Urethritis

Urethritis is an inflammation of the mucous membrane of the urethra.

Urogenital bacterial infections are one of the most pressing problems in modern urology, venereology, gynecology and other areas of medicine.

Information about their frequency is contradictory, which is due to the dependence of this indicator on the characteristics of the examined contingent, the place and time of the studies, and the level of laboratory diagnostics.

Causes urethritis

The diversity of clinical forms of non-specific urethritis is due to various etiological factors. The occurrence of a significant part of them is associated with infection. According to modern concepts, urethritis can be caused by microorganisms that are usually present in the microbial flora of the lower parts of the genital tract or that enter them from the outside during sexual intercourse or when the composition of the vaginal and urethral microflora changes in favor of virulent microorganisms.

Bacterial urethritis is a disease in which bacteria of the "common" microflora of various genera are detected: Escherichia coli, Klebsiella, Enterobacter, Serratia, Proteus, Citrobacter, Providenci, Staphylococcus aureus. The latter predominates and plays a role in the occurrence of urethritis not only as a monoculture, but also in microbial associations, with which the persistent course of the disease in such patients is associated.

The most common pathogens of urethritis in men are Chlamydia trachomatis and Neisseria gonorrhoeae. However, in a significant proportion of patients with clinical urethritis (up to 50%), these microorganisms are not detected. In such cases, non-chlamydial non-gonococcal urethritis is diagnosed, which, however, is presumably classified as an STI. Although, despite numerous studies, the predominant role of any microorganism in the development of non-chlamydial non-gonococcal urethritis has not yet been proven.

The high incidence of Chlamydia trachomatis in patients with urogenital gonorrhea has led to recommendations for prophylactic administration of antichlamydial drugs to patients with gonorrhea.

Mycoplasmas can cause not only non-specific urethritis, but also kidney and urinary tract diseases. Studies confirm that infection caused by Mycoplasma genitalium is quite common among men seeking outpatient care with urethritis symptoms. In patients with clinical symptoms of non-chlamydial non-gonococcal urethritis, M. genitalium was detected in 25%. In patients without urethritis symptoms, the frequency of M. genitalium isolation was significantly lower and amounted to only 7% (p=0.006). The frequency of M. genitalium isolation among men with gonococcal and chlamydial urethritis was 14 and 35%, respectively.

At the same time, the role of other intracellular pathogens, in particular Ureaplasma urealyticum, in the development of postgonococcal urethritis remains unclear.

Trichomonas urethritis ranks 2-3 after gonorrheal and chlamydial. In most cases, the disease occurs without clearly expressed clinical symptoms and any features that distinguish it from urethritis of other etiologies. The causative agent of Trichomonia is classified as a genus of Trichomonas, which are united in the class of flagellates. Of all the types of Trichomonas, Trichomonas vaginalis is considered pathogenic. In women, it lives in the urethra and vagina, in men - in the urethra, prostate and seminal vesicles. In 20-30% of patients, Trichomonas infection can occur as a transient and asymptomatic carrier.

Viral urethritis is caused by herpes simplex virus type 2 (genital) and pointed condylomas. In recent years, there has been a tendency for their widespread distribution. Both viruses cause disease only in humans. Infection occurs through close, intimate contacts. In this case, you can become infected from an infected patient both with and without symptoms of the disease. Primary infection is often accompanied by pronounced symptoms, after which the virus goes into a latent state. Repeated exacerbation of the disease is observed in 75% of patients.

Fungal infections of the urethra most often occur in patients with immune and endocrine disorders (diabetes mellitus) or as a complication of long-term antibiotic therapy. Fungal infections include candidal infections of the urethra, the cause of which is the yeast-like fungus Candida. It is found in the discharge from the urethra in the form of a large amount of pseudomycelium in thick, dense mucus. In women, candidal urethritis occurs due to damage to the reproductive system by Candida due to the widespread use of antibacterial agents. In men, candidal urethritis is isolated, and infection occurs sexually.

Gardnerella urethral infection occupies a certain place among sexually transmitted diseases. In recent years, gardnerella infections have increasingly attracted the attention of researchers.

