotton fibers can inhibit the growth of certain fastidious organisms (4).
B. Clinical laboratory investigations
1. UD Gram’s stain. The test involves staining the UD with Gram’s stain and examining it under a microscope. The presence of polymorphs with intracellular diplococci is diagnostic of GC. Polymorphs without the intracellular diplococci are suggestive of NGC disease. Few or no polymorphs are suggestive of other causes. The Gram’s stain is quite accurate for men but it is not very sensitive for women (50%).
2. UD culture is essential to identify specific organisms. Other useful tests are:
a. Detection of bacterial DNA by polymerase chain reaction (PCR)
b. DNA probes
c. Direct monoclonal testing and enzyme-linked assays. These tests have a high sensitivity and specificity. Cultures of throat, rectum, and sometimes conjunctivae may be required to establish the diagnosis.
3. UD wet preparation is done to establish the diagnosis of trichomoniasis, candidiasis, and some viral and bacterial infections.
4. Urine analysis and urine cultures are essential for the diagnosis of urinary infections. Collect the urine specimen [as described by Stamey (5)] with four sterile containers (before and after prostatic massage), which is useful to identify the site of infection in men.
5. Urinary leukocyte esterase is a useful screening test for chlamydial and GC infections in asymptomatic men. The usefulness of other neutrophil enzyme (elastace, myeloperoxidase) studies of urine have been reported.
6. Blood studies, including a complete blood count, serum chemistry profile, serologic test for syphilis, blood test for human immunodeficiency virus infection, and immunologic studies, may be required in an appropriate clinical setting.
C. Diagnostic imaging. Urethrogram, urologic diagnostic studies, and pelvic, vaginal, and rectal ultrasound studies are indicated in some clinical conditions.
D. Diagnostic procedures. Children and elderly patients may need to be examined under anesthesia to evaluate UD. Anoscopy is done for patients who have had anal intercourse or for those with anal and rectal symptoms. Cystourethroscopy and laparoscopy are also useful in certain conditions.
Diagnostic assessment
A. Special concerns. Neisseria gonorrhoeae and C. trachomatis infections are reportable to State Health Departments and a specific diagnosis is essential. UD secondary to STD involves many psychosocial and medicolegal implications to the patient, his or her partner, their families, and society. Sexual partners can be traced, tested, and treated. In children with UD, sexual abuse may be suspected. Pregnant women with gonococcal infection or chlamydia can infect the infant at birth (ophthalmia neonatorum).
B. Complications following UD and urethritis. Some of the complications following UD are postgonococcal urethritis, pelvic inflammatory disease (in women) and infertility, perihepatitis, chronic pelvic pain (Chapter 11.3), adhesions of the intraabdominal organs, obstructions in the gastrointestinal and genitourinary tracts, chronic urethritis, periurethral abscess, fistula, prostatitis, epididymitis, orchitis, urethral syndrome, psychosexual problems, and Reiter’s syndrome.
References
1. Centers for Disease Control and Prevention. National Center for HIV, STD, and TB Prevention. Sexually Transmitted Disease Surveillance. Atlanta: CDC, 1997.
2. American Social Health Association. Sexually transmitted diseases in America: how many cases and at what cost? Menlo Park, CA: Kaiser Family Foundation, 1998.
3. Institute of Medicine. Committee on Prevention and Control of STD. Eng TR, Butler WT, eds. The hidden epidemic: confronting STD. Washington, DC: National Academy Press, 1997.
4. Williams R, Kreder KJ Jr. Examination of UD and vaginal exudates. In: Tanagho EA, McAninch JW, eds. Smith’s general urology, 14th ed. Norwalk, CT: Appleton & Lange, 1995.
5. Stamey TA. Diagnosis, localization, and classification of urinary infections. In: Stamey TA, ed. Pathogenesis and treatment of urinary tract infections. Baltimore: Williams & Wilkins, 1980:262.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2008 Williams & Wilkins.
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