Urethritis

Urethritis - inflammation of the mucous membrane of the urethra.

Urogenital bacterial infections represent one of the most urgent problems of 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 surveyed contingent, the place and time of research, the level of laboratory diagnosis.

Causes of the urethritis

The variety of clinical forms of nonspecific urethritis is due to various etiological factors. The emergence of a significant part of them is associated with infection. According to modern concepts, urethritis can cause microorganisms, usually present in the microbial flora of the lower genital tracts or falling into them from the outside during sexual intercourse or when changing the composition of the vaginal and urethral microflora in favor of virulent microorganisms.

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

The most frequent pathogens of urethritis in men are Chlamydia trachomatis and Neisseria gonorrhoeae. However, in a significant proportion of patients with a clinic of urethritis (up to 50%), these microorganisms do not reveal. In such cases, non-chlamydial non-gonococcal urethritis is diagnosed, which, nevertheless, is presumably attributed to STI. Although, despite numerous studies, until now, the prevailing role of any microorganism in the development of non-chlamydial non-gonococcal urethritis has not been proven.

The high incidence of Chlamydia trachomatis in patients with urogenital gonorrhea led to recommendations for the prophylactic administration of antichlamydia drugs to patients suffering from gonorrhea.

Calling not only nonspecific urethritis, mycoplasma can cause diseases of the kidneys and urinary tract. Studies confirm. That infection caused by Mycoplasma genitalium is quite common among men who seek outpatient care with symptoms of urethritis. In patients with clinical symptoms of non-chlamydial non-gonococcal urethritis, M. Genitalium was detected in 25%. In patients without symptoms of urethritis, the frequency of M. Genitalium was significantly lower and was only 7% (p = 0.006). The incidence of M. Genitalium in 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 post-gonococcal urethritis is still unclear.

Trichomonas urethritis takes 2-3 place after gonorrhea and chlamydia. In most cases, the disease occurs without clearly defined clinical symptoms and any features that distinguish it from urethritis of another etiology. The causative agent of trichomonias is attributed to the genus Trichomonads, united in a class of flagella. Trichomonas vaginalis is considered to be pathogenic from all types of Trichomonas. In women, it lives in the urethra and in the vagina, in men in the urethra, the prostate and seminal vesicles. In 20-30% of patients, trichomonas infection can proceed according to the type of transient and asymptomatic carriage

Viruses of herpes simplex type 2 (genital) and spiky kondillomas are referred to the pathogens of viral urethritis. In recent years, there has been a trend towards widespread distribution. Both viruses cause disease only in humans. Infection occurs at close, intimate contacts. At the same time, it is possible to get infected from the infected patient both in the presence of symptoms of the disease, and in their absence. Primary infection is often accompanied by severe symptoms, after which the virus passes into a latent state. A repeated exacerbation of the disease is observed in 75% of patients.

Fungal lesions of the urethra most often occur in patients with immune and endocrine disorders (diabetes mellitus) or as a complication of prolonged antibiotic therapy. To fungal candidiasis affect the urethra, the cause of which is yeast-like Candida fungus. It is found in the discharge from the urethra in the form of a large amount of pseudomycelia in thick dense mucus. In women, candidal urethritis occurs due to the defeat of the genital system of Candida due to the widespread use of antibacterial agents. In men, candidal urethritis is isolated, and infection occurs sexually.

Gardnerella disease of the urethra takes a definite place among diseases transmitted by sexual intercourse. In recent years, infections caused by gardnerella, are increasingly attracting the attention of researchers.

Gardnerellae urethritis is currently being paid attention to by various specialists who recognize the involvement of gardnerella in the development of urethritis as in women. And in men. The disease develops as a result of infection of the vagina Gardnerella vaginalis - a fixed Gram-negative rod, transmitted sexually. Often noted mixed infection with chlamydia, ureaplasmas, protozoa, fungi and anaerobic microorganisms.

