Gonorrheal urethritis

Gonorrheal urethritis is a venereal disease caused by gonococcus, a gram-negative diplococcus of the Neisseriae family.

In approximately 10%-40% of women, urethritis is complicated by pelvic inflammatory disease, which can subsequently lead to infertility and ectopic pregnancy.

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Symptoms gonorrheic urethritis

Depending on the duration of the disease and the severity of symptoms, a distinction is made between fresh (if infection occurred within 2 months) and chronic (if infection occurred beyond this period) forms of gonorrhea.

Depending on the intensity of symptoms of gonorrheal urethritis, there are 3 types of fresh gonorrhea:

• acute, in which there is abundant discharge from the urethra with severe dysuria:
• subacute, in which there is also a lot of discharge from the urethra, but dysuria is almost completely absent;
• torpid, characterized by a complete absence of subjective symptoms and, very importantly, imperceptible discharge from the urethra, discovered by chance.

Chronic gonorrhea can proceed similarly to torpid gonorrhea, and in the acute stage - like one of the two acute variants of fresh gonorrhea.

Immediately after infection, the gonococcus enters the scaphoid fossa of the glans penis and from there begins to spread along the urethra passively, since it does not have the ability to move independently. The inflammatory process usually spreads canalicularly over a greater or lesser extent. In both cases, the inflammation affects only the spongy part of the urethra up to the external sphincter (anterior gonorrheal urethritis). But sometimes the inflammatory process spreads along the entire urethra up to the entrance to the bladder (posterior gonorrheal urethritis).

Gonococci multiply on the surface of the epithelial layer, then penetrate deep between the epithelial cells, causing an inflammatory reaction of the tissues, which is accompanied by the expansion of capillary vessels and abundant migration of leukocytes. The glands and lacunae of the urethra are also involved in the inflammatory process. Their epithelium is loosened, in places exfoliated and infiltrated with leukocytes, the lumen of the glands of the urethra is filled with rejected epithelium, leukocytes. The mouths of the glands are often blocked by inflammation products as a result of inflammatory edema. Pus, having no outlet, accumulates in the lumen of the gland, as a result of which small pseudo-abscesses are formed.

The first symptoms of gonorrheal urethritis are discomfort in the urethra during prolonged urinary retention, then grayish-yellow (a mixture of epithelial cells and leukocytes) and later yellow purulent discharge appear. The first portion of urine is cloudy, urethral threads are visible - long whitish settling to the bottom; the second portion of urine is transparent.

At the beginning of urination, the patient notes a sharp, quickly disappearing pain. One of the signs of the transition of the gonococcus beyond the external sphincter is the imperativeness of the urge to urinate, which is quickly joined by frequent, painful urination at the end of the act. Pain at the end of urination is explained by the pressure of the striated muscles of the perineum on the posterior section of the urethra. Ejaculations also become painful. Urine becomes cloudy in both portions.

Often the urge to urinate becomes unbearable, and by the end of urination a few drops of blood appear (terminal hematuria). In acute cases of posterior urethritis, the above symptoms are accompanied by frequent erections, pollutions sometimes with blood in the semen (hemospermia), which indicates inflammation in the seminal tubercle. The discharge from the urethra decreases or disappears completely. Pus from the prostatic part of the urethra enters the bladder. When performing a three-glass test, the urine in all three portions is cloudy (total pyuria).

In a number of observations, acute gonorrheal urethritis becomes chronic, in which acute and subacute symptoms of gonorrheal urethritis disappear, and the inflammatory process in the urethra becomes protracted, torpid, and sluggish. The transition of acute gonorrheal urethritis to the chronic stage is facilitated by irrational treatment of gonorrheal urethritis, interruptions in treatment and violation of its regimen, self-medication, anomalies of the urethra, chronic diseases (diabetes mellitus, tuberculosis, anemia, etc.).

Subjective symptoms of chronic gonorrheal urethritis are usually much less pronounced than those of acute gonorrheal urethritis.

Patients complain of discomfort (itching, burning) in the urethra. When its prostatic part is affected, urination and sexual dysfunctions are observed (increased frequency and intensity of urge to urinate, pain at the end of urination, painful ejaculation, blood and pus in the sperm). Discharge from the urethra is usually insignificant and appears mostly in the morning.

Chronic gonorrheal urethritis, which proceeds sluggishly, periodically worsens under the influence of various causes and can simulate the picture of acute gonococcal urethritis. However, unlike the latter, exacerbations of chronic gonococcal urethritis soon pass spontaneously.

Chronic gonococcal urethritis may be associated with gonococcal infection of the glands of the urethra - the prostate and seminal vesicles.

