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 inflammatory diseases of the pelvic organs, which can later lead to infertility and ectopic pregnancy.

[1], [2], [3], [4], [5], [6], [7], [8]

Symptoms of the gonorrheal urethritis

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

According to the intensity of the symptoms of gonorrheal urethritis, there are 3 variants of fresh gonorrhea:

• acute, in which there is copious 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 lack of subjective symptoms and, very importantly, imperceptible discharge from the urethra, detected by chance.

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

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

Gonococci multiply on the surface of the epithelial layer, then penetrate deep into the cells of the epithelium, causing an inflammatory tissue reaction, which is accompanied by expansion of the 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 it is sloughed and infiltrated with leukocytes, the lumen of the urethra gland is filled with a rejected epithelium, leukocytes. The mouth of the glands is often blocked by the products of inflammation as a result of inflammatory edema. Pus, not having access to the outside, accumulates in the lumen of the gland, resulting in the formation of small pseudoabscesses.

The first symptoms of gonorrheal urethritis are discomfort in the urethra with prolonged urination, then grayish-yellow (a mixture of epithelial cells and leukocytes) appear, and later yellow purulent discharges. The first portion of urine is turbid, visible urethral filaments - long whitish deposited on the bottom; The second portion of urine is clear.

During the beginning of urination, the patient notes a sharp, quickly disappearing pain. One of the signs of the transition of gonococcus to 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. The pain at the end of urination is explained by the pressure of the striated muscles of the perineum on the posterior part of the urethra. It also becomes painful ejaculation. Urine becomes cloudy in both portions.

Often, the urge to urinate becomes unbearable, by the end of the act of urination appear a few drops of blood (terminal hematuria). The above symptoms in acute cases of posterior urethritis are accompanied by frequent erection, pollutions, sometimes with an admixture of blood in the semen (hemospermia), which indicates inflammation in the seminal tubercle. Discharge from the urethra decreases or disappears completely. Pus from the prostatic urethra enters the bladder. When conducting a three-cup test, the urine in all three portions is turbid (total pyuria).

In a number of cases, acute gonorrheal urethritis becomes chronic, in which the acute and subacute symptoms of gonorrheal urethritis disappear, and the inflammatory process in the urethra becomes prolonged, torpid, sluggish. The transfer of acute gonorrheal urethritis to the chronic stage is promoted by the irrational treatment of gonorrheal urethritis, interruptions in treatment and violation of its regimen, self-treatment, abnormalities of the urethra, chronic diseases (diabetes, tuberculosis, anemia, etc.).

The subjective symptoms of chronic gonorrheal urethritis are usually much less pronounced than in acute.

Patients complain of discomfort (itching, burning) in the urethra. With the defeat of his prostatic part, there are disorders of urination and sexual functions (increased and increased urge to urinate, pain at the end of urination, painful ejaculation, admixture of blood and pus in the semen). Discharge from the urethra is usually insignificant and appear mostly in the morning.

Flowing sluggishly, chronic gonorrheal urethritis under the influence of various causes is periodically exacerbated and can simulate a picture of acute gonococcal urethritis. However, unlike the last exacerbation of chronic gonococcal urethritis, they soon pass spontaneously.

Chronic gonococcal urethritis can be associated with gonococcal lesions of the urethral glands - the prostate and seminal vesicles.

[9], [10], [11],

Treatment of the gonorrheal urethritis

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

Complex pathogenetic therapy was shown to patients with complicated, torpid, chronic forms of gonorrhea in postgonoreinny inflammatory processes.

Basic principles of treatment of gonorrheal urethritis:

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

When choosing the means of antibacterial therapy, it is necessary to take into account the sensitivity of the gonococcus to the drug, indications and contraindications to its purpose, pharmacokinetics, pharmacodynamics, the 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 consider ceftriaxone 125 mg intramuscularly once or cefixime 400 mg orally.
• Second-line drugs - ciprofloxacin, 500 mg orally, or once ofloxacin, 400 mg orally, once, or levofloxacin, 250 mg orally, once.

According to the latest data, fluoroquinolones are no longer used in the USA for the treatment of gonorrhea due to the high resistance of the causative agent to them. In Russia, a high level of resistance of Neisseria gonorrhoeae to ciprofloxacin was also detected: the number of resistant strains is 62.2%. Comparison of the data with the results of LS Strachunsky et al. (2000) showed a significant increase (almost 9 times!) In Neisseria gonorrhoeae antibiotic resistance indicators in relation to fluoroquinolones.

[12], [13], [14], [15], [16], [17]

Alternative treatment of 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 these cephalosporins has any advantages over ceftriaxone.

Since gonorrhea is often combined with chlamydial infection, patients in this group should be treated with C. Trachomatis.

In case of ineffectiveness of therapy, the presence of infection should be assumed. Caused by Trichomonas vaginalis and / or Mycoplasma spp. 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-gonorrhea infection provide simultaneous treatment of gonorrhea and trichomoniasis. When combining gonorrhea with a mycoplasma or ureaplasma infection, a course of treatment for gonorrhea is first prescribed, and anti-mycoplasma or anti-plasma therapy.

[18], [19], [20], [21], [22]

Immunotherapy

As a specific immunotherapeutic drug, a gonococcal vaccine is used, which is administered intramuscularly: 200-250 million microbial cells each at the first injection; the next injection is in 1-2 days, each 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 - 6-8.

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

[23], [24], [25], [26]

Determination of cure for gonorrhea

The cure rate of patients undergoing 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 perform palpation of the prostate, seminal vesicles and laboratory diagnosis of their secret. In the absence of gonococcus in the test material, a combined provocation is carried out - 6-8 ml of 0.5% silver nitrate solution is injected into the urethra and at the same time 500 million microbial gonovaccine intramuscularly. Instead of gonovaccine, you can enter intramuscularly 100-200 MPD pyrogenal. Apply bougienage and massage the urethra together with spicy foods that irritate the urinary tract membrane. After 24-48-72 hours for laboratory tests, a secret is taken from the prostate and seminal vesicles. In the absence of gonokokkov and other pathogenic microflora, the following control with clinical and urological examination is carried out after a combined provocation in 3-4 weeks. The third (last) control is the same, 1 month after the second.

Gonorrheal urethritis is considered cured with a persistent absence of gonococci with microscopic and bacteriological examination of urinary organs discharge, no palpatory changes in the prostate, seminal vesicles, and an increased number of leukocytes in their secret, unsharp inflammatory changes (or their absence) in the urethra when urethroscopy.

[27], [28], [29], [30], [31], [32], [33], [34], [35],