In the development of nonspecific urethritis, a significant role among the risk factors is deterioration of the general condition of the body, alcohol intake, lack of physical activity, and venous congestion in the submucosa of the urethra, often due to sexual excesses.

A significant role in the pathogenesis of nonspecific urethrites is played by autoimmune processes, especially with a mixed specific and nonspecific infection, which often leads to low effectiveness of monotherapy with antibiotics and prolonged persistent disease course.

[1], [2], [3], [4], [5]

Symptoms of the urethritis

Infectious urethritis can be transmitted sexually and if the incubation period is well known for gonorrhea and trichomoniasis urethritis, then for most nonspecific urethritis it is not definitively established. Its duration ranges from several hours (allergic urethritis) to several months (with viral and other urethritis). Clinically, according to the severity of the signs of the disease, there are three main forms of urethritis:

• sharp;
• torpid;
• chronic.

Symptoms of urethritis are characterized by the following symptoms:

For acute urethritis is characterized by an abundance of discharge from the urethra on the head of the penis, they can shrivel into yellowish crusts. The sponges of the urethra become bright red, edematous, the urethra can slip out a little.

With palpation, the urethra is thickened and painful, which is especially noticeable with periurethritis. The affected large paraverlethral glands are found in the form of small formations similar to large grains of sand. Sharply expressed subjective disorders - burning and pain at the beginning of urination, its frequency. The first portion of urine is turbid, can contain large filaments that quickly settle on the bottom of the vessel. When the posterior urethral canal is affected, the clinical picture changes - the amount of discharge from the urethra decreases, the frequency of urination sharply increases, at the end of the act of urination there is a sharp pain, sometimes blood.

Symptoms of torpid and chronic urethritis are approximately the same. Subjective symptoms of urethritis are poorly expressed, discomfort, paresthesia of the itching in the urethra, especially in the scaphoid fossa, are characteristic. As a rule, free discharge from the urethra is absent, but there may be clumping of the urethra sponges. In some patients, symptom retinitis is negative emotional color, associated with the individual characteristics of the experience of the disease itself. In the first portion of urine, usually transparent, small threads can float and settle to the bottom.

With the above symptoms in the first 2 months, urethritis is called torpid, while in the course of further flow, it is called chronic.

Forms

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

• Infectious:
  • specific:
  • • tubercular;
    • gonorrhea;
    • trichomonads;
  • nonspecific:
    • bacterial (due to mycoplasmas, ureaplasmas, gardnerella, etc.);
    • viral (candidiasis of the urethra);
    • chlamydial;
    • Mycotic (candida, etc.);
    • urethritis caused by a mixed infection (Trichomonas, Hidden, etc.);
    • transitory short-term (with the spread of urogenital infection through the urethra to the prostate).
• Non-infectious:
  • allergic;
  • exchange;
  • traumatic;
  • congestive;
  • caused by the disease of the urethra.

There are also residual, psychogenic, iatrogenic inflammations of the urethra.

In addition, bacterial urethritis is often divided into gonococcal and non-gonococcal (non-specific). However, this classification is currently not used by most researchers. Separately, it is necessary to distinguish urethritis, caused by nosocomial infection, which can be accidentally entered into the urethra with various manipulations:

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

With transient urethritis, it is a question of lightning-fast urethritis during passage of urogenital latent infection (chlamydia, ureaplasma, mycoplasma, gardnerella, rarely less - genital herpes virus of type 2) during infection of the patient after sexual intercourse with a sick partner. In such patients, clinical signs are barely perceptible. Such patients are identified among those who have had sexual intercourse with a dubious partner without a condom. As a rule, these are men with significant sexual experience, treated and fully recovered from hidden and even sexually transmitted diseases.

In recent decades, the number of cases of nonspecific urethritis has increased, the number of which has increased 4-8 times in all other types of urethritis, according to various venereological clinics.

