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Written by Dr Geoff Hackett, consultant in sexual dysfunction
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What is penile discharge?
Penile discharge is the abnormal loss of fluid that is not urine
or semen from the urethra (urine tube) at the tip of the penis.
It is commonly the sign of a
sexually transmitted
disease (STD), and requires prompt and accurate diagnosis and treatment,
usually by staff at a specialist genitourinary medicine (GUM) or STD
clinic.
What are the symptoms?
The discharge can vary in amount from scanty to profuse, and in
colour from clear to yellow/green. The timing can vary from loss in the morning
only, to throughout the day. The discharge is often accompanied by other
symptoms such as:
-
burning on passing urine (dysuria)
-
frequent need to pass urine (frequency)
-
excessive need to urinate at night (nocturia)
-
rash in the genital area, which can be painful or
itchy
-
swollen lymph nodes (glands) in the groin.
What are the causes of penile discharge?
Common causes are:
-
gonococcal urethritis
-
non-gonococcal or non-specific urethritis (NSU).
Gonococcal urethritis (gonorrhoea)
Gonorrhoea is caused
by Neisseria gonorrhoeae.
-
Incubation period: it usually takes two to
five days from infection to symptoms. Without treatment, symptoms of urethritis
(inflammation of the urethra) and purulent (pus-containing) discharge peak
within two weeks.
-
Symptoms: discharge occurs in 95 per cent
of men and is purulent in 75 per cent, white or cloudy in 10 per cent and clear
in 5 per cent. Recent urination can make the discharge appear less purulent.
When the infection begins to resolve, the discharge changes from purulent to
mucoid (mucus-like).
-
Transmission: transmitted by sexual
intercourse, including oral sex. Without treatment, the infection can continue
for many months.
-
Complications: spread up the urethra to the
epididymis (sperm-storing tube connected to the testicles) is rare and
infertility can be a rare late complication. Anal infection is common
especially, but not only, when the infection is transmitted by anal
intercourse. Bloodstream infection occurs in less than 1 per cent of patients,
causing arthritis of the knees, wrists and hands plus fever, chills and skin
lesions, usually papules or pustules (red or pus-containing raised spots or
bumps) on the hands or feet.
Non-gonococcal or non-specific urethritis (NSU)
NSU is the most common form of penile discharge accounting
for over 60,000 new cases per year in England alone. The number of cases has
fallen slightly over the past three years. Men aged between 20 and 35 years are
most commonly affected. Several different organisms ('bugs') can cause the
syndrome:
-
Chlamydia trachomatis (25-60 per
cent).
-
Mycoplasma genitalium (up to 25 per
cent).
-
Ureaplasma urealyticum (15-25 per
cent).
-
Trichomonas vaginalis (17 per cent).
-
Herpes simplex (rarely).
Routine tests are not available to detect all of these
infections, so the cause of the NSU might not be found. In some patients, no
sexual contact has occurred and the symptoms are blamed on irritants, soaps or
detergents, but no firm evidence exists to support this theory.
How is the diagnosis made?
Penile discharge or urethritis is diagnosed by finding white
blood cells (neutrophils or pus cells) on a urethral swab or 'first catch'
urine sample (ie urine taken from when you first begin to pass water).
The infecting organism might be identified from these samples.
Ideally, the patient should be seen in an STD clinic for prompt examination of
specimens because transfer of specimens to a hospital laboratory can lead to a
missed diagnosis. The colour and consistency of the discharge does not help to
distinguish NSU from gonococcal urethritis.
Gonococcal urethritis is diagnosed in 98 per cent of men by
microscopic examination of the discharge obtained from a urethral swab. Other
infections are less easily diagnosed. Between 6 and 11 per cent of sexually
active UK men carry chlamydia in their urethra with minimal or no symptoms.
The development of more sensitive tests such as polymerase chain
reaction and ligase chain reaction might allow for more precise diagnosis,
particularly in patients with no symptoms, especially if they are sexual
contacts of proven infected women - but this is not used routinely in STD
clinics.
How is penile discharge treated?
Gonococcal urethritis
One of several antibiotics can be given as a single
dose:
-
ceftriaxone 250mg by intramuscular injection
-
cefixime 400mg orally
-
ciprofloxacin 500mg orally
-
ofloxacin 400mg orally.
In addition, doxycycline 100mg twice daily for seven days is
often given to treat chlamydia in case it is present. Sexual partners are given
similar treatment.
NSU
Usual antibiotic treatment includes doxycycline 100mg twice
daily for seven days or a single dose of azithromycin 1g if the infection is
due to Chlamydia trachomatis.
Sexual partners should be given similar treatment. Patients
should be followed up after two weeks with repeat swabs (known as 'test of
cure') because of the high risk of re-infection often due to failure of all
sexual partners to comply with therapy.
Contact tracing
It is essential that sexual contacts of men with gonococcal
urethritis and NSU are traced and treated, preferably in an STD clinic. Without
treatment of sexual contacts, recurrence is likely and treatment will probably
fail. Pregnant or potentially pregnant sexual partners should not be given
erythromycin or tetracycline antibiotics (including doxycycline).
Conventional therapy for NSU fails in 25 per cent of cases.
Longer courses of antibiotics have not been shown to be of benefit and
re-infection from a new or untreated partner is the usual cause.
It is important to realise that recurrence of NSU can cause
considerable psychological strain on individuals and relationships and it is
important that both partners in a relationship have a full explanation and
understanding of the nature of the condition.
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Last updated 12.09.2005
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