Clinical and bacteriological study of urethral discharge

Introduction

Urethritis is probably one of the common presentations seen in STD clinics in many developing countries. It is broadly divided into gonococcal and non-gonococcal urethritis (NGU). In developing countries the majority of cases of urethritis seen are due Neisseria gonorrhoea, which has been isolated from 53-80% of cases.[1] Incidence of NGU is reported to be on the rise in different parts of the world. Infections Chlamydia trachomatis account for 3060% of cases of NGU.[2] The other common causative organisms of NGU are ureaplasma, mycoplasma and herpes simplex virus. There has been a gradual increase in the number of antibiotic resistant mutants with reports describing resistance to quinolones.[3]

There is a particular concern in developing countries where laboratory facilities are not readily available and where clinical algorithms are in use for diagnosis and treatment of NGU.

Thus the present study was carried out to assess the association of various organisms, in patients with urethritis and to ascertain current pattern of antibiotic sensitivity of Neisseria gonorrhoea.

Materials and Methods

The study was carried out in the out patient department of Dermatology at Command Hospital, Southern Command, Pune and Military Hospital, Kirkee during the period from May 1996 to Dec 1997. In addition to a recording of a detailed relevant history, a general, systemic and dermatological examination was carried out for each patient. The Gram staining of all smears was done. It was followed by cultures for Neisseria gonorrhoeae in chocolate agar and Modified Thayer Martin medium, in cases positive for Gram negative intracellular diplococci. Antibiotic sensitivity test by disc diffusion method was performed. Darne et al criteria were used for nongonococcal urethritis i.e.more than 5 polymorphonuclear leucocytes per high power field in at least 5 fields of Gram stained urethral smear in absence of Gram negative diplococci. Detection of chlamydia was done by enzyme immunoassay method. Culture for mycoplasma and ureaplasma was also carried out. Wet mount of the specimen and Gram stained smear for candida and trichomonas was also carried out. All the patients were investigated for HIV infection (serum ELISA).

Results

A total of 52 patients were found to have urethral discharge, of which 50 were males and 2 were females. The age varied from 7 to 50 years. Majority of patients was seen in age group 21-30 years (58%). History of solitary sexual exposure was available in 16 (31%) patients and multiple exposure in 28 (54%) patients. The mean incubation period in gonorrhoea was found to be 4 days while in NGU it varied from few days to months. 34 (65%) cases were diagnosed as gonococcal urethritis while 18 (35%) cases as NGU. The patients with gonorrhoea mainly presented with purulent discharge in 28 (82.3%) cases, and dysuria in 24 (75%) cases [Table - 1], 16 (88.9%) cases had mucoid discharge and 12 (66.7%) had dysuria in patients with NGU. Out of 52 patients, In 30 (57%) patients Neisseria gonorrhoeae, 5 (10%) chlamydia trachomatis, 2 (4%), ureaplasma, 2 (4%) mycoplasma and in 4 (8) Staphy\ococcus auceus were isolated [Table - 2].7(20%) cases of gonorrhoea and 2 (11.2%) cases of NGU were HIV positive. 13 (38.3%) strains of Neisseria gonorrhoeae were resistant to penicillin and 2(5.9%) resistant to ciprofloxacin and norfloxacin each [Table - 2].

Discussion

There are several reports in literature regarding prevalence of gonococcal and non gonococcal urethritis, mostly from Western countries. There have been very few Indian studies, which have tried to analyse the prevalence, mainly due to limited availability of laboratory facilities. There has been a gradual increase in the number of antibiotic resistant mutants, with few reports from India reporting resistance to quinolones.

Gonococcal urethritis was the commonest type of urethritis in our study as observed in various other studies reported from India.[4],[5] The reported incidence of nongonococcal urethritis in Western countries is due to increased availability of laboratory facilities to isolate various organisms causing NGU.[6] The incidence of chlamydia causing NGU in present study was 27.8% of NGU cases, which is in accordance with western studies. This study also reflects importance of gram stained smears in diagnosis of gonorrhoea, which was 100% while culture sensitivity was 88% only, in accordance with other studies.[7] [Table - 3]

This study also reports rising trend of quinolone resistant strain in cases of gonorrhoea. There are few reflecting increased trend of quinolone resistance which is very alarming.[3] High level of HIV positivity was found in cases of gonorrhoea. Khopakar et al reported 14% positivity rate in all STD cases and Bhushanam et al 2.3%.[8] Multiple sexually trasmitted diseases in terms of gonorrhoea, primary syphilis and HIV are seen in 2 cases of child sexual abuse, which is a wide spread problem with no definitive information available on prevalence. Published studies indicate that as many as 5-10% of sexually abused children may have STD.[9] [Table - 4]