Sexually Transmitted Infections (STIs)

Subtopic:

Urethral Discharge Syndrome

A common sexually transmitted infection (STI) in males, Urethral Discharge Syndrome is characterized by a discharge from the urethra, typically pus-like, and may or may not include painful urination. The volume of discharge can differ based on the specific germs causing the infection and any previous antibiotic use.

Clinical Presentation:

  • Primary Complaint: Individuals with this condition frequently report fluid leaking from the urethra. This may be noticed as mucus or pus at the penis opening, or as stains on undergarments.

  • Associated Symptoms: Patients might experience a burning feeling when urinating and an increased need to urinate more often.

Physical Examination:

  • Visual Assessment: A physical exam could show a pus-filled discharge from the urethra.

  • Eliciting Discharge: If discharge isn’t immediately apparent, gently pressing and moving the penis forward might help make it visible.

  • Caution with Copious Discharge: Avoid pressing or squeezing if the discharge is already plentiful.

  • Foreskin Examination (Uncircumcised Patients): In uncircumcised men, examination should be done with the foreskin pulled back to confirm the discharge originates from the urethra and not from under the foreskin.

  • Discharge Appearance: The nature of the discharge can vary from thick pus to a mixture of mucus and pus.

Definition:

The condition is defined by the presence of discharge from the urethra in males, with or without painful urination.

Etiology:

  • Common Causes: Neisseria gonorrhoeae and Chlamydia trachomatis are the most frequent causes, accounting for the vast majority of cases (over 98%).

  • Less Common Causes: Other infectious agents include Trichomonas vaginalis, Ureaplasma urealyticum, and Mycoplasma species.

  • Co-infections: Infections involving both Neisseria gonorrhoeae and Chlamydia trachomatis can also occur.

Management Strategy:

The recommended approach for managing all male patients presenting with urethral discharge is to follow established syndromic management guidelines.

Medicines

Recommended medications typically involve a combination approach to address the most likely causes of urethral discharge syndrome.

  • Initial Therapy: A common first-line treatment includes a single intramuscular injection of Ceftriaxone 250 mg or a single oral dose of Cefixime 400 mg, combined with Doxycycline 100 mg taken orally twice daily (every 12 hours) for a 7-day duration. This dual therapy aims to effectively treat both gonorrhea and chlamydia infections, which are frequently responsible for this syndrome.

  • Pregnancy Considerations: If the patient’s sexual partner is pregnant, Doxycycline should be replaced. Suitable alternatives include Erythromycin 500 mg taken orally every 6 hours for 7 days, or if readily available, a single oral dose of Azithromycin 1 gram.

Treatment Procedure:

A structured approach to managing urethral discharge syndrome is essential for effective patient care and preventing further transmission.

  • Patient Evaluation: Begin with a detailed collection of the patient’s medical history and a thorough physical examination. If urethral discharge is not immediately apparent, employ the urethral milking technique to aid visualization. In individuals with a foreskin, ensure it is retracted during examination to check for any ulcers.

  • Comprehensive Care Approach: Treatment should be extended to both the patient and all sexual partners to prevent re-infection and further spread. Patient counseling is crucial, emphasizing either abstinence from sexual activity or consistent condom use to minimize transmission risks.

  • Pharmacological Intervention: Administer the chosen antibiotic regimen. This usually starts with either a Ceftriaxone 250 mg injection (IM) or a single 400 mg dose of Cefixime orally. Alongside this, prescribe Doxycycline 100 mg orally twice daily for 7 days.

  • Adjustments for Pregnant Partners: In cases where the partner is pregnant, substitute Doxycycline with Erythromycin 500 mg orally every 6 hours for 7 days, or consider a single dose of Azithromycin 1 gram orally if accessible.

  • Managing Persistent Symptoms (Post-Partner Treatment): If symptoms like discharge or painful urination continue even after partner treatment, check for ulcers that might be hidden under the foreskin. If persistence is noted, repeat Doxycycline 100 mg every 12 hours for 7 days and add Metronidazole 2 grams as a single oral dose.

  • Addressing Untreated Partners Initially: If partners were not treated concurrently from the start, re-initiate the primary treatment plan and ensure that all partners receive treatment at the same time.

  • Holistic STD Management: Incorporate a full package of care including:

    • Education: Reinforce the importance of adhering to the prescribed treatment.

    • Condom Promotion: Provide condoms and demonstrate correct usage techniques.

    • Partner Management: Ensure all sexual partners are treated, regardless of whether they are showing symptoms.

    • HIV Voluntary Counselling and Testing (VCT): Offer or facilitate access to HIV testing and counseling services.

  • Persistent Discharge Management: If discharge continues despite treatment, administer Ceftriaxone 1 gram IM. If symptoms still persist after this, consider referring the patient to a specialist for further evaluation and management.

  • Patient Education and Counseling: Provide thorough counseling to all patients, emphasizing:

    • Adherence to the complete treatment course.

    • Consistent condom use and provide condoms.

    • The necessity of partner treatment.

    • Offer or refer for HIV VCT services if indicated.

    • Schedule a follow-up appointment.

    • Abstinence from sexual intercourse until all symptoms have completely resolved.