Urethritis

URETHRITIS, urethritis (from Latin urethra), inflammation of the mucous membrane of the urethra, accompanied by discharge from it, itching, burning, or pain during urination. A distinction is made between anterior urethritis (urethritis anterior) in inflammation of the anterior urethra (from the external opening to the external sphincter) and posterior urethritis (urethritis posterior) in lesions of the posterior urethra (from the external sphincter to the neck of the bladder). Inflammation of the anterior and posterior urethra is called total urethritis (urethritis totalis). By course, acute, subacute, and chronic urethritis are distinguished. The etiology of urethritis is very diverse: it can develop as a result of the effects of infectious, chemical, traumatic, and thermal agents on the urethral mucosa. In the vast majority of cases, urethritis is of an infectious nature and develops mainly as a result of pathogenic infection entering the urethra from the external environment (sexual infection, introduction of infection by instruments inserted into the urethra, etc.). In some rarer cases, saprophytic microorganisms, which always inhabit the anterior part of the urethra, become the causative agents of urethritis, becoming pathogenic due to changes in the mucosa (post-gonorrheal urethritis, urethritis as a result of catheterization). Chemical, traumatic, and thermal urethritis occur less frequently than infectious ones. Urethritis is conventionally divided into two types: 1) gonorrheal urethritis and 2) non-gonorrheal, or non-specific urethritis. Gonorrheal urethritis (triper, blennorrhea) is caused by the gonococcus of Neisser (see Gonococcus, Gonorrhea), and infection occurs in the vast majority of cases during sexual intercourse with a person suffering from gonorrhea. Pathological anatomy. The gonococcus, having entered the mucous membrane of the urethra, spreads along it not per continuitatem, since it does not possess the ability to move independently, but is transferred mainly by the flow of lymph from one part of the urethra to another, as well as from the anterior urethra to the posterior one. On the cylindrical epithelium of the urethra, the gonococcus begins to multiply rapidly in the interepithelial spaces of the mucosa, which reacts with dilation of the vessels and emigration of leukocytes both into the lumen of the urethra, which causes the appearance of purulent discharge from it, and into the thickness of the mucosa, which is expressed by infiltration of the walls of the urethra. The epithelium necrotizes, desquamates, and exposes deeper layers of the mucosa. After several days, leukocytic infiltration is joined by small-cell infiltration. As the inflammatory process intensifies, gonococci also spread to the submucosal tissue, where they can be found already 72 hours after infection. Due to infiltration of the urethra, a painful curvature of the penis occurs during erections with concavity downward (chorda venerea). Picker, Pezzoli, and Scholz believed that in gonorrheal urethritis, the Littré glands and the Morgagni sinuses are usually involved in the inflammatory process, however, pathological-anatomical studies by Gertsenberg and Porudominsky show that even with long-existing gonorrheal urethritis, the Littré glands may remain unchanged (infiltrative form). In lesions of the Littré glands (follicular form), their epithelium becomes loose, desquamates, and is replaced by young granulation tissue, which in the future may undergo reverse development or, organizing, compress the excretory duct of the gland and lead to its closed suppuration and periurethral abscess (Fronstein). Similar phenomena can also be observed in the Cowper's glands located in the region of the bulbar part of the urethra. Usually, 15-20 days after the onset of the disease, the reverse development of the process begins. The small-cell infiltrate begins to resolve, the destroyed epithelial covering of the urethra is restored, but part of the cylindrical epithelium is replaced by flat epithelium, and approximately on the 5th or 6th week recovery occurs. However, in a significant number of cases, the disease lasts much longer because, having penetrated into the glands, lacunae, and submucosal tissue of the urethra, the infection becomes inaccessible to therapeutic effects carried out from the lumen of the urethra. In addition, when the seminal vesicles and prostate are involved in the process, urethritis can be maintained by the infection coming from them, which is clinically expressed in recurrences and exacerbations of urethritis. If within 1½-2 months urethritis does not end and gonococks can be detected in the urethral discharge, although scanty, they speak of the transition of acute gonorrheal urethritis to chronic. Other authors extend this period to 3-6 months. Nielsen, Finger, and