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Penile discharge

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Penile discharge

Written by Dr Geoff Hackett, consultant in sexual dysfunction

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.

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