The urethral discharge corresponds to a discrete flow meatus occurring spontaneously outside of urination. It can be heavy, painful or otherwise unobtrusive.
He signed urethritis, bacterial, linked to a sexually transmitted infection (STI).
It is typically morning.
DIAGNOSTIC:
Symptoms causing the patient or the patient can be shown in addition to the flow itself, dysuria, of burning on urination, pollakiuria, ductal pruritus, glued meatus.
Two germs dominate this pathology: Neisseria gonorrhea (gonorrhea) and Chlamydia trachomatis. Classically, gonorrhea gives an abundant flow, possibly greenish yellow, with marked urethritis and Chlamydia a whitish discharge, discreet or even asymptomatic.
Asymptomatic forms are discovered during a routine examination carried the infection to the partner.
In women, it is often cervicitis with leucorrhoea greenish, yellow or white, accompanied by cystalgia, urethritis, dyspareunia and spotting.
Urethritis is more common in women in cases of gonococcal infection, and in case of Chlamydia, one can see a speculum friable and hemorrhagic ectropion, cervical weakness.
Two important facts to note: the current prevalence of Chlamydia trachomatis infections on gonococcal infections, and increased frequency of resistance isolated gonococcal strains to penicillins.
Classically, gonorrhea is associated with a low socioeconomic level, in major cities, and Chlamydia trachomatis is rather common in young women from wealthier households.
Examination:
A police-type examination is required, in order to clarify: patient history, specifying those of sexually transmitted disease;
– Sexual habits (homo-, hetero- or bisexuality, homosexuality if the active or passive reporting, the number of partners, the concept of new partners, protected or not reports, attendance of prostitution) ;
– Term antibiotic treatment;
– Flow characteristics, time to onset from the last report;
– Notion of other mucocutaneous lesions.
Physical examination:
Clinical examination should be complete of course, emphasizing the oral cavity (pharyngitis) and the external genitalia.The anal margin is also inspected in women and homosexual (purulent anorectite). All suspicious lesions are removed.In women, it must do a pelvic examination with a speculum examination. In humans, it must feel scholarships looking for epididymitis and perform a rectal examination for fever or pelvic pain to search prostatitis.
Partners are sought and examined and the results of STIs should be proposed to them.
Biological samples:
A comprehensive review of the type STI must be done outside of the flow related levies: serology for hepatitis B (HBsAg and anti-HBc Ab), TPHA-VDRL (repeat one month if negative), HIV status 1 and 2 and p24 Antigen. A urine dipstick and urine culture (urine culture) should still be practiced.
ETIOLOGY TREATMENT:
Treatment should be active on gonorrhea and Chlamydia trachomatis, because of the possible association between the two seeds. Probabilistic, it is proposed without awaiting the results of bacteriological samples.
After treatment, the patient is reviewed.
For prostatitis associated with urethritis, treatment should be extended for 4 to 8 weeks,
preferably choosing a fluoroquinolone (Oflocet® oral 200 mg 2 times a day).
If epididymitis, treatment is the same for ten days.
Neisseria gonorrhea (gonorrhea):
Diagnostic:
Abundant urethral discharge, greenish yellow, accompanied by dysuria, voiding of burns, evokes a gonococcal infection.
The table is usually noisy humans. Extra-urethral locations can be (see above).
The infection is usually asymptomatic in women. Urethritis is associated with cervicitis in women in the infection (drop of pus in the urethral massage the anterior valve speculum).
In the passive homosexual men and women, gonorrhea can cause anorectite.
Usually asymptomatic, look for anal itching, anal purulent discharge, false needs, anorectal bleeding.
The oropharyngitis is asymptomatic.
The notion of unprotected intercourse within 2 to 7 days is important to clarify this period corresponding to the incubation of the germ.
If the flow is abundant, the patient may be sent to the laboratory for smear flow methylene blue or Gram stain. Infection with gonococcus is asserted if the smear demonstrates intracellular diplococci. If the flow is less abundant, a urethral swab (special swab down to 4 cm into the urethra) can be performed in the laboratory swab on calcium alginate. The smear is cultured (on chocolate agar).
Antimicrobial susceptibility was obtained in 24 to 48 hours if the culture is positive.
Serology is of no interest because cross-reactions with meningococcal (Neisseria meningitidis). PCR (Polymerase Chain Reaction) is not common practice.