Gardnerella urethritis is currently the subject of attention from various specialists, who recognize the participation of gardnerella in the development of urethritis in both women and men. The disease develops as a result of infection of the vagina with Gardnerella vaginalis, a non-motile gram-negative rod transmitted sexually. Mixed infections with chlamydia, ureaplasma, protozoa, fungi and anaerobic microorganisms are often noted.

In the development of non-specific urethritis, a significant role among the risk factors is played by the deterioration of the general condition of the body, alcohol consumption, insufficient physical activity, as well as venous congestion in the submucosal layer of the urethra, often caused by sexual excesses.

Autoimmune processes play a significant role in the pathogenesis of non-specific urethritis, especially in mixed specific and non-specific infections, which often leads to low effectiveness of antibiotic monotherapy and a long-term persistent course of the disease.

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Symptoms urethritis

Infectious urethritis can be transmitted sexually and, if the incubation period is well known for gonorrhea and trichomonas urethritis, then for most non-specific urethritis it has not been definitively established. Its duration ranges from several hours (allergic urethritis) to several months (viral and other urethritis). Clinically, according to the severity of the symptoms of the disease, three main forms of urethritis are distinguished:

• sharp;
• torpid;
• chronic.

Symptoms of urethritis are characterized by the following signs:

Acute urethritis is characterized by an abundance of discharge from the urethra on the head of the penis, they can dry up into yellowish crusts. The lips of the urethra become bright red, edematous, the mucus of the urethra can turn outward a little.

On palpation, the urethra is thickened and painful, which is especially noticeable in periurethritis. The affected large paraurethral glands are found in the form of small formations similar to large grains of sand. Subjective disorders are sharply expressed - burning and pain at the beginning of urination, its frequency. The first portion of urine is cloudy, may contain large threads that quickly settle to the bottom of the vessel. With damage to the posterior section of the urethra, the clinical picture changes - the amount of discharge from the urethra decreases, the frequency of urination increases sharply, at the end of the act of urination there is a sharp pain, sometimes blood.

The symptoms of torpid and chronic urethritis are approximately the same. Subjective symptoms of urethritis are weakly expressed, discomfort, paresthesia, itching in the urethra are characteristic, especially in the area of the scaphoid fossa. As a rule, there is no free discharge from the urethra, but there may be adhesion of the urethral sponges. In some patients, the symptoms of urethritis have a negative emotional coloring associated with the individual characteristics of experiencing the disease itself. In the first portion of urine, usually transparent, small threads may float and settle to the bottom.

With the above symptoms in the first 2 months, urethritis is called torpid, and with further progression - chronic.

Forms

In clinical practice, it is customary to classify urethritis into two large groups.

• Infectious:
  • specific:
  • • tuberculosis;
    • gonorrheal;
    • trichomonas;
  • non-specific:
    • bacterial (caused by mycoplasmas, ureaplasmas, gardnerella, etc.);
    • viral (candidiasis of the urethra);
    • chlamydial;
    • mycotic (candidal, etc.);
    • urethritis caused by mixed infection (trichomoniasis, latent, etc.);
    • transient short-term (when urogenital infection spreads through the urethra to the prostate).
• Non-infectious:
  • allergic;
  • exchange;
  • traumatic;
  • congestive;
  • caused by disease of the urethra.

Residual, psychogenic, and iatrogenic inflammations of the urethra are also possible.

In addition, bacterial urethritis is often divided into gonococcal and non-gonococcal (non-specific). However, most researchers do not currently use this classification. Separately, it is necessary to highlight urethritis caused by a hospital-acquired (nosocomial) infection, which can be accidentally introduced into the urethra during various manipulations:

• urethroscopy;
• cystoscopy;
• bladder catheterization;
• installation.

In transient urethritis, we are talking about a lightning-fast course of urethritis during the passage of a urogenital latent infection (chlamydia, ureaplasma, mycoplasma, gardnerella, much less often - genital herpes virus type 2) during the infection of the patient after sexual intercourse with a sick partner. In such patients, clinical signs are barely noticeable. Such patients are identified among those who had sexual intercourse with a dubious partner without a condom. As a rule, these are men with significant sexual experience, who have been treated and completely recovered from latent and even venereal diseases.

In recent decades, there has been an increase in the number of people suffering from non-specific urethritis, the number of which, in relation to all other types of urethritis, has increased, according to data from various venereal disease clinics, by 4-8 times.

