Urethral discharge

This is nearly always a complaint of men. Ensure that the discharge is from the urethra and not from under the foreskin. Ascertain the colour and duration of the discharge. A purulent discharge suggests gonorrhoea, whereas chlamydial or ‘non-specific’ urethritis and Trichomonas vaginalis are more likely to give rise to a scanty mucoid or mucopurulent discharge. Sometimes the patient only notices the discharge in the morning, or by staining of his underwear. Prostatic secretions, which are physiological, may present as urethral discharge in men who have abstained from sexual intercourse or masturbation.

Dysuria

Urethral pain on passing urine may be described as burning or stinging. False dysuria may occur if urine comes into contact with inflamed areas on the prepuce or vulva (ulcerated).

Urinary frequency

The frequent passage of urine, usually in small quantities, suggests bladder infection or involvement of the trigone of the bladder from ascending urethritis. It also occurs physiologically in irritable bladder syndrome and in anxiety.

Vaginal discharge

Ask if the discharge is itchy or offensive. An itchy vaginal discharge is suggestive of thrush or, occasionally, trichomoniasis. Smelly discharges are usually due to trichomoniasis, bacterial vaginosis or retained foreign bodies such as tampons. Physiological discharge can occur after sexual stimulation or during pregnancy, but is not itchy or offensive. Vaginal discharge may also arise from gonococcal, chlamydial or herpetic infections of the cervix.

Dyspareunia

This is pain on sexual intercourse. In women, superficial dyspareunia is pain in the vulvovaginal area and can be due to vulvitis or lichen sclerosus. This must be differentiated from vulvodynia, which is chronic localized burning and soreness in the vulva and may be associated with vestibulitis, vestibular papillomatosis or subclinical warts, or may be idiopathic. However, vulvodynia can be aggravated by intercourse or tampon insertion. Deep dyspareunia is pain deep in the vagina and may result from pelvic inflammatory disease, endometritis and other gynaecological diseases, particularly endometriosis.

Anogenital ulcer

This is usually described as a ‘sore’. Ask if it is painful or recurrent. Painful ulcers are usually due to genital herpes, chancroid, Stevens-Johnson syndrome, Behçet’s disease or trauma, whereas a painless ulcer may be due to syphilis or lymphogranuloma venereum. However, syphilitic ulcers can be painful. The evolution of the ulcer is important. Genital herpes may start with local irritation followed by erythema, a group of papules, then blisters which ulcerate and crust before healing, but the majority present atypically such as an anogenital fissure. If the infection was acquired in a tropical country, chancroid, lymphogranuloma venereum and donovanosis should also be considered. Lymphogranuloma venereum is endemic among men who have sex with men (MSM) but is more likely to present with a proctitis rather than an ulcer. Ask whether the patient has applied any medicament that might interfere with microbiological tests. An acute anogenital ulcer is syphilitic or herpetic unless proved otherwise; herpetic ulceration persisting more than 1 month is an AIDS-defining illness.

Painful scrotal swelling

Acute epididymo-orchitis may complicate a sexually transmitted infection. Painful scrotal swelling is also a feature of acute surgical emergencies such as torsion of the testis and strangulated inguinal hernia. Other causes include trauma and recent vasectomy. Acute epididymo-orchitis in sexually active men below the age of 35 is likely to result from gonococcal or chlamydial infection and in those over the age of 40 from bacterial urinary tract infection, such as that due to Escherichia coli. Testicular cancer may sometimes present as a painful swelling.

Pubic and genital itch

This is usually due to pediculosis pubis, scabies or other inflammatory genital conditions, such as allergic dermatitis, but may be psychological or be due to lichen simplex. Ask if sexual or household contacts also complain of itching. In pediculosis pubis, patients may notice ‘crabs’ and nits on the hair shaft. Itching at night is suggestive of scabies and is likely to be generalized except for the face.

Genital rash

An itchy rash on the vulva, glans penis or prepuce is seen in thrush, scabies and inflammatory dermatological conditions such as lichen sclerosus, lichen simplex or contact dermatitis. Non-itchy rash may be seen in secondary syphilis, circinate balanitis, which is a manifestation of Reiter’s disease, and in other genital dermatosis. Fixed drug eruptions, Stevens-Johnson syndrome, lichen planus and penile or vulval intraepithelial neoplasia may present as a genital rash.