[6], [7], [8], [9], [10]

Diagnostics of the urethritis

The main methods of diagnosis of urethritis:

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

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

The basic rules of taking material from women:

• the material is collected no earlier than an hour after urination;
• Separated from the urethra is collected with a sterile cotton swab;
• if the material can not be obtained, then introduce a thin sterile "urethral" tampon to the urethra to a depth of 2-4 cm, gently rotate it for 1-2 seconds, remove it, place it in a special transport medium and deliver it to the laboratory.

The basic rules for collecting material from men:

• the material is collected no earlier than 2 hours after urination;
• insert a thin sterile swab into the urethra to a depth of 2-4 cm, gently rotate it for 1-2 seconds, remove it, place it in a special transport medium and deliver it to the laboratory.

With torpid and chronic forms of urethritis, the material for examination can be obtained by careful scraping from the mucus of the anterior urethra with a Folkman spoon.

Bacterioscopic method includes the study of secretions from the urethra by means of staining (according to Gram, Romanovsky-Giemsa, etc.) and is designed to detect microbes (primarily gonococcus) and protozoa. To detect trichomonias, a study of native drugs

This method allows us to identify, in addition to microbes and protozoa, cellular elements - leukocytes, epithelial cells, as well as various versions of microorganism associations. In addition to detecting the direct pathogens of urethritis, it is also indicated by the detection of 5 or more polymorphonuclear leukocytes in the field of vision.

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

In clinical practice for the diagnosis of gonorrhea, in addition to the bacterioscopic method, use bacteriological methods, less immunofluorescent, immunochemical and serological tests. At a bacterioscopy of smears from an urethra find out gram-negative diplococci. Located intracellularly, characterized by polychromasia and polymorphism, as well as the presence of a capsule. Bacteriological study consists in isolating the pure culture of the gonococcus on meat-peptone agar.

The diagnosis of trichomoniasis urethritis is based on the clinical signs of the disease and the detection of trichomonads in the test material. For this purpose, the bacterioscopy of an unpainted fresh preparation and the examination of a Gram stained preparation are performed, less often bacteriological examination is carried out using solid nutrient media.

Diagnosis of gardnerellosis urethritis is based on a bacterioscopic study of native drugs, as well as preparations stained by Gram. In native preparations, flat epithelial cells are found, to the surface of which are attached gardnerella, giving them a characteristic "pinned" appearance. This is considered a pathognomonic sign of gardnerella. For the cytological picture in stained smears, the presence of separate, scattered in the field of view of leukocytes, a significant number of small gram-negative rods located on epithelial cells.

The clinical manifestations of urethritis, in which various variants of staphylococci, streptococci, Escherichia coli, enterococci and some other opportunistic microorganisms are found, depend on the localization of the pathological process and can not be differentiated from infections caused by other pathogens. In these cases, a multistage urine sample is considered mandatory. Bacteriological methods allow to determine the number of pathogens in 1 ml of fresh urine, their specific and typical accessory, as well as sensitivity to antibiotics.

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

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

• direct visualization of the agent in clinical specimens when staining with a bacterioscopic method;
• determination of specific chlamydial antigens in clinical specimens;
• direct isolation from the patient's tissues (bacteriological method):
• serological tests, in which antibodies are determined (demonstration of changing titers);
• determination of specific chlamydial genes in samples of clinical material.

Bacterioscopic method for the detection of chlamydia involves the identification of morphological structures of chlamydia in affected cells. Currently used rarely due to low sensitivity (10-20%).

To detect bacterioscopy in clinical samples of chlamydia antigens, both direct and indirect immunofluorescence methods can be used. With direct immunofluorescence, the drug is treated with specific mono- or polyclonal antibodies labeled with fluorescein. With the indirect immuno-fluorescent method, the preparation is first treated with a serum containing unlabeled anti-Chlamydia antibodies and then with anti-fluorescent serum. The viewing is done with a fluorescent microscope. The sensitivity of this bacterioscopic examination is 70-75% for cervical mucus in women and 60-70% for scraping from the urethra in men.