Wassermann believe that chronic gonorrheal urethritis can be spoken of when the inflammatory process in individual areas deeply penetrates the submucosal tissue, however, Kristeller and Jacoby point out that small-cell infiltration of the submucosal layer can be detected even in the first days of the disease. Oberlander considers the appearance of connective tissue fibers in the small-cell infiltrates of the mucosa and submucosal tissue of the urethra as a sign of chronic gonorrheal urethritis. From a practical point of view, it is more correct to consider as chronic that form of urethritis that proceeds sluggishly, with scanty discharge, without sharp clinical manifestations, and such a chronic form can be observed from the very first days of the disease. In chronic gonorrheal urethritis, the inflammatory process has a focal rather than diffuse nature. Gonococci lie in separate, few foci—in the Littré glands, the Morgagni lacunae, and in individual infiltrates located in the deep layers of the mucosa and in the submucosal tissue. Pathologically, there are foci of round-cell infiltration here, which over time is replaced by connective tissue, which in turn later passes into scar tissue. As long as the infiltrate is mainly of small-cell nature, and connective and scar tissue changes are weakly expressed, they speak of soft infiltration; where connective and scar tissues predominate, they speak of hard infiltration. The infiltrate can compress the excretory ducts of the Littré glands, as a result of which outflow from them is delayed and individual glands turn into retention cysts filled with normal secretion or, if the gland itself is inflamed, with pus. This form is called follicular urethritis. With inflammation of the urethral glands with undisturbed outflow of their pathological contents into the lumen of the urethra, we will be talking about open adenitis of the urethra. If the chronic inflammatory process is localized in the more superficial layers of the urethral mucosa, then the latter reacts with pathological growths in the form of granulations and polypoid growths—granulomatous form of chronic gonorrheal urethritis. The favorite localization of the latter is the posterior urethra due to the fact that here the foci of infiltration lie more superficially, since the posterior urethra has a less loose submucosal tissue, and also because the mucous membrane of the posterior urethra is constantly irritated by changed urine (Porudominsky). In most cases, in the same patient with chronic gonorrheal urethritis, not individual forms of the latter are observed, but a combination of all or several forms. Course and symptoms. The incubation period in gonorrheal urethritis averages 3-5 days, sometimes lasts up to 10-15 days, and in very rare cases even longer. The first manifestations of the disease are expressed in the appearance of itching and burning during urination. At the same time, slight redness and swelling appear around the external opening of the urethra, which gradually increase. Then discharge appears from the external opening of the urethra. These discharges in the first 2-3 days have a mucous or mucopurulent nature and under the microscope consist of mucus, epithelial cells, individual leukocytes, and gonococci. After 1-2 days from the appearance of the first symptoms of urethritis, the discharge takes on a purely purulent nature, their consistency becomes thicker, cream-like, they take on a yellowish-white or greenish tint. The external opening at this time is already strongly inflamed and edematous, the lips are glued together by dried pus. Under the microscope, the secretion consists of leukocytes and a large number of gonococci. The patient's subjective sensations increase, the burning sensation during urination intensifies, frequent and painful erections occur, often swelling and tenderness of the inguinal glands are observed, mainly with sharp inflammatory phenomena around the external opening of the urethra. If the process is limited to the anterior urethra, then urine released sequentially into two glasses (Thomson's two-glass test) is turbid, purulent in the first portion and clear in the second, because the first portion washes away all the pus from the lumen of the urethra. This is the usual picture of acute anterior gonorrheal urethritis. Along with this, cases of sluggish or, conversely, very stormy course of gonorrheal urethritis are also encountered. In the sluggish form, the inflammatory phenomena around the external opening of the urethra are very weakly expressed or absent altogether. The discharge from the urethra is insignificant and has a non-purulent, but mucopurulent nature. Subjective sensations are weakly expressed. The first portion of urine is only slightly turbid or clear with flakes. This form is most often observed in recurrent gonorrheal urethritis.