Anorectal symptoms

Anal soreness, pain or itching, rectal discharge, pain on defaecation, a feeling of incomplete defaecation (tenesmus) and constipation may occur in infective proctitis resulting from herpes simplex, gonococcal or chlamydia D-K serovar infection or lymphogranuloma venereum. The latter may mimic chronic inflammatory bowel disease such as Crohn’s disease or ulcerative colitis. Anal itch (pruritus ani) may be secondary to rectal discharge or due to thrush, anal warts, dermatitis and poor anal hygiene. If the itch is worse at night, threadworm infestation should be considered. Pruritus ani is frequently psychological in origin. Sexually transmitted enteric infections such as giardiasis, shigellosis and salmonellosis in MSM may present with diarrhoea. Diarrhoea is also a common problem in HIV infection.

Systemic review

The skin, mouth, eyes and joints are commonly associated with sexually transmitted infections. Rashes may be seen in acute HIV infection, secondary syphilis, gonococcal septicaemia, Reiter’s disease and occasionally in acute viral hepatitis. Kerato-conjuctivitis may be seen in chlamydial, gonococcal and herpetic infection and is usually unilateral, whereas in Reiter’s disease it is usually bilateral. Anterior uveitis may be seen in Reiter’s disease, syphilis, HIV and human T-cell leukemia virus (HTLV)-1 infection. Joints may be involved in gonococcal arthritis, Reiter’s disease and congenital (Clutton’s joints) and late syphilis (Charcot’s joints). Lower abdominal pain may indicate pelvic inflammatory disease, and right hypochondrial pain may indicate perihepatitis or FitzHugh-Curtis syndrome, which are all related to chlamydial or gonococcal infections.

The penis

Note the appearance and size of the penis, the presence or absence of the prepuce and the position of the external urethral orifice. Examine the penile shaft for warts, molluscum, ulcers, burrows and excoriated papules of scabies and rashes. In Peyronie’s disease, there may be induration or a fibrotic lump inside the penile shaft. In the uncircumcised, establish that the prepuce can be readily retracted by gently withdrawing it over the glans penis. This allows inspection of the undersurface of the prepuce, the glans, the coronal sulcus and the external urethral orifice (meatus) for warts (Fig. 21.1), inflammation, ulcers and other rashes. Always carefully draw the prepuce forwards after examination; otherwise paraphimosis – painful oedema of the foreskin due to constriction by a retracted prepuce – may ensue.

Figure 21.1 Genital wart on the frenum of the penis.

Phimosis is narrowing of the preputial orifice, thereby preventing retraction of the foreskin; it may be due to lichen sclerosus. This predisposes to recurrent episodes of infection of the glans (balanitis), the prepuce (posthitis) or both (balanoposthitis). Circinate balanitis in Reiter’s disease appears as erythematous eroded lesions which coalesce with a slightly raised and polycyclic edge. Multiple small yellow or white submucous deposits (Fordyce’s spots) may be seen on the inner prepuce. These are ectopic sebaceous glands and do not require treatment. Smegma, which is greyish–white cheesy material arising from Tyson’s glands, may accumulate under the prepuce if unwashed.

Hypospadias is a congenital abnormality in which the external urethral orifice is not at the tip of the glans penis but opens at its ventral surface in the midline, anywhere from the glans to the shaft, or even in the perineum. Epispadias, a similar opening situated on the dorsal surface of the penis, is rare.

Tiny regular papules arranged in rows around the coronal sulcus are coronal papillae and may be mistaken for warts. The coronal sulcus is the commonest site for a chancre. Inspect the meatus for inflammation, urethral discharge, narrowing (stricture) and warts. Retract the lips of the meatus to look for meatal chancre and intrameatal warts. Tyson’s gland is on the fraenum of the penis and is not normally palpable, whereas the median raphe leads from the fraenum to the inferior aspect of the penile shaft; both can be infected by gonococcal or chlamydial infection, leading to tysonitis and median raphe abscess, respectively.

