PROOFS OF CURE IN GONORRHOEA

By

M. P. Vora, M.B.B.S.

The Medical Bulletin

Vol. IX, No.5 of 1 st March, 1941; Pages: 153-158

The question of ‘Cure’ of gonorrhoea is a common topic in the practitioner’s daily work and is, indeed, not of minor importance. When can one safely pronounce a patient, suffering from gonococcal infection, as cured? Obviously the answer is not an easy one. The word cure is used differently to mean symptomatic cure, apparent or clinical cure and bacteriological cure. The cure in the sense of the former two is possible in every case within a short period. Bacteriological cure, an ideal cure, which should be aimed at in every case, is obtainable in cases early and with few complications such as prostatitis, vesiculitis, epididymitis, salpingitis etc. In chronic and complicated cases, it is rather difficult, and it becomes more so on account of the long and tedious treatment, prolonged and irksome tests of cure, and the cost thereof. It also requires the fullest co-operation between the patient and the doctor. It is unfortunate that, in spite of the recent advances in the medical science, while one can definitely pronounce a clinical cure, it is very difficult to say positively and decisively that bacteriological cure or a thorough and complete cure has been effected. At the same time it is very hard to lay down an absolute standard of cure which can be applied rigidly to all cases. It is difficult in the male and doubly so in the female. “As to the presence of gonococci the question can only be answered categorically. A man may be well and normal in clinical sense and still may harbour latent gonococci in his genital tract, which may become activated when deposited on a virgin soil. The lapse of time will tell better than the most exact series of tests, whether or not the element of infectiousness has been completely removed from the patient”. One has, therefore, to use the greatest thoroughness and judgment and to allow sufficient time to pass before telling a patient that he or she is ‘cured’; otherwise the doctor would fail to discharge his obligations that are imposed upon him.

Even A VERY EARLY CASE, WHEN UNDER PROPER TREATMENT, MAY NEED AS MUCH AS EIGHT WEEKS, PROBABLY MORE BUUT NOT LESS, FOR A THOROUGH CURE. Older the infection or more complications in the disease, longer will be the period of treatment, and more difficult becomes the complete cure. This holds good notwithstanding the recent chemotherapeutic advance, which has helped not only to reduce the period and the cost of the treatment, but also to carry out the whole course of treatment rapidly, more successfully and with least complications. All the same, the importance of local treatment in the complete eradication of infection, must not be lost sight of. To establish a cure, it is essential that certain standard tests should be passed by every person. They are proceeded more or less on the same lines in both sexes. For all practical purposes the following plan may be adopted for general guidance.

I. Male Infection

The conditions to be examined for a cure of male infection. (A) where the anterior urethra alone is involved and (B) where the whole urethra is involved. Though the nature and the scope of examination do not vary greatly in the two, this division seems more appropriate and convenient to the present day when early cases with anterior urethritis only are not uncommon. In these cases, the tests of cure need not be gone through relatively easily and in a short time.

A

• Negative clinical examination: -

• absence of urethral discharge especially on rising and known as gleet or morning drop. This discharge should not be confused with the mucoid discharge, which is met with in some persons due to the overactivity of the urethral glands.
• examination of the prostate, seminal vesicles, Cowper’s glands anf epididymis should show them free from infection and clinically normal.

• Absence of pus cells in appreciable number in all night urine or early morning sample, after about four hour’s retention. A coverslip preparation is made and seen under microscope. Pus cells, five or more per microscopic field, with 1/6 objective is abnormal and must be viewed with suspicion.

• Negative microscopic and cultural examination of

• the centrifugalized deposit from the urine retained all night.
• the urethral discharge obtained by squeezing or milking the urethra.

Smears are made from the above material, stained with gram’s stain and examined carefully for the presence of pus cells and gram-negative intra and extra cellular diplococci. At the same time cultures are made on a suitable medium and watched for the growth of the organism. As regards the examination of the urinary deposit, one should make a point to examine the fresh urine; for gonococci autolyse and disappear from the stale or alkaline samples.

• Absence of any clinical or bacteriological sign of the disease after any provocation.