A violently progressing gonorrheal U. is characterized by severe swelling and inflammation of the external urethral orifice, as well as of the prepuce, which often leads to phimosis (see) and paraphimosis (see). The discharge from the urethra is very abundant, has a distinctly purulent character, and sometimes a purulent-bloody character (Russian tripper, Schwabentripper). In some cases, inflammation of the lymphatic pathways of the penis, located on its dorsal surface, is observed. In individual cases, the Tyson's glands are also involved in the U. process, often with the formation of abscesses in them that rupture outward. - Whatever the form of acute anterior gonorrheal U., over time the inflammatory phenomena gradually subside, especially with properly conducted treatment. The discharge becomes increasingly scanty, the number of leukocytes and gonococci gradually decreases, the urine becomes less and less cloudy, then transparent with flakes. Subsequently, the discharge disappears, the first portion of urine becomes clear, the flakes disappear from it, and recovery occurs. In other cases, much rarer, a scanty purulent discharge persists stubbornly, sometimes for months and even years, and in it gonococks can be found in small numbers upon examination. In these cases, we are dealing with a transition of the process to a chronic state, with chronic anterior gonorrheal U. The transition of acute gonorrheal U. to chronic can be facilitated by: general weakening of the body under the influence of other diseases - tuberculosis, syphilis, diabetes, anemia, etc.; stagnant phenomena in the pelvis with constipation, hemorrhoids, colitis; sexual intercourse, alcohol consumption. Untimely applied or forced instrumental treatment and cauterization with strong chemicals, destroying the urethral mucosa and pushing the infection into deeper layers of the urethral wall, thereby gives the process a prolonged chronic character. Local causes in the form of a narrow urethral orifice, hindering the outflow of pus from it, and the presence of infected paraurethral passages, from which infection can periodically enter the urethra, can also be the cause of chronic course of gonorrheal U. The clinical picture of chronic gonorrheal U. consists of insignificant sensations in the form of tingling and a feeling of itching in the urethra or slight burning during urination. The patient experiences mild itching and tickling in the urethra. The external orifice of it is sealed by a purulent crust or a purulent drop is squeezed from it (morning drop, goutte militaire). Discharges from the urethra are extremely insignificant. With soft infiltration, the urine is cloudy and contains many leukocytes; with hard infiltrates, it may be clear and only contains threads and flakes. Chronic gonorrheal urethritis, proceeding sluggishly, tends to periodically exacerbate under the influence of certain external factors (alcohol, coitus) or the entry of infection into the urethra from the affected prostate and seminal vesicles or from infected paraurethral passages. - Finally, a third outcome of acute anterior gonorrheal urethritis can be a state in which the gonococcal infection in the urethra has died, but the phenomena of sluggish urethritis continue, and the latter is maintained not by the gonococcus, but by that saprophytic flora that usually vegetates on the mucous membrane of the anterior part of the urethra (post-gonorrheal U.). This depends on the fact that the normal flora of the urethra, among which there are also pathogenic forms, remains harmless only as long as the integrity of the mucous membrane is not violated and as long as some cause does not bring it out of a state of equilibrium, then these previously calm 'companions' can cause an independent inflammatory process (Semenyako and Ovchinnikov). According to Voskresensky, the gonococcus plows up the mucous membrane of the urethra, and then after the cessation of the gonorrheal process, a post-gonorrheal U. can persist on it for a long time, caused and maintained by other microbes. Acute posterior gonorrheal U. (urethritis acuta posterior gonorrhoica) develops when the gonorrheal process passes from the anterior part of the urethra to the posterior. This transition is significantly hindered by the external sphincter (sphincter externus) of the urethra, although Zeissl, Rona and Wossidlo deny its role as a mechanical obstacle to the spread of gonorrheal inflammation. Scholz believes that under the influence of the inflammatory process in the anterior urethra, the posterior one is in a state of reflex tonic contraction, which prevents infection from penetrating into it. Finally, the circumstance that the mucous membrane of the membranous urethra, separating the anterior urethra from the posterior, is very poor in glands and lacunae, favorite foci of gonococcal infection, leads to the fact that when the gonorrheal infection reaches the membranous urethra, it does not spread further. However, despite all these factors, the posterior urethra is involved in the process quite often; according to statistical data from various authors, this happens in 90% (Khol'tsov, Oelze). The indicated figure is undoubtedly exaggerated, in any case it refers to the bactericidal method of treatment with an enema and does not correspond to observations of the present time when treating gonorrheal U. by the large irrigation method according to Janet. Sexual intercourse or alcohol consumption favor the transition of infection to the posterior urethra; sometimes forced treatment, the introduction of instruments into the urethra during the acute process, is the cause. In the vast majority of cases, posterior U. develops on the 2nd or 3rd week of the disease and manifests itself by the onset of frequent urges to urinate of an imperative nature. At the end of urination, a sharp pain is felt, sometimes the last drops of urine are colored with blood (terminal hematuria). All these symptoms, clinically giving a picture of acute cystitis (see), are explained by the simultaneous involvement of the mucous membrane covering the neck of the bladder in the process. As with anterior U., mild, acute, and most acute forms are observed here, and if the first can pass completely unnoticed for the patient, manifesting only in slight cloudiness