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Diagnostics urethritis

The main methods for diagnosing urethritis:

• bacterioscopic;
• bacteriological;
• immunological, including serological;
• clinical.

The initial and one of the most important stages of etiological diagnosis of genitourinary infections is the collection and transportation of biological material.

Basic rules for taking material from women:

• the material is collected no earlier than one hour after urination;
• discharge from the urethra is collected with a sterile cotton swab;
• If it is not possible to obtain the material, then a thin sterile “urethral” swab is inserted into the urethra to a depth of 2-4 cm, it is gently rotated for 1-2 seconds, removed, placed in a special transport medium and delivered to the laboratory.

Basic rules for collecting material from men:

• the material is collected no earlier than 2 hours after urination;
• A thin sterile swab is inserted into the urethra to a depth of 2-4 cm, gently rotated for 1-2 seconds, removed, placed in a special transport medium and delivered to the laboratory.

In torpid and chronic forms of urethritis, material for research can be obtained by carefully scraping the mucous membrane of the anterior urethra with a Volkmann spoon.

The bacterioscopic method involves the examination of discharge from the urethra using staining (Gram, Romanovsky-Giemsa, etc.) and is designed to detect microbes (primarily gonococcus) and protozoa. To detect trichomonads, native preparations are examined

This method allows to detect, in addition to microbes and protozoa, cellular elements - leukocytes, epithelial cells, as well as various variants of microorganism associations. In addition to detecting the direct causative agent of urethritis, it is also indicated by the detection of 5 or more polymorphonuclear leukocytes in the field of view.

The bacterioscopic method not only allows to establish the presence of an infectious process in the urethra, but also helps to determine its etiology, as well as further tactics of patient management. In the absence of signs and symptoms of urethritis or polymorphonuclear leukocytes during bacterioscopic examination, the implementation of therapeutic, and sometimes additional diagnostic measures are postponed.

In clinical practice, in addition to the bacterioscopic method, bacteriological methods are used to diagnose gonorrhea, less often immunofluorescent, immunochemical and serological tests. When bacterioscopy of smears from the urethra, gram-negative diplococci are detected. located intracellularly, characterized by polychromasia and polymorphism, as well as the presence of a capsule. Bacteriological research consists of isolating a pure culture of gonococcus on meat-peptone agar.

The diagnosis of trichomonas urethritis is made on the basis of clinical signs of the disease and detection of trichomonas in the material being examined. For this purpose, bacterioscopy of an unstained fresh preparation and examination of a Gram-stained preparation are performed; less often, bacteriological examination is performed using solid nutrient media.

Diagnostics of gardnerella urethritis is based on bacterioscopic examination of native preparations, as well as preparations stained by Gram. In native preparations, flat epithelial cells are found, to the surface of which gardnerella are attached, giving them a characteristic "peppered" appearance. This is considered a pathognomonic sign of gardnerella. The cytological picture in stained smears is characterized by the presence of individual leukocytes scattered in the field of vision, a significant number of small gram-negative rods located on the epithelial cells.

Clinical manifestations of urethritis, in which various variants of staphylococci, streptococci, E. coli, enterococci and some other opportunistic microorganisms are detected, depend on the localization of the pathological process and cannot be differentiated from infections caused by other pathogens. In these cases, a multi-glass urine test is considered mandatory. Bacteriological methods allow determining the number of pathogens in 1 ml of fresh urine, their species and type, as well as sensitivity to antibiotics.

Clinical research methods also include urethroscopy, which is indicated to clarify the nature of damage to the mucous membrane of the urethra, complications of prostatitis, vesiculitis, etc.

The basic principles of diagnosing chlamydial infection are the same as for other bacterial diseases. Test procedures include:

• direct visualization of the agent in clinical samples using bacterioscopic staining;
• determination of specific chlamydial antigens in clinical material samples;
• direct isolation from the patient's tissues (bacteriological method):
• serological tests that detect antibodies (demonstrating changing titers);
• Determination of specific chlamydial genes in clinical material samples.

The bacterioscopic method of detecting chlamydia involves detecting morphological structures of chlamydia in affected cells. It is rarely used at present due to its low sensitivity (10-20%).

