1. Dr. Shilpa Soni
MGMCH

4.  medial horizontal gp of
Inferior vena
superficial
cava
inguinal LN

5.  Superficial Inguinal LN
- Penile skin
- Scrotal skin
 Deep inguinal LN
- Anterior male urethra & glans
penis
- Vulva
- Vagina, lower third
- Uterus, lower part
- isthmus of fallopian tube
 Sacral LN
- Vulva
- Cervix

6.  Iliac LN
 Pre & para aortic group of LN
- Posterior urethra
- Testes & epididymis
- Vulva
- Uterus, upper part
- Upper third & middle third vagina
- Ovaries
- Cervix
- Fallopian tubes
- Prostate
- Cervix

7. Urethritis
Inflammation of the urethra.
Discharge +/- dysuria or may be
asymptomatic.

8. Causes of urethritis
 Infectious causes-
- Gonococcal – Neisseria gonorrhoea (50-90%)
- Non gonococcal –
- Chlamydia trachomatis. (20-50%)
- Ureaplasma urealyticum. (20-80%)
- Mycoplasma genitalium. (10-30%)
- Trichomonas vaginalis. (1-70%)
- Yeast.
- HSV.

9.  Non Infectious Causes
- Trauma
- Urethral stricture.
- Catheterization.
- Chemical irritants.
- Dehydration.

10. Gonococcal Urethritis
1.
N gonorrhoea – gram negative, non motile, non spore
forming diplococci.
2.
Oxidase positive
3.
Ferments glucose
4. PPNG – penicillinase produc-
- ing N. gonorrhoea: cefotaxime,
ceftriaxone, ciprofloxacin, tetrac-ycline can be used.

11.  N gonorrhoea – present predominantly intracellularly
in the polymorphonuclear leucocytes (PMN).
 Penetrates columnar epithelium.

12.  Structure –
- capsule – polyphosphate
- trilaminar membrane
– outer membrane – type 1 protein (por) - A
&B
- type 2 protein(Opa pro)
- RMP protein
- peptidoglycan – muramic acid & N-acetyl
glucosamine.
- cytoplasmic membrane – penicillin binding proteins.
- Pili - filaments

13.  Strains
- Pathogenic strains – N. gonorrhoea
- N. meningitidis
- Non pathogenic strains – N. catarrhalis
- N. pharyngis sicca
- N. lactamica
- N. subflava

14. Clinical features :
 Affects urethra in both sexes.
 Transmission – sexual contact
 Incubation period – 2-5 days
 Intense burning sensation.
 Fever & malaise.

15.  In men anterior urethritis is more common.
 Discharge – profuse, purulent & yellowish
green.
 15% males – mild or asymptomatic.

16. 
Complications –
- Posterior urethritis
- Epididymitis
- Acute or chronic prostatitis
- Untreated – periurethral abscess & watercan
perineum.

17.  In females – 90% infection
 50% of infected females are
asymptomatic.
 Primary site - endocervical canal
 Symptoms of urethritis includes - Discharge - scanty, mucopurulent cervical discharge.
- Vaginal pruritus
- Dysuria

18.  Proctitis through autoinoculation from cervical
discharge or as a result of direct contact from an
infected partner’s penile secretions.

19. 

Complications in femalesPID
Tubo ovarian abscess
Subsequent ectopic pregnancies
Chronic pelvic pain
Infertility
Fitz-Hugh-Curtis syndrome – inflammation of liver
capsule associated with genitourinary tract infection.
Present in upto ¼ of women with PID caused either by
N. gonorrhoea or C. trachomatis.

20.  Complications common to both sexes -
- Disseminated gonococcal infection (DGI)
- Acute arthritis-dermatitis syndrome – acute
arthritis, tenosynovitis, dermatitis or combination
of these findings.
- Gonococcal arthritis
- Meningitis
- Endocarditis

21.  Laboratory diagnosis –
- Microscopy – gram staining
- gram negative
diplococci

22.  Culture – thayer martin medium
- chacko nayer medium
- martin lewis media
- new york city media

23.  PCR
 DNA hybridisation
 ELISA
 The complement fixation
 Latex agglutination immunofluoroscence & anti
surface pili assays
 Radioimmunossay
 Immunoblotting

24. 
-
Treatment – uncomplicated gonorrhoea
Cefixime 400 mg stat or
Ceftriaxone 125 mg stat IM or
Ciprofloxacin 500 mg stat or
Ofloxacin 400 mg stat or
Levofloxacin 250 mg stat
+
If chlamydia infection is not ruled out
- Azithromycin 1 gm stat or
- Doxycycline 100 gm BD for 7 days.

25.  Treatment – DGI
- Ceftriaxone 1 gm IM or IV every 24 hrs or
- Cefotaxime 1 gm IV every 8 hrly or
- Ciprofloxacin 400 gm IV every 12 hrs or
- Ofloxacin 400 gm IV every 12 hrs or
- Levofloxacin 250 gm IV daily. or
- Spectinomycin 2 gm IV every 12 hrly.

