Urethral Disorders

s/s of urethritis

itching, tingling or dysuria in the urethra

+/- discharge

most common infections that may include symptom of urethral discharge, include:

- n. gonorrhoeae

- chlamydia trachomatis

*other pathogens are possible, including: parasitic, bacterial or viral agents

it is _________ that urethritis would be diagnosed in a male who is NOT sexually active

unlikely

1 multiple choice option

what is the recommended physical exam technique when a male patient reports a history of discharge?

palpate down the dorsal shaft of the penis

- in a "milking" fashion, to produce discharge

- this can be done by the patient while you observe

physical exam (PE) includes:

- palpate the penis

- inspect & palpate for inguinal lymphadenopathy

- inspect skin for ulcers or vesicles

- palpate scrotum to evaluate for epididymitis or orchitis

- examine pharynx

- optional DRE

if the infection is limited to urethritis, will the epididymis or testicles be tender?

NO

1 multiple choice option

when should a DRE be done?

if the patient reports rectal pain

- consider examining the anus even if not doing this

what is the initial diagnostic test for urethritis?

urine dipstick

- most will have + leukocyte esterase & WBCs

in urethritis, the urine sample can be used for..

both the dipstick & NAAT

in the case of urethritis, ______________ urine is preferred

first catch

is pre-cleaning of the urethral meatus recommended when providing a urine sample for possible urethritis?

no

• in this case, FIRST CATCH urine is preferred… therefore, do NOT clean the urethral meatus

• urethral meatus = the most distal part of the urethra located on the tip of the penis

when can presumptive diagnosis of urethritis be made w/o waiting for additional exam results?

when mucopurulent urethral discharge is seen on exam

_________________ can cause urethritis in both males & females, but is symptomatic in women

c. trachomatis

how does c. trachomatis usually appear in women?

as cervicitis, salpingitis, or pelvic inflammatory disease

how is definitive diagnosis of urethritis made?

NAAT

- using either urine or swab

when is screening asymptomatic men for urethritis recommended?

- men who have sex w/ men (MSM)

- men who are HIV positive

what is the DOC for treatment of chlamydia?

doxycycline 100 mg 2x/day for 7 days

- alt. = azithromycin 500. mg on day 1, then 250 mg days 2-5

treatment for chlamydia is usually offered ____________, especially if the patient is unlikely to follow-up

empiricially

if someone is found to have chlamydia, does the partner need treated too?

yes

1 multiple choice option

1% of men w/ chlamydia develop ___________________.

reactive arthritis

- NSAIDs are main tx

- abx NOT indicated unless active chlamydial infection confirmed by NAAT

in the case of co-infection w/ chlamydia & mycoplasma genitalium, what should the doxycycline be followed by?

a course of either moxifloxacin or azithromycin

s/s of n. gonorrhoeae in men:

- burning w/ urination

- urethral discharge that can be serous, milky, creamy or blood-tinged

similar to females where STDs can spread from cervix upward to cause PID, what can they do in men?

can spread to epididymis & prostate

gonorrhea can cause _______________________.

urethral strictures

oral sex can lead to pharyngeal gonorrhea infection which will resolve on it's own; however, will the coexisting genital infection resolve on its own?

no

1 multiple choice option

disseminated infection w/ gonorrhea can occur. how can this present?

purulent, monoarticular arthritis, or triad of:

- rash

- tenosynovitis

- arthralgias

w/ disseminated gonorrhea infection, how may the rash appear?

as hemorrhagic painful pustules w/ erythema on palms & fingers

how is gonorrhea diagnosed?

NAAT using either first-catch urine or urethral swab

- swabs can also be used to dx rectal or oropharyngeal infections

how is gonorrhea treated?

ceftriaxone 500 mg IM (1 g if > 300 lbs)

- alt: cefixime 800 mg po stat OR gentamicin 240 mg IM + azithromycin 2 g po stat

does the partner need treated in the case of gonorrhea?

yes

1 multiple choice option

empiric treatment would likely include 2 meds, to cover:

chlamydia

&

gonorrhea

aside from chlamydia & gonorrhea, what is the 3rd most common pathogen causing urethritis?

mycoplasma genitalium

- can also be diagnosed through NAAT

what should you do if discharge persists after treatment?

culture the discharge for possible alternative pathogen

trichomonas vaginalis is usually _____________ in men, but can cause urethral burning & scant discharge

asymptomatic

1 multiple choice option

how is trichomonas vaginalis diagnosed?

wet mount & observation of motile organisms under microscopy, NAAT, or point of care antigen tests

how is trichomonas vaginalis treated?

tinidazole or metronidazole 2 g dose STAT

for all STIs, patients should practice abstinence for ____________ once therapy has started

one week

how can STIs be prevented?

