Urethritis
Dr.Wael Mohamed Saudi
Ass. Prof of Dermatology and Venerology
(MUST) University
STDs
Group of Contagious diseases in
which the main mode of
transmission is sexual contact
Anatomy of the Male Urethera
Extend from the bladder neck to the external urinary meatus
 20 cm length
Male Urethera (20 cm)
Posterior Urethera
(5 cm)
Lined by Transitional
epithelium
Posterior
Urethera
Anterior
Urethera
Anterior Urethera
(15 cm)
Lined by Columnar epithelium
Except
Last 12mm (Fossa navicularis )
Lined be Stratified squamous epithelium
epitepithelium
Posterior Urethera (5cm)
Prostatic Urethera
Begin:
Bladder Neck
Membranous Urethera
2Cm
Begin:
Apex of the prostate
End:
Post. Layer of
End:
Bulb of Penis
3 Cm
Ligament
Lies in:
Prostatic substance
Lies in:
2 layers of
Ligament
Posterior surface:
Open into it:
Ducts of prostatic acini (Anteriorly)
Opening of Ejaculatory duct (Posteriorly)
Cowper glands
on either side
Anterior Urethera (15 cm)
Bulbous
Urethera
Begin:
Anterior layer of
triangular ligament
End:
penile angle
Pendulous Urethera
Begin:
Penile angle
End:
Fossa navicularis
Open into it:
Open into it:
Cowper`s glands
Littre's glands
(Fossa navicularis)
Male Urethera
Related glands
 Cowper`s glands:
- Pair of glands present on either side of the posterior
surface of the Membranous urethera
- Open in the bulbous urethra
- Secrete Mucoid secretion during the foreplay (Prosemen)
Littre's glands:
- Multiple mucous glands present on the roof and sides of
the penile urethra
- Open in Fossa navicularis
 Tayson`s glands:
- Present on either side of the Frenulumn
- Secrete cheesy sebaceous material (Smegma).
 Parauretheral ducts:
- Parallel to the terminal part of urethera and open
near the external meatus
Anatomy of the female urethra (4 cm)
 Proximally---lined with transitional epithelium
 Distally------- lined with stratified epithelium
 From the bladder base to the external urinary meatus
 Anterior to the vaginal opening
Female Urethera
Related glands

Skene`s glands:
- Present on either side at the lower
end of urethera
- Open into the uretheral meatus.
 Bartholin`s glands:
- Present within the posterior lower
third of each labium Majora
- Open on the inner surface of the labium minus
- Secrete mucous for vaginal lubrication
Q & A1
Anatomy Questions
MALE URETHRA
1-Male Urethra extends from ----to ---------- It measures ------ cm
2-Posterior Urethra is lined by --- while Anterior urethera is lined
by ---- except last 12 mm which is called ------- lined by ------3- ---- and ----- open into prostatic Urethra while ------ are present
on the posterior surface of Membranous Urethra
4- Cowper´s glands open in ----- and secrets----- while Littre's
glands open in -----
FEMALE URETHRA
1-Female Urethra extends from ----to -------- It measures ---- cm
and lined by-----2- --------- are Present on either side at the lower end of urethera
and Open into ------3- Bartholin`s glands Present within the -------- and Open on the
-----------------
Male Uretheral discharge
Physiological
Pathological
Prosemen
Prostatorrhoea
•Viscid
Transparent
Secretion
- Greyish white turbid
• Cowper `s gland
Alkalinize
Urethera
before semen
Gonococcal
NonGonococcal
secretion
- At the end of micturation or defecation
fromcongested prostate or unsatisfactory
sexual stimulation
MALE URETHERAL DISCHARGE
1- Male uretheral discharge can be ----- or -----
2- Prosemen results from ----------- gland secretion while
congested prostate results in--------- secretion
Urethritis
Gonococcal
Chlamydia +ve
Non Sexual
Non-gonococcal (NGU)
Chlamydia -ve
NSU
Mycoplasma
and Ureaplasma
Urealyticum
In recent years, the incidence of NGU
has increased
Other infectious agents
Trichomonas vaginalis
Compared with gonorrhoea NGU is more frequent in the higher
socioeconomic class and is less common in homosexuals.
GONOCOCCAL URETHRITIS
Definition
Gonorrhea is an infectious disease
involving the genito-urinary tract of both
sexes which is usually transmitted by
sexual intercourse.
Neisseria Gonorrhoea
Gram negative diplococci
 kidney shaped
 Pili or fimbriae on surface
 Intracellular (PML)
Affinity to columnar& transitional epithelium.
Stratified squamous epithelium Resist infection
Modes of infections
A) Sexual (common):
1- Heterosexual: urethra
3- Orogenital: pharynx.
2- Homosexual: rectum
B) Asexual:
1-Neonatal:Pass during labour in infected females
ophthalmia neonatorum
2- Childhood: vulvovaginitis????
(Immature st squamous epithelium, low glycogen,
Alkaline PH)
3- Adulthood: rare due to contaminated towels.
Sites of involvement
1- In males: Urethera, littre’s glands
cowper’s glands,prostate, seminal vesicle,
and epididymis.
2-
Females: Urethera, Skene’s gland,
Bartholin’s,endocervix and fallopian tubes
3- Both males and females:
rectum, conjunctiva and oropharynx
Incubation Period
2 - 5 days
Clinical picture
1-Male
2-Female
1- Acute anterior Urethritis
1- Asymptomatic 50%
2- Acute Posterior Urethritis
2-Urethritis and Cervicitis
3- Complications
3- Complications
Clinical picture
1- In males:
A- Acute anterior urethritis
 Symptoms
Profuse,Purulent Thick creamy
Yellowish Discharge
Signs
Red,edematous external meatus and inguinal LN
maybe enlarged and tender