The bacteriological method for diagnosing chlamydial infection is based on the isolation of chlamydia from the test material by contamination of primary or transplantable cell cultures, since on artificial nutrient media chlamydia do not multiply. During the cultivation, the pathogen is identified and antibiotic susceptibility is determined. The method of diagnostic isolation of chlamydia in cell culture can be used throughout the period of the disease, except for the period of antibiotic therapy, and within a month after it. However, at present, this method is mainly used in the control of cure for the detection of chlamydia, capable of carrying out a full cycle of development. The sensitivity of the method varies from 75 to 95%.

Methods of serological diagnosis of chlamydia are based on the determination of specific antibodies in the blood serum of patients or who have undergone a chlamydial infection. Serological tests for the determination of IgG in 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, pelvic organs). With localized urogenital infection, it is informative to study the indices of local immunity (in cervical mucus in women, in prostate secretion and in seminal plasma in men). In the study of infertile couples, IgA in these media is more informative than in the study of serum. However, IgA appear in these media some time after the onset of the inflammatory process, and therefore these tests are not suitable for the diagnosis of acute chlamydial infection. 

Indices of local immunity (IgA in secrets) in importance are usually comparable with the parameters of humoral immunity (IgG in serum) in women and statistically significantly do not coincide in men, apparently due to the presence of a hematotestick barrier. Serological tests should not be used as a test to control cure, since the antibody titer remains high enough for several months after treatment. However, they are informative for differential diagnosis of chlamydia. The value of this method is especially high for chronic asymptomatic forms of chlamydial infection of the pelvic organs. The sensitivity and specificity of such test systems for the detection of antibodies to chlamydia is not less than 95%.

Nucleic acid amplification methods (DNA diagnostic methods) are based on complementary interaction of nucleic acids, which allows to identify with almost 100% accuracy the sequence of nucleotides in the genes of the desired microorganism. From the numerous modifications of this method in clinical practice, PCR was widely used. For the diagnosis of chlamydia infection by nucleic acid amplification, any material of tissue origin is suitable. A great advantage of the method is the possibility of examining a material obtained by a non-invasive method, for example, examining the first portion of morning urine. It should be noted that in men this study is more informative than in women (it is better to use cervical specimens).

Determination of nucleic acids of chlamydia should not be used as a control of cure, since it is possible to determine fragments of nucleic acids of nonviable microorganisms within a few months after the treatment. As noted above, a culture diagnostic method should be used for this purpose. The advantage of PCR is the ability to detect a wide range of pathogens in one clinical sample, i.e. To obtain complete information about the presence of all pathogens in the studied clinical trial (Mycoplasma genitalium, Mycoplasma hominis, Ureaplasma parvum and Ureaplasma urealyticum). At the same time, it should be remembered that the use of the molecular biological diagnosis method alone can not be considered a guarantee against receiving erroneous results. High sensitivity of PCR makes it necessary to strictly adhere to special requirements for the operating mode of the laboratory.

Thus, the main methods for diagnosing urethritis caused by N. Gonorrhoeae are culture studies and the method of nucleic acid amplification, and for urethrites caused by S. Trachomatis. M. Genitalium, U. Urealyticum, herpes simplex virus type 1 and type 2 - the method of amplification of nucleic acids.

[11], [12]

Treatment of the urethritis

Treatment of urethritis, first of all, must be etiotropic and pathogenetic. Unlike other urological diseases in the treatment of bacterial and viral urethritis, much depends on the epidemiological measures to sanitize the focus of repeated infection, which can lead to sexual partners, if they were not treated at the same time.