- treat partners

- encourage behavioral change that will reduce recurrence (monogamous relationships)

- offer testing for syphilis, HIV, & hep B

- encourage condom use

- educate regarding spermicides

____________ reduces risk of STD

circumcision

other possible differentials (may NOT cause discharge):

- ureaplasma urealyticum bacteria

- reactive arthritis (Reiter syndrome); considered non-infectious

- adenovirus serotypes 2, 8, & 37 (can cause urethritis & genital ulcers)

- atrophic vaginitis &/or atrophic urethritis (w/ possible incontinence) which may improve w/ topical estrogen

- UTI

how does a UTI differ from urethritis?

- no discharge

- more severe dysuria

- hx lacks sexual exposure

- UA positive for nitrites

2 categories of epididymitis:

1. STD progression of chlamydia or gonorrhoeae (usually men < 40 y/o)

2. non-sexually transmitted forms assoc. w/ UTI (older men w/ BPH or pediatric pts < 14 y/o)

what is the likely path for pathogens to take to get to the epididymis?

urethra --> ejaculatory duct --> vas deferens --> epididymis

s/s of epididymitis

- fever

- irritative voiding sx (dysuria, frequency)

- gradual, unilateral, severe painful enlargement of epididymis (early) or entire scrotum (late)

- sx of urethritis may or may not be present

- prostate may become tender

- prehn sign

- palpation will reveal extreme tenderness to epididymis

what is the prehn sign?

lifting the scrotum above the pubic symphysis may partially relieve pain

- not very reliable

how is epididymitis diagnosed?

- CBC (leukocytosis & increased neutrophils)

- CRP (usually elevated)

- UA (+ leukocyte esterase, nitrites, & possibly blood) & CULTURE!

- NAAT (if hx warrants)

- if dx uncertain, US may be warranted

how is epididymitis treated?

depends on pathogen, but an extended course of antibiotics is often warranted (up to 21 days)

- outpatient treatment w/ 1 wk f/u is recommended in most cases

w/ epididymitis, if STD is likely, start treatment empirically w/:

ceftriaxone IM 500 mg + doxycyline 100 mg BID x 10 days or longer

- or for MSM: ceftriaxone IM 500 mg + levofloxacin 500 mg qd x 10 days

which antibiotic is used for non-sexually transmitted epididymitis in adults?

levofloxacin

which abx are used for non-sexually transmitted epididymitis in children?

trimethoprim-sulfamethoxazole (Bactrim) or cephalexin

what does additional tx of epididymitis include?

analgesics & rest/avoidance of physical exertion

prompt treatment of epididymitis prevents complications, but what can delayed treatment lead to?

scrotal pain, abscess or infertility

what may children w/ epididymitis be referred for?

eval of possible anatomic abnormality of urinary tract

what may older men w/ epididymitis be referred for?

prostate eval if no previous hx

how do urethral strictures usually present in men?

as a chronic voiding problem, w/ a sense of obstruction/decreased stream & an inability to fully empty the bladder

- may also have frequent UTIs or ejaculatory dysfunction

what causes urethral strictures?

procedural instrumentation or trauma to the urethra or infection (gonorrhea)

the development of the stricture is ____, so the pt often does not associate the stricture w/ the previous procedure or infection. it may appear to be idiopathic.

slow

1 multiple choice option

how are urethral strictures diagnosed?

several different tests can be utilized (refer to urology!).

treatment options include:

- cystourethroscopy

- retrograde urethrogram

- voiding cystourethrogram

- ultrasound urethrography

how are urethral strictures treated?

refer to urology for treatment

- the location & size will guide treatment

- endoscopic techniques are usually preferred & include various forms of dilation, if not possible surgery is indicated

what does the anterior urethra include?

meatus of the penis & bulbar urethra

what does the posterior urethra include?

prostatic urethra & the bladder neck

what can urethral strictures lead to if not treated?

bladder stones due to postvoid residual urine

what is the name of the pathogen that causes syphilis?

treponem pallidum

- usually transmitted through contact w/ active lesions of a sexual partner or from mother to fetus via the placenta

what do syphilis lesions include?

- chancre

- condyloma lata

- mucous patches

what are the stages of early syphilis?