Look at the scrotal skin for any redness, swelling or ulcer. Lift the scrotum to inspect its posterior surface. Tiny dark-red papules of angiokeratoma, or round, firm, whitish nodules of sebaceous cysts can sometimes be seen. Scabies causes erythematous nodular lesions on the scrotum and glans penis. If intrascrotal swelling is present, observe whether it appears to extend into the groin and note whether both testes are in the scrotum. Ulceration can result from Behçet’s disease, fungation of an underlying tumour of the testis, or from a gumma.

The testes

Place both hands below the scrotum, the right hand being inferior, and palpate both testes. Arrange the hands and fingers as shown in Figure 21.2: this ‘fixes’ the testis so that it cannot slip away from the examining fingers. The posterior aspect of the testis is supported by the middle, ring and little fingers of each hand, leaving the index finger and thumb free to palpate. Gently palpate the anterior surface of the body of the testis; feel the lateral border with the index finger and the medial border with the pulp of each thumb. Note the size and consistency of the testis and any nodules or other irregularities. Now very gently approximate the fingers and thumb of the left hand (the effect of this is to move the testis inferiorly, which is easily and painlessly done because of its great mobility inside the tunica vaginalis). In this way, the upper pole of the testis can be readily felt between the approximated index finger and thumb of the left hand. Next move the testis upwards by reversing the movements of the hands and gently approximating the index finger and thumb of the right hand, so enabling the lower pole to be palpated. The normal testes are equal in size, varying between 3.5 and 4 cm in length.

Figure 21.2 Palpation of the testis. Gloves should be worn.

The epididymis

The head of the epididymis is found at the upper pole of the testis on its posterior aspect. It is a soft nodular structure about 1 cm in length. The tail lies on the posterolateral aspect of the inferior pole of the testis. The tail is also soft, but unlike the head it has a coiled tubular form. Occasionally the epididymis is situated anterior to the testis.

The spermatic cord

Finally palpate the spermatic cord with the right hand. Then exert gentle downward traction on the testis, place the fingers behind the neck of the scrotum and, with the thumb placed anteriorly, press forward with fingers of the right hand. The spermatic cord will be felt between the fingers and thumb; it is about 1 cm in width. The only structure that can be positively identified within it is the vas deferens, which feels like a thick piece of string.

Repeat the examination on the other side. Remember that the patient should also be examined standing up to look for varicocele – dilated tortuous veins like a bag of worms in the scrotum. Hydrocele of the tunica vaginalis or cysts of the epididymis are common causes of a painless scrotal swelling. Hydrocele can be demonstrated by transillumination, using a bright light source held in contact with the enlarged testicle, preferably in a darkened room. A painless, unilateral, hard, enlarged testis must be considered malignant. Other painless enlargements include testicular gumma and tuberculous involvement. Acute epididymo-orchitis, torsion of the testis, strangulated inguinal hernia and some cases of testicular neoplasm cause a painful swelling. In torsion, the epididymis cannot be differentiated from the swollen testis, which lies at a higher level than the normal testis. In old age, the testes may become atrophic. In younger men, testicular atrophy often indicates chronic liver disease, usually alcoholic in aetiology, or it may be associated with previous torsion or varicocele. In swellings of uncertain origin, ultrasound is useful.

Anorectal examination

The anorectal region is particularly important in homosexual and bisexual men. Ask the patient to lie in the standard left lateral position with the knees drawn up, or in the knee-elbow position. Examine the anal and perianal skin for inflammation, ulceration, fissures and tags. Primary syphilis and herpes simplex virus infection can present as an anal fissure. Anal tags should not be confused with anal warts (condylomata acuminata), which are sessile or pedunculated papillomata. Anal warts in turn should not be confused with the flat warty lesions of condylomata lata, which are the highly infectious lesions of secondary syphilis.

Gently insert a lubricated proctoscope and examine the rectal mucosa for pus, inflammation, ulceration, warts and threadworms. Take rectal tests. In patients who practise frequent receptive penoanal intercourse, the anus may be lax.