of the second portion of urine, then the latter strongly affect the general condition of the patients, depriving them of sleep and rest due to frequent urges. Objectively, gonorrheal inflammation of the posterior urethra is accompanied by a decrease in the amount of discharge from the external orifice of the urethra. Along with this, cloudiness of the second portion of urine is observed, which depends on the backflow of purulent discharge from the posterior urethra into the bladder. It should be borne in mind that in a sluggishly proceeding posterior gonorrheal U., the amount of discharge from the posterior urethra can be so insignificant that it freely fits in the lumen of the posterior urethra, not flowing into the bladder, and thus the second portion of urine may remain clear. Involvement of the posterior urethra in the process is always an unfavorable factor in the course of gonorrheal U. because it opens the way for gonorrheal infection to the sex glands: the prostate gland, seminal vesicles, and epididymis. Pezzoli considers prostate involvement in posterior U. inevitable. According to the data of Casper, Welsh and Hoffman, posterior U. is complicated by prostatitis in 81-94%. With modern methods of treatment, this percentage is significantly lower. According to Belostotsky it is 14.1%, according to Rosenfeld also 14.1%. With the bactericidal method of Motz he obtained 40% prostatitis, with treatment according to Janet's method he obtained only 3% prostatitis. The same applies to epididymitis. Older statistics (Zeissl, Lewis, Wildbolz) give from 20% to 66% epididymitis, while newer ones (Rosenfeld, Leites and Litvak, Motz) give from 0.2% to 9.4%. As for the course of posterior gonorrheal U. as such, on the mucous membrane of the posterior urethra, which has fewer glands, follicles, and lacunae, as well as a less loose submucosal tissue, gonococci do not find such favorable ground for their existence as in the anterior urethra, and therefore posterior U. proceeds less stubbornly and has less tendency to transition to a chronic state than anterior U. Path-anatomical studies of Oberlander and Kolman, Kristeller and Jacobi show that the infiltrative process in the posterior urethra with its gonorrheal inflammation is expressed weaker than in the anterior. Therefore, in those cases where the lesion of the prostate gland and seminal vesicles does not join the posterior U., the latter ends faster than the anterior U. However, in most cases, a lesion of the sex glands joins, which maintains the stubborn course of posterior gonorrheal U. and contributes to its transition to a chronic state. Diagnosis. Diagnosis of gonorrheal U. in the acute stage is extremely easy. The anamnesis, incubation period, consistency and color of the discharge are so characteristic that the diagnosis can be made without any additional research. However, one should never limit oneself to only the clinical picture, but must necessarily examine the urethral discharge bacterioscopically for the presence of gonococci. Examination for the same purpose of urine is irrational, since it is extremely difficult to find a gonococcus in urine. For more details, see Gonorrhea, laboratory diagnosis.

When examining the patient, the area of the external urethral orifice, the prepuce, and the glans penis should be examined in detail, and it should be determined whether there are infected preputial and paraurethral canals, which, when examined, can maintain a persistent course of gonorrheal U. A slowly developing gonorrheal U. may be confused with the so-called nonspecific U. (see below). The differential diagnosis is based on a longer incubation period, scanty mucous discharge, and the absence of inflammatory phenomena from the external urethral orifice in nonspecific U., and must be confirmed by the results of bacterioscopic examination of the discharge. It should also be borne in mind that in some, although rare, cases of hard and soft chancres located on the urethral mucosa near the external orifice, they cause acute purulent U. and may give rise to an erroneous diagnosis of gonorrheal U. A gradual onset, focal ulcerative changes on the urethral mucosa, and in doubtful cases, examination of a scraping for Ducrey-Unna rods and the pale spirochete will clarify the true nature of the disease. The diagnosis of chronic gonorrheal U., as opposed to acute, is in most cases quite difficult, except, of course, for those cases where gonococci are found in the urethral discharge. Since we usually deal here with focal b. or m. deep, often encapsulated foci of infection, it is not always easy to detect the gonococcus. In these cases, it is necessary to resort to "provocation" - irritation of the urethral mucosa by taking alcohol internally, the introduction of sounds into the urethra, and instillations of argyrol, injections of gonococcal vaccine-followed by examination of the discharge for 2-3 days for the presence of gonococci (Fronstein). Along with the examination of the discharge, in these cases the threads in the urine should also be subjected to microscopic examination. Examination of the canal with a probe or palpation of its walls on an introduced metal probe reveals soft and dense infiltrates in the wall of the urethra, inflamed and enlarged Litre's glands. For the same purpose, urethroscopy (see) can be applied. Focal hyperemia and swelling of the mucosa, reduction of folds, characteristic of soft infiltration, pale mucosa with a gaping central figure in dense infiltrates, inflamed Litre's glands protruding into the lumen of the urethra, sometimes with pus plugs sticking in their orifices, granular growths on the mucosa of the anterior, and more often the posterior urethra will indicate the presence of a gonococcal process here. However, bearing in mind that a long-lasting chronic gonorrheal U. causes persistent changes in the urethral mucosa, which usually cannot be completely eliminated, the role of urethroscopy for the specific diagnosis of gonorrheal U. should not be overestimated, and it should be considered only as one of the auxiliary factors in the long chain of examination of chronic gonorrheal U. In those cases where the gonorrheal nature of U. was not established at the beginning of its occurrence and there is doubt as to whether the observed chronic U. was nonspecific from the very beginning, the Bordet-Gengou reaction (see Gonorrhea, laboratory diagnosis of gonorrhea) can be used for diagnosis. Prevention of gonorrheal U.