Microbiological study of urethritis in males with special reference to Candida urethritis.
Urethritis in males is a sexually transmitted disease and is classified into gonococcal (GU) and nongonococcal urethritis (NGU). NGU in western countries is stated to be on the increase. Bhujwala et al, from India also reported an increase in the incidence of NGU. Hence, the present study was undertaken to find out the incidence of NGU and also to elucidate the role of different micro-organisms as causative agents of urethritis in male patients.
Two hundred and ninety male patients in the age group 15-45 years suffering from urethritis and attending the skin and venereology department of a municipal hospital were investigated. One hundred male patients, in the similar age group attending the outpatient department for some skin diseases but without any urogenital tract infection formed the control group.
Two urethral swabs and fresh urine sample from the patients in the study group and fresh urine sample from the control group patients were processed. The procedures were as described earlier.
(1) Urethral swabs and urine sediments were examined microscopically by wet preparation, with Gram's and Giemsa staining.
(2) Culturing of the samples was done on Thayer-Martin medium, McConkey's medium, Sabouraud's agar medium, PPLO broth supplemented with urea at pH 6.5, and A7 agar medium for Ureaplasma urealyticum (U. urealyticum). PPLO broth was incubated in candle jar under reduced oxygen tension so as to achieve 5-10% CO2. A7 agar was incubated in an anerobic jar with special gas mixture of 95% N2, and 5% CO2. at 37°C for 48 hours.
Standard procedures were used for identification of various micro-organisms.6 Case histories of the patients showing urethral candidiasis were reviewed.
The classification of 290 patients (study group) in relation to the clinical diagnosis is shown in [Table 1]. Bacteriological isolates are shown in [Table 2]. U. urealyticum, N. gonorrhoea and coagulase positive staphylococci were the common isolates. Candida albicans was isolated in 3 cases, while Gardnerella vaginalis and Trichonwnas vaginalis were not isolated from any sample. Patients with polymicrobial etiology were excluded from this study.
86.95% strains of N. gonorrhoea were sensitive to penicillin (100 IU/dics), 96.73% to ampicillin, 94.56% to chloramphenicol, 95.65% to oxytetracycline and 85.86% to gentamicin. None of the penicillin resistant strains produced beta-lactamase. Minimum inhibitory concentration (MIC) of penicillin for N. gonorrhoea was 0.08 µg/ml.
From the control group, in 20 cases U. urealyticum was isolated.
Three patients with urethral candidiasis were in the age group of 18-22 years. All of them presented clinically with the history of burning micturition and exposure to venereal diseases. Two of them also complained of penile irritation and were diagnosed clinically as balano-posthitis but did not have any urethral discharge, whereas the remaining one had scanty discharge for urethra.
In 2 cases yeast cells could be observed in the Gram-stained preparation. The colonies developed on Sabouraud's glucose agar slants within 48-72 hours of incubation at 37°C. The colonies grown on the Sabouraud's agar slants were confirmed by Gram staining, sugar fermentation tests for Candida and germ tube formation test which is confirmatory for Candida.
The sugars which were used for identification of Candida were dextrose, maltose, sucrose, lactose and galactose. The germ tube formation test was carried out according to Ahearn's method using human serum.
Urethral candidiasis was treated by local antifungal (clotrimazole) application and saline baths. The patients improved within 10-15 days. After the treatment was completed Candida could not be reisolated from these patients.
Out of 135 clinically diagnosed cases of gonococeal urethritis, in 92 cases N. gonorrhoea was isolated. The proportion ratio of NGU : GU was 1.89 : 1; U. urealyticum could be isolated in 45.8% of NGU patients. Tarunkumar et al have reported 64.28% isolation rate of U. urealyticum in NGU cases. The isolation rate from the controls in the present series was 20% and to Tarunkumar et al's series 29%. This indicates colonisation of U. urealyticum in healthy individuals.
Penicillin resistance was seen in 13.04% of the strains of N. gonorrhoea in the present series. Bhujwala et al encountered the same in 12.8%.
The isolation rate of Candida albicans was 1.034% compared to the reported incidence,, varying between 0.5% and 1% among the men with NGU. Men with NGU and balanoposthitis seem to be more likely to carry Candida than men with gonorrhoea or normal men. Since all the 3 cases had a positive history of exposure to venereal diseases, the chances of these patients acquiring the Candida infection from postitutes was high. After treatment, with saline bath and antifungal agents the patients were relieved of their complaint. This proves the pathological role of C. albicans in causing NGU and balanoposthetis.