With microbial forms of urethritis etiotropic therapy is possible only with bacteriological detection of the pathogen. Viral nonspecific urethritis is treated with sensitivity of pathogens. When candidiasis urethritis therapy should be antifungal. For metabolic nonspecific urethritis, etiotropic measures should be considered to eliminate metabolic disturbances (phosphaturia and oxaluria, uraturia, cystinuria). Traumatic and "tumor" urethritis can be cured by eliminating etiological factors, i.e. Trauma and tumor.

Pathogenetic treatment of urethritis consists in the elimination of anatomical and other factors predisposing to the development of this disease. Among them - 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, the lesion of the paraurethral passages and large glands of the vestibule. Pathogenetic should be considered and measures aimed at increasing the immunoreactivity of the body, which can be common and specific.

Therapy of nonspecific urethritis should be general and local. The use of a particular type of treatment depends largely on the phase and stage of the disease. In the acute phase, general methods of therapy should predominate or be the only ones; In the chronic phase of the disease, local treatment can be added.

Treatment of nonspecific urethritis

Treatment of nonspecific urethritis is divided into:

• medicamentous;
• operational;
• Physiotherapeutic.

Antibacterial therapy of bacterial urethritis is expedient to carry out taking into account the sensitivity of the isolated microorganism, giving preference to semi-synthetic penicillins and cephalosporins in cocci flora, with non-negative flora-aminoglycosides and fluoroquinolones. It is necessary to take into account some tropism of tetracyclines and macrolides to the male sexual organs. Selecting drugs for the treatment of nonspecific urethritis should take into account the possibility of nitrofurans, especially furazolidone. They are quite active in relation to the simplest trichomonads. The greatest difficulties arise in the treatment of staphylococcal urethritis, when there are strains of bacteria resistant to all antibiotics and chemotherapy. Such patients are treated with staphylococcal anatoxin, staphylococcal y-globulin (anti-staphylococcal human immunoglobulin) administered intramuscularly, and if it is ineffective, autovaccine should be obtained and administered twice.

With Reiter's syndrome, when joint damage is so severe. Which lead to the development of ankylosis, glucocorticoid therapy is indicated. Assign also drugs that improve microcirculation (dipyridamole), NSAIDs (indomethacin, diclofenac, etc.).

Antibiotic treatment for chronically occurring forms of urethritis should be supplemented by methods of nonspecific immunotherapy.

It is possible to prescribe pyrogenal, and since all patients with urethritis are usually treated out-patient, the daily administration of it is possible in a day hospital in a polyclinic. Instead of pyrogenal, you can use prodigiozan intramuscularly.

Nonspecific immunological treatment of chronic urethritis may be supplemented with the introduction of a 5 mg extract of prostate (prostatylene) diluted in 2 ml of sterile isotonic sodium chloride solution or 0.25% solution of procaine intramuscularly once a day, with a course of 10 injections, with possible recurrence through 2- 3 months

In the chronic phase of urethritis and rarely in subacute, local treatment of urethritis is sometimes indicated. With the introduction of drugs into the urethra, it should be remembered that due to the good vascularization of the submucosa, its mucosa has a significant absorption capacity. Washing of the urethra is carried out with solutions of nitrofural (furacilin) 1: 5000. Mercury oxycyanide 1: 5000, silver nitrate 1: 10000, protargola 1: 2000. Recently, instillations in the urethra and its washing have begun to produce 1% solution of dioxidine or miramistin, as well as hydrocortisone 25-50 mg in glycerol or in vaseline oil. However, the attitude to local treatment should be restrained.

It is advisable to perform a combined treatment for urethritis, which should include physiotherapeutic methods (ultrahigh-frequency exposure, diathermy, antibiotic electrophoresis, hot baths, etc.). Physiotherapy is especially indicated for complications (prostatitis, epididymitis). In the treatment of nonspecific urethritis, sexual intercourse, the use of alcoholic beverages, spices, spicy seasonings are prohibited.

Hospitalization of patients with urethritis is indicated in the development of complications (acute retention of urination, acute prostatitis, epididymitis, epididymorchitis, acute cystitis, etc.).