Urethral Discharge
Any inflammatory condition within the urethra may cause a discharge. It is important to diagnose venereal conditions so that appropriate treatment is given, not only to the patient but also to sexual contacts.
History
General
For any sexually transmitted disease, check for a history of sexual contact, time of last sexual intercourse, contraceptive methods, number and duration of relationships, sexual practices and unusual sexual practices.
Prostatitis
Urethral discharge is rare with acute prostatitis. With chronic prostatitis, there may be a clear white urethral discharge. The patient may also complain of suprapubic pain, low back pain, perineal discomfort and pain referred to the testicles.
Non-gonococcal urethritis
The patient complains of urethral discharge, which may be thinner than with gonorrhoea. The presentation may be less acute than with gonorrhoea.
Gonorrhoea
The patient will complain of a thickish, purulent urethral discharge and dysuria. Prostatitis and epididymitis may occur, the patient complaining of deep perineal pain or scrotal swelling.
Other bacterial
Urethritis may occur with urinary tract infections. Infection with Haemophilus ducreyi causes chancroid or soft sore. It is a tropical infection causing painful genital ulcers and swelling of the inguinal glands. The soft sores may affect the terminal urethra, resulting in dysuria and a profuse, thin, watery discharge. TB of the urethra is very rare. It is usually secondary to TB elsewhere in the genitourinary tract. A syphilitic chancre is now rare but presents as a painful swelling involving the terminal urethra.
Reiter’s disease
The patient is usually a young male with recent non-specific urethritis, or it may follow an attack of dysentery. Apart from a urethral discharge, there may be a history of conjunctivitis and joint pains.
Trauma
Urethral instrumentation or prolonged catheterisation may cause urethritis. There will be a clear history of this. Foreign bodies may be introduced by the patient. The variety of these defies description! Other foreign bodies include stones passing from the bladder or fragments of urethral catheters. The patient may also be too embarrassed to confess that s/he has introduced a foreign body into the urethra.
Chemical
Chemical urethritis is more common in females. There may be a history of change of soap or bath oils.
Neoplastic
Urethral carcinoma is rare. The patient will complain of dysuria and bloodstained urethral discharge.
Examination
Prostatitis
There may be a tender, occasionally boggy prostate on digital rectal examination.
Non-gonococcal urethritis
Pus may again be seen at the external urethral meatus. Check for prostatitis and epididymitis.
Gonorrhoea
Often a bead of pus may be seen at the external urethral meatus. It is appropriate to check for evidence of proctitis or anal discharge (homosexuals). There may be evidence of prostatitis, there being a tender, boggy prostate on digital rectal examination. Palpation of the scrotum may reveal epididymitis.
Other bacterial
Other forms of urethritis may show a discharge at the external urethral meatus. With chancroid, there may be sores on the genitals with sores around the meatus. Check for inguinal lymphadenopathy. Urethral TB is very rare. Check for evidence of TB elsewhere, e.g. lungs, kidneys, epididymis. With a syphilitic chancre the meatus is oedematous and swollen. There may be inguinal lymphadenopathy.
Reiter’s disease
Examine for conjunctivitis and arthritis. There may be co-existent plantar fasciitis and Achilles tendonitis. Examine for abscesses on the soles of the feet and palms of the hands (keratoderma blenorrhagica).
Traumatic
Feel along the course of the urethra for tenderness or palpable stone or foreign body.
Neoplastic
A hard lump may be felt along the course of the urethra. Pressure on it may cause a bloodstained urethral discharge.
General Investigations
■ FBC, ESR
WCC ↑ in infection, e.g. gonorrhoea. ESR ↑ inflammation, e.g. syphilis.
■ Swab
Microscopy and culture and sensitivity of urethral discharge. This may grow gonococcus, Chlamydia trachomatis, Trichomonas spp, Ureaplasma urealyticum. Secondary infection, e.g. with candida or coliforms, may occur. Haemophilus ducreyi may be grown in chancroid. Dark-ground microscopy may reveal treponemes in syphilis.