-see Gonorrhea. Treatment of gonorrheal urethritis. Abortive treatment, i.e., the method of treating acute gonorrheal U., aimed at the rapid destruction of the gonococcal infection and curing the patient within a few days, has some chance of success only if applied within 48 hours after infection, while the discharge from the urethra is of a mucous nature and contains, upon microscopic examination, besides gonococci and epithelial cells, a scanty amount of leukocytes. In this period, the use of concentrated solutions of silver salts (4% albargin, 2-5% protargol, 20% argyrol, etc.), introduced into the urethra with an enema syringe, sometimes in combination with large washings of the urethra according to Jane with potassium permanganate solution or weak solutions of antiseptics, gives cure in a few days in a significant number of cases. Jane indicates 64% success rate from abortive treatment, Blyashko-40%. However, experience shows that abortive treatment practically has no serious significance, firstly because the above percentages of cure are in reality much lower, and secondly because patients usually seek help in the stage of fully developed acute gonorrheal U. with clearly purulent discharge from the urethra, when abortive treatment is no longer applicable at all, because by this time the gonococci have already penetrated into the deep layers of the mucosa. Treatment of acute gonorrheal U. is usually conducted on an outpatient basis. Inpatient treatment has an advantage only if the patient is placed under working conditions (Maryasin and Baevsky, Pechersky), which to a large extent reduces sexual excitations that occur when patients with generally good health are transferred to bed rest, all the more since the inflammation of the urethra itself causes hyperemia of the blood vessels of the penis. Since erections adversely affect the course of gonorrheal U., and on the other hand, patients are carriers of infection, it is natural that they are categorically forbidden sexual intercourse and are advised to avoid sexual excitement. The patient must wash hands after each touch to the penis to avoid transferring infection to the conjunctiva of the eyes. Wearing a suspensory is recommended, which, when properly worn, improves blood circulation in the scrotal organs and reduces trauma to the latter, thereby reducing the danger of epididymitis formation. Alcohol in the form of wine, vodka, and beer is forbidden. Also forbidden are spicy and irritating substances: vinegar, pepper, horseradish, mustard, etc. Otherwise, the diet is not restricted. Copious drinking is prescribed for more frequent and abundant washing of the urethra with urine. It is recommended not to engage in sports during the acute period of the illness, especially to avoid horseback riding and cycling, which injure the perineum and posterior urethra. To prevent nocturnal erections, it is recommended not to drink liquids at night, since overfilling of the bladder itself can cause an erectile state of the penis. Camphora monobrom. 0.3 is prescribed internally, one powder at night. Essential oils (sandalwood oil, copaiba balsam, kava kava, etc.) are prescribed internally. These drugs are attributed with the ability to reduce pain and violent inflammatory phenomena in acute gonorrheal U. because, being excreted with urine in the form of terpene-alcohols, they have an anesthetic effect on the urethral mucosa, reduce secretion, and relax the spasm of the smooth muscles of the urethra. Local treatment of acute gonorrheal U. consists in washing the urethra with solutions of potassium permanganate. (Justification and technique of the method-see Jane method.) Treatment with antiseptic solutions (argyrol, protargol, collargol, albargin, itargan, etc.) with the help of a Tarnovsky syringe currently has no supporters, because on the one hand, strong silver preparations do not penetrate as deeply into the thickness of the mucosa as the gonococcus, and at the same time their cauterizing properties adversely affect the integrity and protective properties of the urethral mucosa. On the other hand, treatment with a syringe, usually performed by the unskilled hands of the patient himself, most often in unsanitary conditions, gives a series of complications. In any case, in the USSR the syringe has now been completely replaced by the Jane method, which has been universally applied in the treatment of gonorrheal U. From the 3rd-4th week of the illness, in the urethral discharge, it is usually possible to detect, along with gonococci, other microorganisms, most often coccus flora and Gram-negative rods, unlike smears from the initial period of the illness, in which no microorganisms except gonococci could be detected bacterioscopically (although bacteriological studies of Ovchinnikov and Semyako showed that even in the initial period of the illness, in the urethral discharge, besides gonococci, there are other microbes, but in very small quantities). In this period, it is appropriate to use, after washing with manganese, an additional washing with a solution of mercuric cyanide 1:5,000 or a solution of argyrol 1:2,000. Treatment of chronic gonorrheal U. aims to eliminate focal lesions of the urethra in the form of lesions of Litre's glands and Morgagni's sinuses, in the form of soft or dense infiltration of the submucosal tissue of the urethra in certain areas, or the destruction of polypoid and granular growths of the urethral mucosa, more often of the posterior urethra. Infiltrative and follicular forms of U. do not occur in isolation, in most cases they are observed simultaneously. Their treatment consists in the application of heat with the aim of dissolving infiltrates in the form of hot baths at 40-45° for the pendulous part of the urethra and sitz baths for the posterior urethra. Along with this, treatment with sounds and Coleman dilators is used, which cause hyperemia of the mucous and submucosal tissue of the urethra and thus contribute to the dissolution of infiltrates, and on the other hand, mechanically remove infection and inflammatory products from the suppurated glands and crypts.