B- Acute Posterior Urethritis
 If the condition is neglected(12-14 days)
 Dysuria, Urgency, terminal hematuria
C- Complications
1- Complications of anterior urethritis
3 Glands
3 Urethera
2- Complications of posterior urethritis
1-Complications of Anterior Urethritis
3 Glands
Tysonitis: Red tender swelling on one or either sides of the
frenulum,
-Littritis: Multiple tender swellings along the roof and sides
of urethra.
-Cowperitis: Severe pain in the perineum, frequancy,
urgency and painful defecation
3 Urethra
- Periurethral abscess
- Fistula
- Stricture
2-Complications of posterior Urethritis
-
-
Prostatitis
Seminal vesiculitis
Epididymitis
Fibrosis leads to obstructive infertility.
C/P in Females
1- Asymptomatic (50 %).
2- Micturation symptoms (no hematuria)
3- Genital discharge (from cervix and or
urethra
Signs:
1- Urethral meatus is inflammed and
swollen with pus oozing
2- Cervix is enlarged, congested with
mucopurulent discharge
3- Slightly enlarged tender inguinal lymph
nodes.
2-Complicated:
- Urethra:
- Abscess
- Fistula
- Stricture
Glands:
- Skenitis:
- Dysuria and pus drops on squeezing of the
urethra.
-Swelling on either side of the urethra felt
by index finger in the vagina.
- Bartholinitis:
- Severe pain preventing sitting or walking.
- Swelling and redness on lower third of labia
majora.
- Can be felt by index in vagina and thumb on
lower third of labia majora.
- Pus can be expressed on inner sides of labia
minora.
-Internal organs:
Spread of infection to endometrium,
fallopian tubes and peritoneum→ Pelvic
Inflammatory Disease (PID), (10 % 0f
untreated cases), associated with
infertility, ectopic pregnancy.
Laboratory Diagnosis
Laboratory Diagnosis depends
on :





Microscopic examination .
Culture .
Biochemical
reaction(Confirmatory)
Fluorescent antibody test
Serology.
I-Smear
Acute Stage ----------- (Discharge)
Chronic Stage --------- (Morning Drop)
By Gram’s stain, examination under the microscope with
an oil - immersion lens
Not conclusive for N.Gonorrheia
II- Culture
Growth media