Bimanual examination

Use a bimanual examination technique to detect pelvic inflammatory disease and abnormalities of the upper genital tract. Uterine and fallopian tube tenderness with a positive cervical excitation test may indicate pelvic inflammatory disease. Tubo-ovarian abscess may be present.

Colposcopy

If there are cervical warts, or the cervical cytology is dyskaryotic, the cervix should be examined under magnification using a colposcope. White areas after the application of 5% acetic acid suggest cervical wart virus infection or dysplasia, which can be confirmed by biopsy. Chlamydial follicular cervicitis may also be observed.

Pubic regions and groins

Look for pediculosis pubis (‘crabs’) and nits. Molluscum contagiosum lesions appear as pearly or pinkish umbilicated papules. Look at the groins for tinea cruris, thrush and erythrasma. Tinea cruris and erythrasma give rise to a rash with a well-defined border whereas, in thrush, the border is less well defined, often with erythematous satellite papules outside it. Erythrasma lesions show a coral-red fluorescence with Wood’s light, an ultraviolet light used in the diagnosis of skin conditions.

Swelling in the groin is usually due to hernia, lymphadenopathy or undescended testis in men. Genital ulceration with tender suppurative inguinal lymph nodes (buboes) will suggest chancroid and lymphogranuloma venereum. In lymphogranuloma venereum, the ulcer may be transient and the buboes may have a grooved appearance resulting from lymphadenopathy above and below the inguinal ligament – ‘sign of the groove’. In primary syphilis, lymphadenopathy is painless, with mobile and rubbery nodes, although they can be painful if there is pyogenic secondary infection. Anal, penile and vulval carcinoma may metastasize to the inguinal lymph nodes. Inguinal lymphadenopathy may be part of a generalized disorder, as in lymphoma, secondary syphilis or viral infections, for example infectious mononucleosis and that due to HIV infection. Donovanosis may give rise to pseudobuboes, which are inguinal subcutaneous granulomata.

The skin

A generalized rash occurs in drug allergy and in acute viral infections such as HIV seroconversion illness, acute viral hepatitis, cytomegalovirus infection and infectious mononucleosis as well as acute toxoplasmosis. The generalized rash of secondary syphilis can be itchy or non-itchy, and commonly involves the palms and soles. Gummata of the skin may be present in late syphilis. In disseminated gonococcal infection, pustules with an erythematous base are seen mainly on the limbs, particularly near joints. Excoriated papules and burrows are features of scabies; generalized or crusted scabies may present as widespread crusted lesions. A psoriasis-like rash and keratoderma of the feet may be present in Reiter’s disease. Behçet’s disease causes recurrent painful orogenital ulcers. Stevens-Johnson syndrome can also present with painful orogenital ulceration and target lesions on the skin. In HIV infection, acute herpes zoster or scars of previous shingles, seborrhoeic dermatitis, severe fungal and bacterial infections, facial molluscum contagiosum and warts, bacillary angiomatosis and Kaposi’s sarcoma may be present. The last may present with purplish nodules or plaques (Fig. 21.5).

The mouth

The mouth is a common site for syphilitic lesions: extragenital chancres in primary syphilis, mucous patches and snail-track ulcers in secondary syphilis, and leukoplakia, chronic superficial glossitis and gummatous perforation of the palate in late syphilis. In congenital syphilis, linear scars radiating from the mouth, known as rhagades, and Hutchinson’s incisors – dome-shaped incisor teeth with a central notch – or Moon’s/mulberry molars may be present. Genital herpes can spread to the mouth and vice versa if the patient practises orogenital intercourse. In HIV infection, oral hairy leukoplakia, consisting of persistent white hairy patches on the side of the tongue, and oral thrush, consisting of curdy white patches which can be removed, leaving behind a raw surface (Fig. 21.7) or erythematous areas, may be seen. Other oral manifestations of HIV include aphthoid ulcers, oral warts, gingivitis, severe peridontal disease, Kaposi’s sarcoma and lymphoma.

Figure 21.7 White plaques of oral candidiasis (which can be scraped off to reveal an erythematous base) in an HIV-positive patient.