26. Non
gonococcal
urethritis

27. CHLAMYDIA TRACHOMATIS
 C. trachomatis – gram negative obligate intracellular micro
organism that preferentially infect squamo-coloumnar
epithelium.
 Based on monoclonal antibody assay – 18 serological
variants.
- A, B, Ba & C – trachoma.
- D-K – genital tract infections.
- L1 – L3 – LGV

28.  Two functional & morphological forms- Elementary body – infectious but metabolically inert.
- Reticulate body – metabolically active but non
infectious.
 The intracellular bacteria rapidly modify their
membrane bound compartment into chlamydial
inclusion to prevent the phagosome lysosome fusion.

29.  Clinical features –
- Incubation period – 1 - 3 weeks.
- Low grade urethritis with scanty or moderate mucoid
or mucopurulent urethral discharge & variable dysuria.
- Subclinical urethritis are also common.

30.  In men- Sites of infection are – urethra.
- epididymis.
- systemic.
- Clinical syndrome – urethritis, post gonococcal
urethritis & Reiter’s disease.

31.  Urethritis –
- Dysuria with mild to moderate whitish or clear
urethral discharge.
- On examination – focal urethral tenderness
- meatal or penile lesions may mimic
herpetic urethritis.

32.  Epididymitis – recurrent infections
- Unilateral scrotal pain, Swelling & Tenderness.
- Fever
- Urethritis may often be assymptomatic & evident only
as urethral inflammation.

33.  Prostatitis –
- Ususaly asymptomatic or may
- Presents with discomfort on passing urine & vague
pain in perineum, groins, thighs, penis, suprapubic
region or back.
- Painful ejaculation.

34.  Proctitis – repetitive anal intercourse or by lymphatic
spread from posterior urethra.
- Rectal pain
- Discharge - mucopurrulent
- Bleeding

35.  Reiter’s syndrome – urethritis
- conjuctivitis
- arthritis
- characteristic mucocutaneous lesions as well
as psoriasis such as circinate balanitis &
keratoderma blenorrhagicum.
Reactive arthritis is RF seronegative, HLA-B27 linked arthritis
often precipitated by genitourinary or gastro intestinal infections
usually after 2-3 weks of infection.

36.  Organisms associated with Reiter’s syndrome are
- N. gonorrhoea
- C. trachomatis
- U. urealyticum
- Salmonella
- Shigella
- Campylobacter
 Treatment – antibiotics, NSAIDS, sulfasalazine, corticosteroids &
immunosupressants.

37.  In women –
- Cevicitis – mucopurulent cervical discharge
- cervical erythema & edema with an area of
ectopy
- spontaneous or easily induced cervical
bleeding
- Urethritis – dysuria
- frequency
- pyuria

38. - Bartholoinitis
- Endometritis – abnormal vaginal bleeding
- menorrhagia
- metrorrhagia
- PID – lower abdominal pain
- adenexal tenderness on pelvic examination
- MPC often present
- Perihepatitis (Fitz-Hugh-Curtis Syndrome)

39.  Lab diagnosis
Clinical syndrome Clinical criteria
- male
Presumptive
criteria
Diagnostic
criteria
NGU
Dysuria, urethral
discharge
Gram stian - > 5
PMNL/hpf
Pyuria on first void
urine
Positive culture
Acute epididymitis
Fever, epididymal
or testicular pain,
evidence of NGU
Epididymal
tenderness or mass.
- do -
Positive culture or
non culture test on
epididymal
aspirate.

40. Clinical
syndrome
Clinical criteria
Presumptive
criteria
Diagnostic
criteria
Mucopurulent
cervicitis
Mucopurulent
cervicitis discharge
Cervical ectopy &
edema,
spontaneous or
easily induced
cervical bleeding
Cervical gram
staining > 30
PMNL/hpf in non
menstruating
women
Positive culture or
non culture test.
Acute urethral
syndrome
Dysuria, frequency Pyuria
syndrome > 7 days No bacteria
of symptom
PID
Lower abdominal
pain, adenexal
tenderness on
pelvic examination
evidence of MPC
often present
Cervical
gramstaining
positive for
gonococcus,
endometritis on
endometrial
biopsy
- do Positive culture or
non culture test
(cervix first void
urine,
endometrium,
tubal)

41.  Antigen detection – DFA
- enzyme linked immunosorbant
assay
- monoclonal or polyclonal Ab
against chlamydial
lipopolysacharide (LPS) or MOMP

42.  Nucleic acid hybridization
- rRNA by hybridization with DNA probe.
- PAGE 2 assay by Genprobe
 PCR
 Serology – complement fixation test or
microimmunofluorescence

43.  Treatment
- Recommended
Doxycycline 100 mg BD for 47 days or
Azithromycin 1 gm stat
- Alternative
Amoxycillin 500 mg TDS for 7 days or
Erythromycin 500 mg QID for 7 days or Erythromycin
ethylsuccinate 800 mg QID for 7 days or
Ofloxacin 300 mg BD for 7 days or
Tetracycline 500 mg QID for 7 days

