GUM - Presenting problems in men Flashcards
What is the most common cause of urethral discharge in men?
Gonorrhoea and chlamydia are the most important causes of urethral discharge in UK men. In a significant minority, tests for BOTH of these organisms are negative, called non gonococcal/ specific urethritis (NSU). Some of these cases can be caused by Trichomonas vaginalis, HSV, mycoplasma or ureaplasmas.
How can the symptoms of urethral discharge help to identify the causative organism?
Gonococcal urethritis usually causes symptoms within 7 days of exposure. The discharge is typically profuse and purulent.
Chlamydial urethritis has an incubation period of 1-4 weeks, and tends to result in milder symptoms than gonorrhoea. But there is overlap so get microbiology confirmation.
How should urethral discharge be investigated?
Gram stain smear of urethral exudate showing polymorphs (>5 per high power field). A working diagnosis of gonococcal urethritis is made if gram negative intracellular diplococci are seen, if no GNDC are seen then this is NSU.
Urine samples for NAAT for gonorrhoea and chlamydia. If gonorrhoea suspected then urethral swab should be sent for MC&S.
Swab the pharynx because gonococcal infection from here is not reliably eradicated by single dose therapy.
Rectal swabs in MSM.
How should urethral discharge be treated in men?
Antimicrobial therapy should be designed to cover for both gonorrhoea and chlamydia infection and can be started empirically.
= ceftriaxone 500mg i.m + azithromycin 1g p.o. as a single dose
The azithromycin acts synergistically with the ceftriaxone and covers any co-existant chlamydial infection which is present in over 50% of cases. NSU is treated as per chlamydia. If symptoms clear then test of cure is not necessary, but patients should be re-interviewed to check for vomiting and diarrhoea after treatment, no re-risk of infection and contact tracing has been done.
Name some causes of acute genital itch or rash in men?
The following all cause acute genital itch in men:
Candidiasis (often post coital)
Anaerobic balanitis (offensive)
Genital herpes (painful)
Subclinical urethritis, crab lice infection, lichen planus, dermatoses (e.g. eczema or psoriasis) and circinate balanitis can cause either acute or chronic genital symptoms.
What is balanitis?
Balanitis refers to inflammation of the glans penis, often extending to the under-surface of the prepuce when it is called balanoposthitis. Tight prepuce and poor hygeine may be risk factors. There are different types of balanitis:
1) Anaerobic (erosive) balanitis - causes an acute itch with a yellow offensive discharge from the penis. Treatment is with saline bathing + metronidazole
2) Plasma cell balanitis of Zoon - causes chronic itch, with shiny, inflamed circumscribed areas. Diagnosis sometimes requires biopsy and is treated with strong topical steroids
3) Circinate balanitis - can be acute or chronic. There is no pain or itch but painless erosions with raised edges, usually as part of Reiter’s syndrome. Rx is mild topical steroid
What can cause genital ulcers and what features help differentiate the underlying organism?
Most common cause of ulceration is genital herpes. Classically, multiple painful ulcers affect the glans, coronal sulcus or shaft of the penis. Perianal ulcers may be seen in MSM. Diagnosis is by HSV PCR from scrapings.
Syphilis or other ulcer causing STI is uncommon in UK. At risk groups include MSM or has sexual partner from a region where tropical STIs are more common. The classic lesion of primary syphilis (chancre) is single, painless and indurated, however, multiple lesions are seen rarely and anal chancres are painful. Diagnosis is by dark ground microscopy, PCR and syphilis serology.
Rare causes of genital ulcers include VZV, trauma with secondary infection, chancroid, LGV and granuloma inguinale. Inflammatory causes include Stevens-Johnson syndrome, Behcets and drug reactions. Malignancy should be considered in older patients.
What is the most common cause of genital lumps?
Most common cause of genital lumps is warts. These are classically found in areas of friction during intercourse, such as parafrenal skin and prepuce. Differential diagnosis includes molloscum contagiosum, HPV (genotypes 6 and 11) and skin tags.
What STIs are associated with proctitis?
STIs that may cause proctitis in MSM include gonorrhoea, chlamydia, herpes and syphilis. Substrains of chlamydia trachomatis that cause LGV (L1-3) have been associated with outbreaks of severe proctitis in Europe. Symptoms include mucopurulent anal discharge, rectal bleeding, pain and tenesmus. Do routine investigations but also do PCR test for LGV substrain if chlamydial infection is suspected. MSM may also present with gastrointestinal symptoms from infection with organisms such as Entamoeba and Shigella.