For the pendulous urethra, straight sounds are used, while for the bulbar and posterior urethra, curved sounds are used. The sound is left in place for 10-15 minutes, during which time massage of the urethral walls over the sound is performed to enhance hyperemia. Before sounding, the bladder is first filled with a solution of Kal. hyperm. or mercuric oxycyanide (1:5,000). After removing the sound, the patient urinates, thereby removing pus and infection. Granular and polypoid growths are destroyed by cauterization with solutions of lunar caustic introduced through a bulbous catheter (a few drops of a 1-2% solution), but it is better to under visual control through a urethroscope, smear these foci with a cotton tampon soaked in 10-20% lunar caustic, or else with galvanocautery and electrocoagulation also under visual control. Buro and Vashkevich proposed for the treatment of chronic gonorrheal urethritis the insertion of a cotton tampon soaked in a 2% solution of protargol in glycerin into the urethra. A cotton tampon, rolled around a thin probe and soaked in the specified solution, is introduced into the urethra through the urethroscope tube, the tube is removed, and the tampon remains in the urethra for 2-3 hours and is removed from the urethra by the stream of urine at the first urination. The authors see the mechanism of action of the tamponade in the impregnation of the tissues with protargol. The criterion for cure of acute gonorrheal U., if it was not complicated by involvement of the accessory sex glands, consists of provocative irritation of the urethral mucosa by mechanical and chemical means with subsequent examination of the discharge for the presence of gonococci. Mechanical provocation is performed by introducing a metal sound into the urethra for 5-10 minutes, and chemical provocation by instillation into the urethra of a 1% solution of lunar caustic through a Guyon catheter. In addition, the patient is advised to drink beer. Usually all these provocative measures are prescribed simultaneously. As a result of provocation, a discharge appears, which is subjected to bacterioscopic, and sometimes bacteriological, examination for the presence of gonococci. The examination of smears should be carried out for 3-4 days, if the discharge persists during this time; usually, however, if the process has ended, the discharge ceases 18-24 hours after provocation. If after cessation of local treatment of acute gonorrheal U., a repeated combined provocation gives a negative result in the bacterioscopic examination of the discharge, if no infiltrates are found in the urethra upon palpation over the sound, and if furthermore urethroscopy does not reveal inflammation of the Littré glands and deep infiltration of the urethral wall, then the patient can be considered cured. As for the criteria for cure of chronic gonorrheal U., it should be noted first that at the present time it is an indisputable fact that every case of chronic gonorrheal U., like gonorrhea in general, is undoubtedly curable (Fronstein, Khol'tsov, Yadasson, Bushe-Langer, Zaigraev). However, at the same time, it must be borne in mind that this refers only to clinical cure, i.e., to the fact that the patient ceases to be a gonococcus carrier and does not infect during sexual intercourse, but by no means to recovery in the anatomical sense, i.e., to restitution ad integrum. After prolonged infiltrative chronic gonorrheal U., on the one hand, persistent changes in the urethral tissues remain in the form of development of scar tissue, metaplasia of the epithelium, destruction of the urethral glands, etc., and on the other hand, on the metaplastic epithelium, a nonspecific post-gonorrheal catarrh (see above) very often develops, which has an extremely persistent and prolonged course. Thus, despite the presence of anatomical changes in the urethra and clinical symptoms of chronic U., in a number of cases the patient can be considered cured of gonorrheal U. as such. The main criterion for cure is the presence or absence of gonococci in the urethral discharge. Their presence, of course, with certainty indicates that the disease has not ended, while a negative result is by no means so convincing, even with repeated examinations. In chronic gonorrheal U., the gonococcus can remain hidden in deep, encapsulated foci for a long time without manifesting itself. It is true that such cases are becoming increasingly rare, as they were largely due to irrational treatment by the bactericidal method, however, in deciding the question of cure of chronic gonorrheal U., one must be extremely cautious. It is necessary to perform several times all methods of 'provocation'—mechanical, chemical, and biological (sounds, instillations, alcohol, vaccines, coitus