• After the lapse of two to three weeks of the cessation of treatment, 200 to 300 millions of polyvalent gonococcal vaccine or 1 c.c. of Niltox Brand of Detoxicated Gonococcal Proteoses, is injected hypodermally; and 24 to 48 hours subsequently, specimens of the morning urine and the urethral secretion are collected for bacteriological examination.
• A straight full size metal sound or a bougie (23 to 25 Charrier scale) is passed into the urethra and a gentle massage is given on the body of the penis. Irrigation of the urethra is purposely omitted and the urine and the urethra discharge, if any, are taken in the next morning for examination.
• Spicy food, exercise, sexual excitement like dancing, alcoholic drinks, if the person is used to these, etc, are advised on the previous day and the specimens are taken in the morning. This part of the provocation may be done preferably in combination with 4-a and 4-b above.
• Instillation of one of the following solutions is made into the anterior urethra and retained there for about twenty minutes. Specimens are then taken for examination next morning.
• 1to 2% Silver Nitrate solution 2 to 5 c.c.

(ii) 1 in 4000 Pilocarpin Hydrochloride solution 10c.c.

(iii) 5% Protargol solution 10 c.c.

• Urethroscopic examination of the anterior urethra to ensure that it has regained its normal appearance. It is the most valuable means of testing a patient for cure. He should be instructed to avoid passing urine - an essential precaution - for at least four hours prior to the examination. Attention should be paid especially to the openings of the lacunae and ducts of the Littre’s glands on the roof and sides of the penile urethra, the lacuna magna on the roof of the fossa navicularis, and the openings of the Cowper’s glands on the floor of the bulbous urethra. The whole surface should appear pink, lustrous, dilate regularly in all directions on air-inflation and collapse quickly on relaxing the air pressure.

• Observation or follow-up of the patient for a period of two to three months.

B

Since the disease comes under observation late there is likelihood of the involvement not only of the whole urethra but also of some other organs. In the chronic disease, where prostate vesicle, epididymis etc are affected, it is not often possible to procure complete cure, on the account of the irrevocable nature if the changes that are wrought in the organs. Complicated cases therefore, the organs which have undergone considerable changes, cannot be expected to return back to complete normal state. The tests of cure are naturally more extensive and critical and take longer period. Some extra tests, in addition to the tests described above, require to be satisfied in these cases.

• Negative clinical examination as in A-1.

• Absence of pus cells in the appreciable number in all night urine as in A-2.

• Negative microscopic and cultural examination of the
• Urinary deposit,
• Urethral discharge,
• Secretions of the prostate and seminal vesicles after prostatic massage,
• Semen

Semen are made stained and examined for pus cells and gonococci. Cultures are also made from these materials are examined.

• Absence of any clinical or bacteriological sign of the disease after any provocation.
• The provocative dose of vaccine, 1 c.c. Niltox brand of Detoxicated Gonococcal Proteoses, is injected hypodermally and 24 to 48 hours later, specimens of morning urine, urethral discharge and prostatic secretion are taken for microscopic and cultural examination.
• A full size curved or straight metal sound is passed into the urethra, a gentle massage is given on the penis, usual irrigations are omitted, and the samples of morning urine and urethral discharge are taken in the next morning.
• Spicy food, exercise, sexual excitement like dancing, alcoholic drinks, if the person is used to these, etc, are advised on the previous day and the specimens are taken in the morning. This part of the provocation may be done preferably in combination with 4-a and 4-b above.
• Instillation of one of the solutions given above (see A-4 (d)) is made into the whole urethra and the samples of next morning urine and urethral discharge are taken for examination.
• Coitus with a condom on may be advised. It protects the partner, and is a proof of cure if there is a total absence of any sign or symptom.

• Urethroscopic examination of the whole urethra to ensure that it has regained its normal appearance, dilatability and contractibility. A careful search is made to locate the foci of infection, such as subepithelial infiltration, abnormal granulation tissue, irregularity in striations, vascularity etc., not only in the anterior but also in the posterior urethra. This examination gives true picture of the urethral mucosa and assists in the detection of littritis, lacunitis, and chronic infiltrations, which are often responsible for the maintenance of infection with least external symptoms. The usual precaution of the retention of urine for 3 to 4 hours prior to the examination is necessary.

