Approach to a patient with Urethral discharge.
Case: Mr Robert, 35 years old gentleman presented with urethral discharge for 7 days.
His pulse-80/min
BP- 120/80 mm Hg
temperature - normal
please see and advice.
Possible differentials :
Gonococcal urethritis
Non-gonococcal urethritis
Chlamydia trachomatis
Ureaplasma urealyticum
Herpes simplex virus
Trichomona vaginalis
#Focused History:
Onset and duration: <1week: Gonococcal
1week: non-gonococcal
Type of discharge : purulent : Gonococcal
less purulent:Non-Gonococcal
other genital symtopms: dysuria, genital ulcer,
swelling
Fever and systemic symptoms
Related to complications:
joint pain: Disseminated gonococcal
infection(DGI)
Reiters syndrome
Eye pain and discharge: Reiters/ conjunctivitis
Rash: DGI
Testicular pain: Epididimo-orchitis
Infertility
lower abdominal pain: PID
Sexual history : last sexual intercourse, number of sexual partners, type of intercourse, gender of partners, use of protection, symptom of STI of any partner
past medical history: STI, Hepatitis or jaundice
Drug history: Allergy
Illicit drug use
#Targeted Examination:
Genital examination: ulcer, discharge, tenderness(usually it will not be allowed in exam but you need to ask it)
Digital rectal examination: if anal intercourse
Examination of oral cavity and pharyngeal wall
Inguinal lymph node
Vitals
other exam depending on history: skin examination or joint examination
#Feed back to the patient:
The problem you are having most likely due to infection of your private part. Usually this type of infection occurs due to unprotected sexual intercourse.There are many bugs that can cause this infection. To find out the right bug, we will examine your discharge from private part as well as take early morning urine. This type of infection usually may occur with other infections which might spread through sexual contact like hepatitis and HIV. we need to look for that also.
We will start treating you immediately after taking samples. We also need to treat and test your partner. I will reffer you to GUM, they will help you regarding this.
Do you have any other concern?
#Investigations:
Urethral discharge for: gram stain(gram negative diplococci) and culture
Early morning first void urine for NAAT( nucleic acid amplification test) to detect chlamydia or gonorrhoea.
HBsAg
AntiHCV
HIV screening
VDRL, TPHA
other routine tests
#Treatment :
MDT approach and referral to GUM clinic
Presumptive treatment with
Inj ceftriaxone (500mg) IM single dose( for gonococcal infection)
tab. Azithromycin( 1gm) single dose( for chlamydial infection)
Contact tracing and treatment of the contacts.
Dr. Ahmed Hossain
MD (Endocrinology and Metabolism)
MRCP (UK)
Mentor,
4D MRCP (UK) BANGLADESH