资产英文9
Penile discharge and dysuria Urethral discharge in men is the typical prentation of urethritis. The term urethritis is usually rerved for xually transmitted dias. The diagnosis of urethritis is confi rmed by taking a swab from the urethra and demonstrating the prence of pus. The usual symptoms are dysuria (discomfort on passing urine)
and discomfort or irritation at the tip of the penis. Balanitis may also occur. Some men may be asymptomatic. Urethritis is divided into two groups: gonococcal and
non-gonococcal urethritis (NGU).
The diagnosis of urethritis is important for a number of reasons:
most cas are xually transmitted
●
the risk of acquiring and transmitting HIV is incread with urethritis
●
the organisms responsible for most cas of urethritis in men are important
●
caus of infertility in women
urethritis can lead to problems such as xually acquired arthritis,
●
epididymitis and prostatitis.
There are caus of urethritis not related to xually transmitted infections. The include post-traumatic urethritis (e.g. found in up to a fi fth of men practising lf-catheterisation), and a number of infectious syndromes such as Reiter’s syndrome (e page 73).
For the purpos of this book we focus on the xually acquired caus of urethritis: gonorrhoea and NGU.
GONORRHOEA
Gonorrhoea is an infection of the mucous membrane surfaces caud by the bacterium Neisria gonorrhoeae. The organism is a highly infectious gram
97难度系数越高越难吗
THE MALE GENITALIA
98negative diplococcus, commonly referred to as the gonococcus. A single act of unprotected xual intercour with an affected individual will give a transmission rate of between 30% and 70%. The risk of a woman developing gonorrhoea from a man is much higher than for a man developing the dia from an infected woman. In men, an acute purulent urethritis occurs in the majority of infected individuals, although some may be asymptomatic.
Incidence
Gonococcal infections are approximately one and a half times more common in men. As with other xually transmitted dias the frequency is highest in adolescents and young adults. Gonorrhoea is a worldwide problem with around 200 million new cas every year. The UK has en an increa of 111% between
Year
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b
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安慰女生o
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310 000
320 000
330 000
340 000
350 000
300 000
360 000
370 000
Year
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成长导师
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杨玉环死因e
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FIGURE 9.2Cas of gonorrhoea in the US 1996–2004.
FIGURE 9.1Cas of gonorrhoea in the UK 2000–2004.
PENILE DISCHARGE AND DYSURIA
99
1995 and 2004. Some ethnic groups have a disproportionately high rate of gonorrhoea. In the US there are around 330 000 new cas each year reported but the true fi gure is probably considerably higher. The problem is more acute in underdeveloped parts of the world.
Clinical history and examination
Symptoms of urethral discharge, discomfort and dysuria due to urethritis occur in most men with gonorrhoea, although the verity of the symptoms varies. If infection has reached the posterior urethra symptoms of painful erec-tions, frequency of micturition and urgency may be experienced. The clinical examination reveals a purulent urethral discharge often with an infl amed urethral meatus.
Unilateral pain and swelling of the scrotum signifi es epididymitis. Rectal infection is usually asymptomatic but pharyngeal infection gives soreness, dis-com f ort and sometimes dysphagia. In 1–2% of cas a disminated form of gonorrhoea occurs with joint pains, constitutional symptoms such as fever and disminated pustules on the body
.
FIGURE 9.3 Typical creamy penile discharge of gonorrhoea.
THE MALE GENITALIA
100Diagnosis
A urethral discharge may not be clinically evident and ‘milking’ or ‘stripping’ the penis may be necessary to obtain a suitable urethral specimen. A urethral swab should be taken from between 1 and 2cm into the urethra. A gram stain is a rapid, cheap and nsitive test. A gram stain showing fi ve or more white blood cells per oil immersion fi eld with intracellular gram negative diplococci has a specifi city for gonorrhoea of over 95% (e Figure 9.4). Urine can be tested using nucleic acid amplifi cation techniques to screen for gonorrhoea. The organism should also be cultured and antibiotic nsitivities established.
Swabs should be taken from all possible expod sites such as the pharynx and rectum.
It is important to screen for other xually transmitted infections, particularly syphilis and chlamydia trachomatis (e below).
Management太极豆腐
A signifi cant emerging problem with the treatment of gonorrhoea is antibiotic resistance. Penicillin, tetracycline and quinolone resistance is becoming common.
Resistance varies according to geographical location, for example gonorrhoea FIGURE 9.4Gram negative diplococci (arrow) within polymorphonuclear leukocytes en under high power microscopy.
PENILE DISCHARGE AND DYSURIA
101
蒲鞭之罚acquired in South East Asia should be presumed to be both penicillin and quinolone resistant.
There are a number of recommended treatment regimes for uncomplicated urethral gonorrhoea:
ceftriaxone 250mg intramuscularly as a single do or ●ciprofl oxacin 500mg orally as a single do or ●ofl oxacin 400mg orally as a single do or ●cefi xime 400mg orally as a single do or
●spectinomycin 2g intramuscularly as a single do.
●Penicillin may still be ud where the isolate is known to be penicillin-nsitive, e.g. amoxicillin 2g or 3g orally with probenecid 1g orally as a single do. Concomitant anti-chlamydial treatment, e.g. azithromycin 1g twice daily or doxycycline 100mg twice daily for ven days is recommended.
It is esntial to perform a test of cure of all affected sites within ven days. Once again, partner notifi cation with up to three months of look back period and test of cure is important.
It is very important to know the resistance of gonorrhoea locally . In addition, knowledge of foreign travel by affected patients is esntial. The graph below demonstrates the wide range of differences in ciprofl oxacin resistance gonococci between countries.
A u
s t r a l i a
B r u
n e i C h i n a H o n g K o n g J a p a n K o r e a M a l a y s i a M o n g o l i a N e w Z e a l a n d P a
p u a N e w G u i n e a P h i l i p p i n e s S i n g a p o r e T h a i l a n d V i e t n a m Y o r k s h i r e L o n d o n L e e d s D e w s b u r y E a s t M i d l a n d s
Country/Location
P e r c e n t a g e o f r e s i s t a n c e
FIGURE 9.5 Gonorrhoea and drug resistance 2002–2003.