Selective Medium
(Chocolate agar)
(Thayer Martin media)
III-Confirmatory tests
A-The oxidase test
It has been of great value in the
detection of gonococcal colonies in
mixed culture . (Oxidase +)
2- Fermentation
Neisseria :
reaction
Glucose Maltose
N.gonorrhoea
+
N.Menengitidis
+
+
N.Catarrhalis
+
+
N.Pharyngitis sicca
-
of
the
Sucrose
+
-
N G ferment Glucose with acid production ( use
phenol red as indicator,it turns yellow upon
positivity)
BUT it takes about 48 hours
-
-
III- ImmunoFluorescent Staining
Direct IF (sensitive and Rapid)
Ag (colony)
AB (High titred antigonococcal serum)
Fluorescein
Apple green Fluorescence = GONOCOCCI
Sensitive test
IV-Radioimmunoassay & ELISA
(most sensitive)
Treatment of gonorrhea
By mouth :
1- Penicillin (interfer cell wall synthesis)
- Cheapest -Most effective -Least toxic .
* Ampicillin :
2-3 gm by mouth + 1 gm
probenicid orally (- penicillin renal secretion ).
* Amoxycillin : 3 gm by mouth + 1 gm
probenicid orally .
* Pivampicillin hydrochloride : 4 caps. (350 mg) by
mouth + 1 gm probenicid orally .
* Talampicillin : 1-5 gm + 1 gm probenicid orally .
2- Beta-lactamase inhibitors : Clavulinic acid
It inhibits lactamase by binding with the enzymes
and when combined with amoxycillin acts
effectively against PPNG.
Clavulinic acid 125 mg + amoxycillin in a capsule
form (Augmentin) 8 capsules are given in PPNG .
3- Cotrimoxazole : (sulphamethoxazole 400 mg +
trimethoprim 80 mg) in a tablet form . 4 tablets by
mouth twice daily for 2 days (4 doses of 4 tab.) or
2x2x5 days .
4- Quinolone derivatives: These drugs are
structurally related to nalidexic acid.


Acrosoxacin : 300 mg by mouth on an empty
stomach effective in both PPNG and non PPNG
infections. Drowsiness, dizziness and headache
are common.
Norfloxacin : Two tablets orally in a single
dose gives 100 % cure rate in PPNG

Ciprofloxacin : 250-500 mg by mouth in a single
dose, effective in genital, oral, and rectal
infections.

Enoxacin : It should not be given to patients who
suffer from epilepsy in any form. Two 200 mg
oral doses 12 hours apart or as a single dose of
600 mg, useful in oral, rectal, and uncomplicated
genital infections.
By injection
1- Procaine penicillin :
4.8 million I.U. of procaine penicillin I.M.
injection [ 2.4 in each buttock ].
preceded by 2 gm probenicid orally
2- Spectinomycine :
is very effective against PPNG and also
against tetracycline resistant strains , 2 gm
by deep I.M. injection , safe if used during
pregnancy.
3- Cephalosporins :
 2nd generation: Cefuroxine sodium 1.5 gm
I.M.I.
 3 rd generation: Cefuroxine disodium, 125250 mg I.M.I. Single dose gives 98 – 100%
cure rate in genital gonorrhea. 250 mg is
also effective in oral and ano rectal
infections, 2nd and 3rd generation are better
than 1st generation.
4- Monobactam derivatives :
 Aztereonam : 1 gm I.M.I is very effective
in PPNG whatever the mechanism of
resistance.
Tests of cure