The eyes

Pediculosis pubis may be seen on the eyelashes. Conjunctivitis can be due to direct infection by Chlamydia, gonococcus, herpes simplex virus or molluscum, or can arise indirectly, as in Reiter’s disease. Anterior uveitis (iritis) can be seen in Reiter’s disease, secondary and late syphilis, Behçet’s disease and HIV and HTLV-1 infection. Secondary and late syphilis can present with cranial nerve palsies including cranial nerves III, IV and VI and choroidoretinitis. Congenital syphilis can present with interstitial keratitis, iritis and choroidoretinitis. Argyll Robertson pupils are small irregular pupils seen in neurosyphilis, particularly tabes dorsalis. They are non-reactive to light, but the accommodation reflex is present. In HIV infection, there may be retinal exudates and haemorrhages due to retinal infarcts, and cytomegalovirus infection may cause a segmental or diffuse retinitis with exudates and haemorrhage while herpes simplex virus and varicella zoster virus can cause acute retinal necrosis.

The joints

Painful joint swelling may be present in Reiter’s disease or disseminated gonococcal infection. Charcot’s joints in tabes dorsalis are generally painless, deformed and hypermobile; Clutton’s joints in congenital syphilis are painless bilateral joint effusions.

The abdomen

Gonococcal and chlamydial infection can cause lower abdominal pain and tenderness if endometritis or salpingitis supervenes, and right hypochondrial pain and tenderness if perihepatitis (FitzHugh–Curtis syndrome) is present. Sexually transmitted hepatitis includes secondary syphilis and viral hepatitis. Hepatosplenomegaly may be present in secondary syphilis, acute viral hepatitis, HIV infection and associated opportunistic infections, or lymphoma. In HIV infection, retrosternal pain on swallowing indicates oesophageal infection by candida, herpes simplex virus and cytomegalovirus infection. Acute pancreatitis may complicate treatment with drugs such as didanosine. Renal colic may result from protease inhibitors (e.g. indinavir, atazanavir, darunavir-induced stones).

Gram staining

The Gram-staining procedure is outlined in Box 21.4. If the patient has passed urine just before the test, the urethral smear may show no polymorphonuclear leukocytes because the urine will have washed out the accumulated urethral material. In such cases, the patient should be asked to reattend for an overnight or late afternoon urethral smear after holding urine for 8 or more hours. Gram-negative intracellular diplococci, which appear as opposing bean-shaped cocci within polymorphonuclear leukocytes under the microscope (Fig. 21.8), suggest gonococcal urethritis. The presence of five or more polymorphonuclear leukocytes per high-power field (×1000 magnification) with a negative test for gonococci indicates non-gonococcal urethritis (Box 21.5). The term non-specific urethritis is used to describe urethritis when specific causes, including Chlamydia trachomatis, Mycoplasma genitalium, trichomoniasis and non-sexually transmitted diseases such as bacterial urinary tract infection, have been excluded. However, the exclusion of C. trachomatis or M. genitalium infection requires specific and sensitive tests. A wet preparation, made by mixing urethral material using a loop with a drop of normal saline on a slide, can be examined by bright- or dark-field illumination for Trichomonas, which appear as ovoid protozoa with beating flagellae and in jerky motion. Continuing symptomatic urethritis a week or more after successful treatment for gonorrhoea indicates that the patient has postgonococcal urethritis, a non-gonococcal urethritis unmasked following treatment for gonorrhoea.

Figure 21.8 Gram-stained smear showing Gram-negative intracellular diplococci typical of Neisseria gonorrhoeae.

‘Two-glass’ test

This test still has a role when there are no facilities for urethral smear. Ask the patient to pass urine into two clear plastic cups, approximately 50 ml in the first glass and 100 ml in the second. The presence of several specks or threads that sink to the bottom in the first glass, with a clear second glass, indicates anterior urethritis; if there are threads in both glasses, posterior urethritis is indicated. Phosphaturia causes hazy urine in both glasses that clears with the addition of acetic acid. If the urine still remains hazy and there is pus in the urethral smear, this suggests either sexually transmitted urethritis with ascending infection in the bladder, or bacterial urinary tract infection with descending non-sexual infection to the urethra. The latter can be tested by a mid-stream urine culture. The urine must always be checked for sugar, protein, blood, cells and casts.