To detect chlamydial antigens in clinical samples during bacterioscopic examinations, both direct and indirect immunofluorescence methods can be used. In direct immunofluorescence, the preparation is treated with specific mono- or polyclonal antibodies labeled with fluorescein. In the indirect immunofluorescence method, the preparation is first treated with immune serum containing unlabeled antichlamydial antibodies, and then with anti-species fluorescent serum. Viewing is performed with a fluorescent microscope. The sensitivity of this bacterioscopic examination is 70-75% for cervical mucus in women and 60-70% for scrapings from the urethra in men.

The bacteriological method of diagnosing chlamydial infection is based on isolating chlamydia from the test material by infecting primary or transplantable cell cultures, since chlamydia do not reproduce on artificial nutrient media. During the cultivation process, the pathogen is identified and sensitivity to antibiotics is determined. The method of diagnostic isolation of chlamydia in cell culture can be used throughout the entire period of the disease, with the exception of the period of antibiotic therapy, and for a month after it. However, at present, this method is mainly used in monitoring recovery to identify chlamydia that are capable of performing a full development cycle. The sensitivity of the method ranges from 75 to 95%.

Serological diagnostic methods for chlamydia are based on the determination of specific antibodies in the blood serum of patients or those who have had chlamydial infection. Serological tests for IgG in the blood serum are informative in generalized forms of infection, as well as in cases where the infected organs are not available for direct examination (for example, the pelvic organs). In localized urogenital infection, the study of local immunity indicators is informative (in cervical mucus in women, in prostate secretion and seminal plasma in men). When examining infertile couples, the IgA indicator in these environments is more informative than when examining blood serum. At the same time, IgA appears in these environments some time after the onset of the inflammatory process, and, therefore, these tests are not suitable for diagnosing acute chlamydial infection.

Local immunity indices (IgA in secretions) are usually comparable in significance with humoral immunity indices (IgG in blood serum) in women and statistically significantly differ in men, apparently due to the presence of the hematotesticular barrier. Serological tests should not be used as a test to monitor recovery, since the antibody titer remains quite high for several months after treatment. However, they are informative in the differential diagnosis of chlamydia. This method is especially valuable in chronic asymptomatic forms of chlamydial infection of the pelvic organs. The sensitivity and specificity of such test systems for determining antibodies to chlamydia is at least 95%.

Nucleic acid amplification methods (DNA diagnostic methods) are based on the complementary interaction of nucleic acids, which allows identifying the nucleotide sequence in the genes of the desired microorganism with almost 100% accuracy. Of the numerous modifications of this method, PCR has become widespread in clinical practice. Any material of tissue genesis is suitable for diagnosing chlamydial infection by nucleic acid amplification. A major advantage of the method is the ability to study material obtained in a non-invasive way, for example, a study of the first portion of morning urine. It should be noted that this study is more informative in men than in women (it is better to use cervical samples).

Determination of chlamydia nucleic acids should not be used as a control of cure, since it is possible to determine fragments of nucleic acids of non-viable microorganisms for several months after the treatment. As noted above, the method of cultural diagnostics should be used for this purpose. The advantage of PCR is the possibility of detecting a wide range of pathogens in one clinical sample, i.e. obtaining complete information on the presence of all pathogens in the clinical sample under study (Mycoplasma genitalium, Mycoplasma hominis, Ureaplasma parvum and Ureaplasma urealyticum). At the same time, it should be remembered that the use of the molecular biological diagnostic method in itself cannot be considered a guarantee against obtaining erroneous results. The high sensitivity of PCR necessitates strict adherence to special requirements for the laboratory operating mode.

Thus, the main methods for diagnosing urethritis caused by N. gonorrhoeae are considered to be cultural studies and the nucleic acid amplification method, and for urethritis caused by C. Trachomatis, M. genitalium, U. urealyticum, herpes simplex virus type 1 and type 2 - the nucleic acid amplification method.

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Treatment urethritis

Treatment of urethritis, first of all, should be etiotropic and pathogenetic. Unlike other urological diseases, in the treatment of bacterial and viral urethritis, much depends on epidemiological measures to sanitize the source of re-infection, which can be caused by sexual partners if they were not treated simultaneously.