After 3 days of treatment ---No discharge
Smears and cultures from urethra and cervix
at least two occasions should have given
negative results.
Causes for treatment faliure
1- Reinfection
2-Wrong diagnosis
3- treatment by Benzasine penicillin (Delayed onset)
4- Infection by penicillin resistant strains ---Spectinomycin 2 gm
I.M.I. twice daily /5 days.
5- Postgonococcal urethritis ---- 80% C.Trachomatis----Doxycycline 100mg twice daily
Q & A2
Gonococcal Urethritis (GU)
1- GU is caused by -----2- Neisseria Gonorrhoea has affinity to --------- while --------epithelium Resist infection
3- Childhood vulvovaginitis resuts from :
ABC-
4- Incubation period of N.Gonorrehea is -------5- Discharge of Acute anterior urethritis is -----------
6-Symptoms of acute posterior urethritis are ----------- , ----and --7- female Gonococcal Urethritis is asymptomatic in -----%
8- Skenitis diagnosed by Dysuria and pus drops on squeezing of
------ . Swelling on -----------felt by index finger in the vagina.
9- on Examination for Bartholinitis Swelling Can be felt by index in
vagina and thumb on-------------.
10- Laboratory diagnosis for NG include :
A--------B---------------C---------------D------------E------------
11- NG ferments ----- only
12- Most sensitive test for NG diagnosis is ------13- the drug of choice in treatment of Penicillin resistant NG is ---in a dose of --------14. Mention 3 Causes for faliure of NG treatment.
Nongonococcal Urethritis
Urethritis
Gonococcal
Chlamydia +ve
Non-gonococcal (NGU)
Chlamydia -ve
NSU
Other infectious agents
Etiology of NGU
Sexually transmitted
microbial agents
Non sexually
acquired urithritis
Sexually Transmitted Microbial Agents
I.
Specific Causes (75%)
a)
1- Bacteria
i)
Chlamydia Trachomatia (main cause):
30-50% of cases of NGU.
15-35% of cases of Gon Urethritis
60% of cases of PGU.
ii) Ureaplasma urealyticum 10-40%
iii) Others. e.g. Mycoplasma geitalium,
corymebacterium genitalium, Treponema pallidum.
2- Viruses
Herpes simplex virus may be the cause in less than
1%. It clears as herpes clears.
3- Fungi
Candida (maybe associated with Can-balenrritis, exclude
DM).
4- Protozoa
Trichomonas Vaginalis.
II
a)
b)
c)
d)
e)
Non-sexually Acquired Urethritis
Bacterial urinary tract infections associated with urethritis.
Urogenital TB with urethritis.
Acute Haemorrhagic cystitis.
Stevens-Johnson syndrome.
Secondary to: urethral instrumentation, urithral stricture,
renal stones, phosphaturia.
Biology of Chlamydia
Although they simulate viruses in being obligatory
intracellular parasites, however they are
considered bacteria due to:
a) Have cell wall similar to that of gram -ve
bacteria.
b) Contain both DNA and RNA.
c) Multiply by binary fission.
d) Sensitive to the antibiotics e.g. Azithromycin,
tetracycline, erythromycin and sulphonamides.
They cannot grow on artificial
media but grow on yolk sac and
chick embryo (as virus).
Clinical picture:
IP: 2-3weeks
Slight mucoid or mucopurulent discharge
Tendency for recurrence and chronicity
Male:
Urethritis – epididymitis-prostatitis- infertilityReiter's disease
Female:
Urethritis – pelvic inflammatory diseaseabortion – still birth-prematurity
Treatment of Non gonococcal urethritis
•Tetracycline 500 mg 1×4×14
•Doxycycline 100 mg 1×2×14
•Azithromycin 1 gm single dose.
Trichomoniasis
Aetiology:
Trichomonas vaginalis is an anaerobic protozoan
with oval shape.
It is motile with an irregular jerky movement.
It can survive outside the body for up to 24 hours
in moist environment.
Epidemiology
•Females are more affected than males
•It may be associated with other types of urethritis.
•Females are more affected since the organism needs the
glycogen available in the vagina.
•Males are transient carriers due to the antitrichomonal
effect of the prostatic discharge.
Mode of infection:
- sexual intercourse.
- non sexual transmission through fomites.
Incubation period:
1week- 3weeks
Clinical Picture
•Females may show minor symptoms of vaginitis and
offensive discharge, urethritis & dysuria
•Upon examination red vaginal wall & red spots on
cervix (strawberry cervix).
•Males might be asymptomatic or may show urethritis
•with a tickling sensation in the urethra.
Diagnosis:
-Direct microscopic examination (wet mount preparation)
(Hanging drop):
Secretions from posterior vaginal fornix or urethral
scrapings in men are taken and a drop of saline
is added/A cover slip is applied & examination is do
under dark field----Jerky movement of the flagellate
:
Treatment:
•Metronidazole 250 mg 1×3×7
•Tinidazole 2 gm single dose.
•Treatment of sexual partner.
Q & A3
Non Gonococcal urethritis
1- Most common cause on Non Gonnococcal urethritis is-------2- Incubation period on Non Gonnococcal Urethritis is-----3- Treatment for Chlamydia urethritis is-----------4- Trichomoniasis is characterized by ---------- movement
5- Trichomoniasis is more in females as it needs ------- which is
present in the vagina
6- strawberry cervix is characteristic for -----------7- Best treatment of Trichomonas vaginalis is -----------