• Observation of the patient for at least three to six months from the date of the suspension of the treatment. During this period tests are repeated and the patient is instructed to report himself immediately if he finds anything abnormal in his urogenital system.

• Serological or complement fixation test may be done if possible. This test is not used commonly in the daily practice as it is not without discrepancies and hence not very useful. It may be negative in early cases which are cured or not cured as well. It may remain persistently positive even in cured cases which had received vaccine treatment. It may be of use in chronic cases which are not given vaccines.

If the primary tests i.e. test No. 1, 2, 3 and 5 are found satisfactory immediately after the suspension of treatment, a provisional assurance that the disease is ‘nearing a cure’ should be given. If, in these tests, any doubt arises as to the presence of infection, a further course of treatment should be prescribed and the tests of cure should be repeated at a later date till the requirements are satisfied. After one to two month’s rest from treatment the patient is examined again. If the test No. 1, 2, 3, 4, and 5 i.e. clinical, microscopic, cultural, provocative and urethroscopic examinations, are found satisfactory, one may declare a patient ‘clinically cured’. At this stage, the patient may be allowed to resume his ordinary habits of life and asked to report himself again for examination three to four months subsequent to the suspension of the treatment. If no signs and symptoms of the disease are apparent during this probationary period and the repetition of tests is found again negative, the use of condom or some such protection, during sexual intercourse, (if the person is married) for the first few times, should be advised. A complete failure to demonstrate any evidence of the presence of infection in a patient after these elaborate and repeated procedures, is a proof of complete ‘cure’ has been effected. But the evidence after all is circumstantial and one cannot be too sure bacteriologically. Does this mean that one can deal lightly and impatiently with the cure of gonorrhoea simply out of mere pessimism? That can by no means be fair. The disease is infectious and as such it is our duty to exhaust all the means that are available to achieve the ideal end.

II. F emale Infection

The conditions to be examined for a cure of the female infection: -

• Negative clinical examination - absence of signs and symptoms of disease for a month after cessation of treatment; bimanual examination of the pelvic contents to exclude the involvement of the fallopian tubes, ovaries etc. Smears are taken from the cervix and urethra and examined.

• Total absence of the evidence of the disease on microscopic and cultural examination of the discharges from the vagina, urethra, cervix, Bartholin’s duct, Skene’s duct etc. The best time to take material for examination is within the first two days after the cessation or before the beginning of the menstrual period. The test should be repeated on three successive times.
• Absence of any clinical or bacteriological sign of the disease subsequent to either provocation.
• Injection of the provocative dose of vaccine.
• Retention of a plug of glycerin high up into the vagina, for a period of about 24 hours, prior to the examination. It makes the test more searching.
• Urethroscopic examination to ensure the absence of the involvement of the urethral mucosa, and the Skene’s ducts.
• Follow-up of the patient for a period varying from six to nine months.
• Serological or complement fixation test of the blood, if possible.

When the primary tests, i.e. test No. 1, 2, and 4 are found satisfactory after the cessation of treatment, the patient may be assured that the disease is ‘nearing a cure’. The test should be repeated monthly during ensuing three months within 24 hours after the cessation of menses, the last time, the test being supplemented by the provocative dose of vaccine and by the retention of glycerine plug into the vagina. If these examinations, i.e. clinical, microscopic, cultural, urethroscopic and provocative, are negative the patient may be declared ‘clinically cured’. When six to nine months have gone without any sign, the previous findings are automatically confirmed. After all these elaborate tests are passed repeatedly, she may be considered completely cured.

My thanks are due to Dr. W. N. Welinkar, Specialist in Venereal Diseases, Sir J.J. Hospital, Bombay, who kindly read through this article and made important suggestions.

references

1. Jelal M. Shah - Phamphlet on treatment of Veneral Diseases.
2. W. N. Welinkar - Indian Journal of Venereal Diseases Vol. 6, No. 1.
3. Livermore and Schumann - Gonorrhoea and Kidney Affections.
4. David Lees - Diagnosis and Treatment of Venereal Diseases.