In microbial forms of urethritis, etiotropic therapy is possible only with bacteriological detection of the pathogen. Viral non-specific urethritis is treated taking into account the sensitivity of the pathogen. In case of candidal urethritis, therapy should be antifungal. For metabolic non-specific urethritis, etiotropic measures should be considered to be those aimed at eliminating metabolic disorders (phosphaturia and oxaluria, uraturia, cystinuria). Traumatic and "tumor" urethritis can be cured by eliminating the etiological factors, i.e. trauma and tumor.

Pathogenetic treatment of urethritis consists of eliminating anatomical and other factors predisposing to the development of this disease. Among them are strictures of the urethra, purulent diseases of individual paraurethral glands located in the submucosal layer of the urethra and in the valvulae fossae navicularis in the hanging part of the urethra in men, in women - damage to the paraurethral passages and large glands of the vestibule of the vagina. Measures aimed at increasing the body's immunoreactivity, which can be general and specific, should also be considered pathogenetic.

Therapy for non-specific urethritis should be general and local. The use of one or another type of treatment largely depends on the phase and stage of the disease. In the acute phase, general methods of therapy should prevail or be the only ones; in the chronic phase of the disease, local treatment can be added.

Treatment of non-specific urethritis

Treatment of non-specific urethritis is divided into:

• medicinal;
• operational;
• Physiotherapy.

Antibacterial therapy of bacterial urethritis should be carried out taking into account the sensitivity of the isolated microorganism, giving preference to semi-synthetic penicillins and cephalosporins for coccal flora, and aminoglycosides and fluoroquinolones for non-negative flora. Some tropism of tetracyclines and macrolides to male genital organs should be taken into account. When selecting drugs for the treatment of non-specific urethritis, it is necessary to take into account the capabilities of nitrofurans, especially furazolidone. They are also quite active against protozoa and trichomonads. The greatest difficulties arise in the treatment of staphylococcal urethritis, when bacterial strains resistant to all antibiotics and chemotherapy drugs are encountered. Such patients are prescribed treatment with staphylococcal anatoxin, staphylococcal gamma globulin (human anti-staphylococcal immunoglobulin), administered intramuscularly, and if this is ineffective, an autovaccine should be obtained and administered twice.

In Reiter's syndrome, when joint damage is so severe that it leads to the development of ankylosis, glucocorticoid therapy is indicated. Drugs that improve microcirculation (dipyridamole), NSAIDs (indomethacin, diclofenac, etc.) are also prescribed.

Antibacterial treatment for chronic forms of urethritis should be supplemented with methods of non-specific immunotherapy.

It is possible to prescribe pyrogenal, and since all patients with urethritis are usually treated on an outpatient basis, its daily administration is possible in a day hospital setting at a polyclinic. Instead of pyrogenal, prodigiosan can be used intramuscularly.

Non-specific immunological treatment of chronic urethritis can be supplemented by the introduction of prostate extract (prostatilen) at 5 mg, diluted in 2 ml of sterile isotonic sodium chloride solution or 0.25% procaine solution intramuscularly once a day, in a course of 10 injections, with possible repetition after 2-3 months.

In the chronic phase of urethritis and less often in the subacute phase, local treatment of urethritis is sometimes indicated. When introducing medicinal substances into the urethra, it should be remembered that due to good vascularization of the submucosal layer, its mucous membrane has significant absorption capacity. Rinsing of the urethra is carried out with solutions of nitrofural (furacilin) 1:5000, mercury oxycyanide 1:5000, silver nitrate 1:10000, protargol 1:2000. Recently, instillations into the urethra and its rinsing have begun to be done with a 1% solution of dioxidine or miramistin, as well as hydrocortisone 25-50 mg in glycerin or vaseline oil. However, the attitude to local treatment should be restrained.

It is advisable to conduct combined treatment of urethritis, which should include physiotherapeutic methods (ultra-high frequency exposure, diathermy, antibiotic electrophoresis, hot baths, etc.). Physiotherapy is especially indicated in the event of complications (prostatitis, epididymitis). When treating non-specific urethritis, sexual intercourse, consumption of alcoholic beverages, spices, and hot seasonings are prohibited.

Hospitalization of patients with urethritis is indicated when complications develop (acute urinary retention, acute prostatitis, epididymitis, epididymorchitis, acute cystitis, etc.).