- primary

- secondary

- early latent

what are the 2 major divisions of syphilis?

- early (infectious)

- late (non-infectious)

what are the stages of late syphilis?

- late latent

- tertiary

- neurosyphilis

main s/s of the primary stage of early syphilis:

chancre at site of inoculation (usually occurs ~3 wks after infection)

- non-tender regional lymph

main s/s of the secondary stage of early syphilis:

- maculopapular rash (trunk, palms & soles)

- oral lesions

- condyloma lata (highly contagious)

- various systemic sx: cranial nerve palsies, jaundice, nephrotic syndrome, alopecia, uveitis, & lymphadenopathy

main s/s of the early latent stage of early syphilis:

no physical signs, can relapse to secondary if not treated

main s/s of the latent stage of late syphilis:

no physical signs

main s/s of the tertiary stage of late syphilis:

- gummas (painless tumors that begin as nodules, then ulcerate)

- multiple system involvement is possible (cardiovascular problems focus on aorta)

- neurosyphilis may be present as well

main s/s of the neurosyphilis stage of late syphilis:

can present at any stage

- cranial nerve irregularities

- poor proprioception & vibration sense

- argyll robertson pupils (do not react to light, but to accomodation)

- tremors

- memory loss

- personality changes

- psychosis

how is syphilis diagnosed?

should include both a positive nontreponemal test & a positive treponemal test

examples of nontreoponemal tests:

- venereal disease research lab (VDRL)

- rapid plasma reagin (RPR)

- toluidine red unheated serum test (TRUST)

what are nontreponemal tests commonly used for?

screening, as well as evaluating efficacy of treatment

false negatives of nontreoponemal tests are possible in the _______ stage

primary

what can false positives of nontreoponemal tests result from?

other medical conditions, esp. connective tissue diseases

what is the most common treponemal test?

t pallidum enzyme immunoassay (TP-EIA)

what do treponemal tests detect?

antibodies specific for treponemes & are more sensitive & specific than the nontreponemal tests

if the nontreponemal (screening) test is positive, but the treponemal test is negative, what is likely?

false positive of the nontreponemal

_______ can also be ordered for confirmation of syphilis, as well as differentiating between past or current infection

titers

how is syphilis treated?

penicillin for all stages

- treat partners

- report to health department

- screen for other STDs

- follow up (test for appropriate tx response w/ nontreponemal test at 6 months & 12 months after tx)

all early stages of syphilis receive ________________ 2.4 million units IM once

benzathine PCN G

what is jarisch-herxheimer reaction?

reaction that occurs w/i the first 24 hrs of abx therapy for syphilis

- s/s: fever, HA, myalgias

who should be screened for syphilis?

- persons at increased risk (MSM, men or women w/ HIV)

- all pregnant women

all patients diagnosed w/ syphilis should also be screened for ____.

HIV

how can syphilis be prevented?

long-term monogamous relationship w/ a partner who has been tested & is known to be uninfected

what is lymphogranuloma verenum?

infection w/ chlamydia trachomatis that enters the lymph system, causing lymphangitis of the lymph drainage field flowing from the site of inoculation

s/s of lymphogranuloma verenum

varies, but could appear as a painless vesicle or ulcer on penis or appear as painful lymphadenoapthy

- may also cause proctitis in MSM

what is inguinal syndrome?

begins 2-6 wks after exposure to chlamydia trachomatis w/ unilateral, tender, enlarged inguinal & femoral lymph nodes, separated by a groove due to the inguinal ligament that runs between them (groove sign)

- skin is erythematous & the swollen area is referred to as a "bubo"

- may progress to abscesses or fistulas

- dx is made w/ NAAT + clinical sx

how is lymphogranuloma verenum treated?

doxycyline 100 mg BID x 21 days

genital herpes

symptomatic & asymptomatic stages, all involve viral shedding

- may appear as painful vesicles, ulcers or erosions

- if primary infection may include HA, fever & lymphadenopathy

how is genital herpes treated?

control sx, but do not provide cure

- acyclovir or famciclovir x 5-10 days or maintenance therapy daily

how can transmission of genital herpes be reduced?

by abstaining from sexual activity when lesions are present & consistent condom use

HPV

cause various types of warts (commonly, condylmona acuminatum)

- tx: varies; cryosurgery, trichloracetic acid

what is one of the biggest risk factors for developing penile cancer?

genital warts

how is HPV prevented?

Gardasil 9 vaccine