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Treatment gonorrheic urethritis

Treatment of gonorrheal urethritis consists of prescribing antibiotics that have a bactericidal and bacteriostatic effect on gonococci. In acute gonorrhea, etiotropic treatment is sufficient to achieve a therapeutic effect.

Patients with complicated, torpid, chronic forms of gonorrhea with post-gonorrheal inflammatory processes are shown complex pathogenetic therapy.

Basic principles of treatment of gonorrheal urethritis:

• thorough clinical and laboratory examination of patients in order to identify concomitant diseases (syphilis, trichomoniasis, chlamydial infection, etc.) and their simultaneous treatment;
• complex nature of treatment, including etiotropic, pathogenetic and symptomatic therapy;
• individual approach taking into account age, gender, clinical form, severity of the pathological process, complications;
• the patient must adhere to a certain diet during and after treatment, and abstain from sexual intercourse and physical activity.

When choosing antibacterial therapy, it is necessary to take into account the sensitivity of the gonococcus to the drug, indications and contraindications for its use, pharmacokinetics, pharmacodynamics, mechanism and spectrum of antimicrobial action, as well as the mechanism of its interaction with other antibacterial drugs.

Etiological treatment of gonorrheal urethritis

For the treatment of gonorrhea (uncomplicated), the following antimicrobial therapy regimens are recommended.

• The first-line drugs are ceftriaxone 125 mg intramuscularly once or cefixime 400 mg orally once.
• Second-line drugs are ciprofloxacin 500 mg orally, or ofloxacin 400 mg orally once, or levofloxacin 250 mg orally once.

According to the latest data, fluoroquinolones are no longer used in the USA to treat gonorrhea due to the high resistance of the pathogen to them. In Russia, a high level of resistance of Neisseria gonorrhoeae strains to ciprofloxacin has also been identified: the number of resistant strains is 62.2%. Comparison of the data provided with the results of L.S. Strachunsky et al. (2000) showed a significant increase (almost 9 times!) in the rates of antibiotic resistance of Neisseria gonorrhoeae to fluoroquinolones.

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Alternative treatment for gonorrheal urethritis

Spectinomycin 2 g intramuscularly once or cephalosporins (except ceftriaxone) - ceftizoxime 500 mg intramuscularly, cefoxitin 2 g intramuscularly, then 1 g orally and cefotaxime 500 mg intramuscularly. However, none of the listed cephalosporins has advantages over ceftriaxone.

Since gonorrhea is often associated with chlamydial infection, patients in this group require additional treatment for C. Trachomatis.

If therapy is ineffective, an infection caused by Trichomonas vaginalis and/or Mycoplasma spp. should be assumed. Recommended treatment. A combination of metronidazole (2 g orally once) and erythromycin (500 mg orally 4 times a day for 7 days) in cases of mixed trichomonas-gonorrhoeal infection; gonorrhea and trichomoniasis are treated simultaneously. In cases of gonorrhea combined with mycoplasma or ureaplasma infection, a course of treatment for gonorrhea is prescribed first, followed by antimycoplasma or antiureaplasma agents.

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Immunotherapy

A gonococcal vaccine is used as a specific immunotherapeutic drug, which is administered intramuscularly: 200-250 million microbial bodies at the first injection; the next injection is in 1-2 days, each subsequent time the dose is increased by 300-350 million microbial bodies. A single dose can reach 2 billion microbial bodies, and the number of injections is 6-8.

For non-specific stimulation of the body, drugs are used that activate a number of cellular and humoral factors of the immune system.

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Determining whether gonorrhea is cured

The recovery of patients who have had fresh gonorrhea is determined 7-10 days after the end of the course of treatment. In the absence of inflammatory changes in the urethra, it is necessary to palpate the prostate, seminal vesicles and laboratory diagnostics of their secretion. In the absence of gonococcus in the test material, a combined provocation is carried out - 6-8 ml of 0.5% silver nitrate solution are introduced into the urethra and 500 million microbial bodies of gonovaccine are simultaneously administered intramuscularly. Instead of gonovaccine, 100-200 MPD of pyrogenal can be administered intramuscularly. Bougienage and massage of the urethra are also used together with spicy food that irritates the lining of the urinary tract. After 24-48-72 hours, secretion is taken from the prostate and seminal vesicles for laboratory testing. In the absence of gonococci and other pathogenic microflora, the next control with clinical and urological examination is carried out after a combined provocation in 3-4 weeks. The third (last) control is similar, 1 month after the second.

Gonorrheal urethritis is considered cured in the case of persistent absence of gonococci in microscopic and bacteriological examination of the discharge of the genitourinary organs, absence of palpable changes in the prostate, seminal vesicles, as well as an increased number of leukocytes in their secretion, mild inflammatory changes (or their absence) in the urethra during urethroscopy.

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