condomatus)—which are used for the diagnosis of chronic gonorrheal U. (see above). Some authors recommend for the purposes of provocation injections of pilocarpine, which enhances secretion. Zaigraev recommends combining the injection of vaccine with urethroscopy. In his opinion, in the presence of gonococcal infection, the provocative injection of vaccine causes sharp changes in the foci in the form of enhancement of hyperemia and swelling of the mucosa, intensification of inflammatory phenomena from the Morgagni sinuses and the excretory ducts of the Littré glands, on the basis of which it can be stated that the gonorrheal process has not yet ended. The Bordet-Jansu reaction (see above) can also be used to clarify the question of cure of chronic gonorrheal U., but it must be borne in mind that it can give a positive result for some time after recovery, especially in cases where gonovaccine was used. Lisovskaya proposes as criteria for cure the determination of gonococcal antigen in the urine. Fronstein, Iozef, Ovchinnikov and others attach importance to eosinophilia in the urethral discharge in the sense that the presence of eosinophils indicates the existence of gonococcal infection. There is also a whole series of criteria for cure of chronic gonorrheal U., proposed by various authors (intracutaneous reaction, provocation by X-rays, etc.), which have not gained significant popularity. In any case, there is not a single criterion that by itself would allow one to state with certainty the cure of chronic gonorrheal U. Only a combination of all or some of the above methods in connection with consideration of the course of the disease, complications that have occurred, the nature of relapses, individual properties of the organism, and the influence of external factors allow in each individual case to correctly decide the question of cure of chronic gonorrheal U. - Nonspecific U. (urethritis non specifica), syn.: non-gonorrheal, simple, banal U. (urethritis non gonorrhoica, urethritis simplex). Under this collective term are understood all kinds of inflammation of the mucous membrane of the urethra except gonorrheal U. The etiological factors of nonspecific U. are extremely diverse and quite numerous. Nonspecific U. are conventionally divided into two main forms: a) venereal and b) nonvenereal. The first includes U. arising after sexual intercourse (except gonorrheal U.), the second includes U. caused by all sorts of other reasons—chemical, traumatic, disturbance of metabolism, general infection, etc. The venereal form (ur. pseudcgonorrhoica) in turn is divided into a bacterial and a nonbacterial group. Bacterial nonspecific U. arises, as already mentioned, after sexual intercourse. The incubation period is 2-4 days. The onset is not acute, the discharge has a mucopurulent character. The first portion of urine is clear or slightly cloudy, contains flakes in moderate amount. In the discharge, a considerable number of microorganisms are found bacterioscopically, such as the intestinal bacillus, streptococcus, pneumococcus, influenza bacillus, streptobacilli, enterococcus, etc. The infection passes from the sexual passages of the woman to the male urethra during sexual intercourse, while infection of the woman, although described in individual cases (Finger), is practically almost never observed, except for infrequent cases of U. in women after the first sexual intercourse, when the infection nests, as it were, in fragments of the hymen and from there enters the urethra. Thus, the bacterial form of nonspecific U. is contracted from clinically healthy partners. The cause of infection should be considered an increase in the virulence of the saprophytic flora of the female genitals, which is why infection is most frequently observed during sexual intercourse with a menstruating woman, with women who have recently given birth or had an abortion or who suffer from a catarrhal condition of the sexual passages with abundant leukorrhea. Bacterial nonspecific U. usually runs a rather sluggish course, subjective sensations are negligible, patients sometimes complain of itching and tickling in the urethra and sticking together of the external orifice. The prognosis is favorable, as the disease usually lasts for a short time—from several days to several weeks—and ends with complete recovery, although complications in the form of epididymitis and prostatitis are also observed. Nonbacterial nonspecific U. [urethrite amicrobienne, aseptique, U. of the Waelsch type] constitutes the second group of the venereal form of nonspecific U. As to its etiological factor (sexual intercourse) and clinical picture (sluggish course), it is completely similar to U. of the previous bacterial group.