Treatment:
The minute treatment is to offer in urethritis and uncomplicated infections (cervicitis, anorectite and pharyngitis). At best, the dose is given at the time of the consultation: ceftriaxone (Rocéphine®) 250 to 500 mg intramuscular or a single oral dose of 400 mg of cefixime (Oroken®). Both treatments are active on achieving throat.
Without it, we can propose an intramuscular injection of spectinomycin (Trobicine®) 2 g or a single dose of 500 mg ciprofloxacin (Ciflox®) per os. The treatment of non-gonococcal urethritis must also be made.
The partners must be identified and examined, which can sometimes be impossible. Sexual intercourse should be interrupted for seven days.
Chlamydia trachomatis:
Diagnostic:
If discrete flow, think, rather than gonorrhea, Chlamydia trachomatis.
Incubation is typically from 7 to 10 days.
The flow is rather clear or viscous scarce, inconsistent, and signs of urethritis less marked. In women, cervicitis is common, with friable and hemorrhagic ectropion, mucopurulent secretions, cervical weakness.
Bacteriological samples are taken on the first urine stream or endocervical swabs of women. PCR Chlamydiatrachomatis is used. Serology has little interest, because of cross-reactions with Chlamydia pneumoniae. In young women, PCR should be performed remotely.
Treatment:
In case of uncomplicated infections, the first-line treatment is azithromycin (Zithromax) at a dose of 1 g a single dose.
One can also propose doxycycline of 100 mg taken twice daily for seven days or ofloxacin (Oflocet®) at a dose of 400 mg 2 times a day for seven days. A gonococcal treatment should be performed.
Other germs:
They are rarely involved: Trichomonas vaginalis, Mycoplasma genitalium and Ureaplasma urealyticum (to evoke in case of failure of standard therapy).
Trichomonas vaginalis:
Diagnostic:
The Trichomonas vaginalis infection is usually asymptomatic in humans.
Urethritis, if present, is discreet.
Recall that this germ gives especially bacterial vaginosis in women. Trichomonas vaginalis can be isolated on the removal of the first morning drop, the first stream of urine or urethral swab.
Treatment:
Treatment is metronidazole (Flagyl®) a single dose of 2 g, to possibly renew fortnight later.
Mycoplasma genitalium and Ureaplasma urealyticum:
Diagnostic:
They are to discuss when trailing urethritis or resistance to treatment.
Treatment:
Treatment consists of taking one minute treatment with azithromycin (Zithromax) 1 g orally. In case of failure, treatment with moxiflocacine (400 mg / day for 10 days) may be proposed but better address the patient to a specialist consultant.
Complications:
They are mostly the prerogative of few forms or asymptomatic or unrecognized. In humans, it is prostatitis or epididymo-orchitis.
In women, the major risk is the occurrence of pelvic inflammatory disease, with the risk of tubal infertility and miscarriage. Salpingitis are primarily related to infection by Chlamydia trachomatis. The PID is typically subacute or chronic, with vague abdominal pain, especially during menstruation.
The vaginal examination is painful, there is an impasto of the vaginal cul-de-sac. If pain in the right upper quadrant, we must think perihepatitis Fitz-Hugh-Curtis, caused by Chlamydia trachomatis (classic adhesions “violin strings” perihepatic during laparoscopy).
In case of fever, we must also think of sepsis gonorrhea. This is reflected most often by asymmetric oligoarthritis associated with papular eruption papulopustular, sitting on the ends, fleeting Chlamydia trachomatis. Is also a common cause of reactive arthritis (Fiessinger Reiter’s syndrome). Reactive arthritis is more common in men after urethritis. It combines psoriasiform skin lesions, balanitis circinée, bilateral conjunctivitis and joint damage (heel pain, tendonitis, arthritis of large joints and axial disease). The patient should be shown to the rheumatologist for treatment of spondyloarthritis kind (non-steroidal anti-inflammatory drugs).
Patient follow up:
The patient should be reviewed systematically after seven days. In case of clinical cure, there is no need to practice other complementary examinations. Ensure that partners have been identified, detected and treated, it can sometimes be difficult or impossible for multiple partners.
If gonococcal pharyngeal location, bacteriological control is indicated to 7 days. Remember that it is better to make a case in infection control Chlamydia PCR-Chlamydia trachomatis in young women 2 to 3 months after the first episode.
In case of non-resolution of symptoms, one must ask whether the treatment was well taken or followed, the question of a possible recontamination and make practice in the laboratory samples for bacteriological referred.
HIV status must also be retested.
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