44. Chlamydial infection in pregnancy

In antenatal period -
1.
Spontaneous abortion
2. Neonatal conjunctivitis
3. Low birth baby
4. Prematurity & preterm delivery

45.  Postnatal infection
1.
Neonatal conjunctivitis
2. Ophthalmia neonatorum
3. Pneumonia
4. Chronic lung or eye disease

46. Neonatal conjuctivitis
 Commonlly starts within 21 days of birth.
 Accounts for 5-15% of conjunctivitis in new borns
 Clinical features – intense redness & swelling of
conjunctiva
- profuse purulent discharge
 Complication – corneal perforation
- scarring
- blindness

47. Treatment
Infection during
pregnancy
Neonatal
chlamydial
conjunctivitis
Infantile
pneumonia
Recommended
regimine
Erythromycin 500
mg QID for 7 days
or
Amoxycillin 500
mg TDS for 7 days
or
Azithromycin 1 gm
stat.
Syp erythromycin
50 mg /kg /day in
4 divided doses for
14 days
Syp erythromycin
50 mg/ kg/ day
orally in 4 divided
doses for 14 days
Alternative
regimine
Erythromycin base
500 mg QID for 7
days or 250 mg
QID for 14 days
or
Erythromycin
ethylsuccinate 800
mg QID for 7 days
or 400 mg QID for
14 days.
Trimethoprim
40mg with
sulfamethoxazole
200 mg orally BD
for 14 days.

48. Ureoplasma urealyticum
 Causes non specific urethritis.
 Transmitted by sexual contact.
 In males causes – urethritis, proctitis & Reiter’s syndrome
 In females causes – acute salphingitis, PID, cervicitis &
vaginitis.
- Also been associated with infertility, abortions, postpartum
fever & low birth baby.

49. Mycoplasma genitalium
 Accounts for 29% of sexually transmitted urethritis
 More common organism in C. trachomatis negative
urethritis in 13-45% of cases
 Common in recurrent urethritis

50. Bacterial vaginosis
 G. vaginalis & M. hominis
 Vaginal discharge
 Ecaluation of sex partner is also necessary.

51. Traetment of NGU
 Tab Azithromycin 1 gm stat
or
Tab Doxycycline 100 gm BD for 10 daysA

52. Complications of urethritis
 Chronic recurrent UTIs
 Trigonitis in females
 Stricture urethra

53. Newer modality in Treatment of
recurrent urethritis
 Tab TRACFREE – 600 mg BD for 3 months
- CRANE BERRY fruit extract which prevents the
bacterial invasion in the urothelium.

54. Herpes genitalis




HSV 1 & HSV 2
Incubation period 5-14 days
Symptoms – painful lesions
Fever, headache, myalgias & malaise
Grouped vesicles
pustules
ulcers.
Diagnosis- tzanck’s smear, histopathology, viral
culture,serology & PCR.
 Treatment – acyclovir 400 mg TDS for 7-10 days/
valacyclovir 1 gm BD for 7-10 days/ famcyclovir 250 mg
BD for 7-10 days

55.  Recurrent episodes –
- Acyclovir 400 mg TDS for 5 days or 800 mg BD for 5
days or 800 mg TDS for 2 days.
- Famcyclovir 125 mg BD for 5 days or 1000 mg BD for 1
days.
- Valacyclovir 1 gm BD for 5 days or 500 mg BD for 3 day.

56. Syndromic approach

57. Urethral Discharge
History / Examine
Milk urethra
Discharge present
No
Yes
Treat for Gonorrhoea &
Chlamydia &
trichomoniasis
ECCV, Partner treatment, Follow up
other STI?
No
Yes
Use appropriate flow chart
ECCV

58. Treatment of Urethral Discharge
Treat patient for both Gonorrhoea
and Chlamydia infection.
The Regime:
Azithromycin 1G orally as a single
dose (to treat chlamydial infection)
PLUS
Cefexime 400 mg orally, single dose
under supervision (to treat
gonococcal infection)
Kit one Gray

59. Treatment of VD- Cervicitis
Treat patient for both Gonorrhoea
and Chlamydia infection.
The Regime:
Azithromycin 1G orally as a single
dose (to treat chlamydial infection)
PLUS
Cefexime 400 mg orally, single dose
under supervision (to treat
gonococcal infection)
Kit one Gray

60. Treatment for Vaginal Discharge
Vaginitis.
Recommended regimen
Scenidazole 2 G orally, single dose, under
supervision ( to treat trichomoniasis and bacterial
vaginosis).
Plus
Fluconazole 150 mg orally, single dose (to treat
candidiasis).
NOTE: Patients taking Metronidazole or Tinidazole should be
cautioned to avoid taking alcohol while on these drugs up to
24-48 hrs.
Kit one Gray
Kit two Green

61. Thank you