The difference lies in the fact that in the discharge in this form of U. no microorganisms can be found, the incubation period is longer (up to 20 days), the disease lasts a very long time—months and years—and rarely gives complications. Some authors (Halberstaedter and Procazek) described special 'inclusion bodies' found by them in the epithelial cells of the urethra in aseptic U. of the Velin type, similar to the 'inclusion bodies' in trachoma. Together with Lindner and Wolfrum, they tend to believe that these 'inclusion bodies' are the causative agent of urethritis. Fischer and Pash, based on their research, deny the presence of 'inclusion bodies' in the female genitals. This question at the present time remains open, although it is very possible that we are dealing here with an organic virus (Callomon) inaccessible to our research methods. The non-venereal form of U. can be caused by both external factors, i.e. lying outside the body, and internal, i.e. originating from the body itself. The first group includes urethritises that arose as a result of intentional (e.g. for the purpose of exemption from military service) or accidental introduction into the urethra of various chemicals—sublimate, ammonia, gasoline, turpentine, etc.—or as a result of systematic injection into the canal of strong solutions of argyrol, protargol, etc. after accidental sexual intercourse for the purpose of preventing gonorrhea. The clinical picture of 'chemical' U. varies depending on the nature and concentration of the introduced substance and ranges from mild catarrhs to very severe U. with subsequent formation of scars and strictures of the urethra up to obliteration of the lumen. U. caused by external causes also include U. caused by the introduction of various foreign bodies into the urethra (straws, pencils, thin wire, wax candles, etc. for the purpose of masturbation), systematic catheterization or a permanent catheter (catheter demeure). This also includes U. as a result of constant trauma to the urethra from the outside, e.g. urethral catarrh in cyclists, drivers, and riders or U. after a single severe injury to the urethra—bruising of the perineum or injury to the pendulous part of the urethra. Among U. of endogenous nature, we note the urethritises observed in some people suffering from phosphaturia and oxaluria, due to constant irritation of the urethral mucosa by the excreted salts. U. also occur in diabetics as a result of the urethra being washed with urine containing sugar, which prepares a favorable environment for bacterial catarrhs (Callomon). Some medicinal substances (cantharidin, iodine), taken internally, being excreted with urine, can cause irritation of the urethral mucosa and symptoms of U. Individual cases of U. have been described in general infectious processes—influenza, typhus, smallpox, mumps. Urethritis herpetica is rarely observed as a result of a herpetic eruption on the urethral mucosa. The process usually lasts only a few days, but in some cases it gives recurrences. Cases of U. due to eruptions on the urethral mucosa of lichen ruber and pemphigus have been described. Bacterial urethritises occur in the presence of balanoposthitis. The inflammatory process in the urethra is maintained by infection entering the canal from the preputial sac, and therefore sometimes has an extremely persistent character. Sometimes such U. leads to the formation of strictures. In some cases, recovery is achieved only after elimination of the primary focus by circumcision. Tuberculous urethritis—see Urethra. Papillomatous and condylomatous growths on the urethral mucosa also cause symptoms of U. They are often observed in the presence of similar growths on the genitals (condylomata acuminata genitalium). In addition to discharge from the urethra, in some cases they can cause difficulty in urination and even retention of urine, sometimes they give rise to urethrorrhagia and hematuria. Hard and soft chancre on the urethral mucosa, as well as papular syphilides, can also cause symptoms of U. The diagnosis of non-specific U. is mainly established by excluding gonorrheal U. The methodology of this differential diagnosis depends on whether we are differentiating from a slowly beginning gonorrheal U. or from a prolonged chronic gonorrheal U. If the diagnosis of non-specific U. is established, then the anamnesis (coitus, trauma, general infectious process, etc.) allows differentiation between venereal and non-venereal forms of non-specific U. Bacterial non-specific U. and U. of the Velin type as varieties of the venereal form are differentiated on the basis of the presence or absence of flora in the urethral discharge. As for the types of non-venereal form, in individual cases the diagnosis is clarified from the anamnesis (catheterization, injection of strong solutions into the urethra), sometimes on the basis of examination and general examination of the patient (condylomata of the genitals, presence of a general dermatosis, diathesis, presence of tuberculous bacilli, Ducrey-Unna rods or the pale spirochete in the discharge, presence of sugar in the urine, presence of foreign bodies in the urethra, etc.). Sometimes urethroscopy provides valuable services (papillomatosis, condylomatosis, lichen ruber, foreign bodies, tuberculous ulcers). Treatment of the non-venereal form comes down to eliminating the main cause of the disease or fighting it, e.g. removal of foreign bodies, condylomas, papillomas, treatment of diathesis, sugar disease, tuberculosis, syphilis, etc., after which U. usually ceases. As for the venereal form, bacterial U. is treated with weak solutions of disinfectants (irrigations with solutions of Hydrargyri oxycyanati 1:5,000, argyrol 1:4,000 or 1:5,000, Kalii hypermanganici 1:5,000, rivanol 1:5,000, or instillations of 1-2% protargol, 1/4% argyrol, 1-2% collargol, 1/1% ichthyol, etc.). Injection of strong solutions and the introduction of bougies worsens the course of the disease. U. of the Velin type usually does not respond to local therapy, often local treatment even exacerbates the process. In view of this, it is most rational to leave it without local therapy, limiting oneself to prescribing a non-irritating diet and abundant drinking. The venereal form of non-specific U., especially the aseptic form of the Velin type, has an extremely persistent, prolonged character. At the same time, experience shows that with the exception of very rare cases, it does not present a danger of infection during sexual intercourse. Therefore, most authors agree that with this form, as with other types of non-specific U., the patient can be allowed sexual intercourse and even marriage. Such permission can be given only after the diagnosis of non-specific U. has been established with complete certainty, and after attempts to achieve a cure by one therapy or another. This especially applies to the bacterial form.