MARRIAGEABILITY OF A GONORRHOEAL PATIENT

By

Major. M.P.Vora, M.B.B.S., D.V.D., I.M.S. (Rtd.)

Hon. Sr. Venereologist, St. George’s Hospital

Indian Medical Record

A monthly journal of Public Health, Tropical Medicine and Surgery etc .

Volume LXXXVII, Number-11 of November 1967

Pages 199-202

This article was solely contributed to Indian Medical Record

When can one pronounce safely the patient who has suffered from gonorrhoea as cured and fit to marry or resume normal relations, if he or she is already married? This question is of very common occurrence and indeed of great importance. The serious implications and repercussions of its reply are not appreciated generally. Its answer is not at all easy and bristles with many difficulties. It is one of the most challenging problems in contemporary medicine. The word cure is used differently to mean symptomatic cure or relief from symptoms, apparent or clinical cure, bacteriologic cure and anatomic cure. The cure in the sense of relief from symptoms is possible in every case within a few days of the institution of modern treatment. Bacteriologic and anatomic cures can be had in patients only who apply for treatment in the very early stages of infection and follow the doctor’s advice and instructions carefully. Bacteriologic cure is an ideal one and must be aimed at in every case. It must be one of the chief goals of the treatment. In complicated and chronic gonorrhoea, it is rather difficult, and still more difficult to obtain in anatomic cure. It becomes more troublesome on account of long and tedious procedures of treatment, irksome and repeated tests of cure and the resultant costs there-of. The changes that have already taken place in important organs such as the urethra, vas deference, fallopian tubes etc. can rarely be undone. They tend to leave a permanent mark of damage in spite of the best treatment and the fullest cooperation on the part of the patient. While one can declare a clinical cure, it is very difficult to say positively and decisively that a bacteriologic cure has been effected not-with-standing the recent advances in the therapeutics and methods of detection and identification of gonococcus. It is also not possible to undo the structural damage that has already resulted to vital organs of the body. It is impossible to lay down an absolute standard of cure which can be applied evenly and rigidly to one and all cases. Such a criterion is difficult in the male and doubly so in the female. A patient may be well and normal in clinical sense and still may harbour in the genital tract or neighbouring sex glands, latent gonococci which may become activated when deposited on a virgin soil. The lapse of time will tell better than the most exact series of tests alone whether or not the element of infectiousness i.e. gonococcus has been totally and completely eradicated. One has therefore to use the greatest thoroughness in judging the issue and allow sufficient time to pass before telling a patient that he or she is cured and fit to marry or resume normal relations with his or her marital partner; otherwise the medical practitioner will be failing in his obligations that are imposed on him when he undertakes to treat a patient with gonorrhoea.

Even a very fresh case of gonorrhoea, when under proper and adequate treatment may take easily as many as 12 to 15 weeks for a bacteriologic cure to be thoroughly confirmed. The older the infection, more the complications, the longer will be the period of treatment and more difficult to achieve a complete cure, bacteriologic and anatomic. This holds good in spite of recent therapeutic advances, which make it possible to carry out the whole course of treatment with great simplicity, rapidity, and least complications. All the same, importance of local measures of therapy in complicated gonorrhoea must not be lost sight o f in the complete eradication of the infection. They are indeed as indispensable as chemotherapy itself. To establish a cure it is essential that certain standard tests spread over a certain period should be performed in every patient. Since about 5% of the cases do acquire an additional syphilitic infection, it is obligatory to exclude in every case of gonorrhoea every possibility of syphilis either incubating or latent. Reasonable care and skill must be uppermost in settling the issue.

The risks which are involved in the problem are:-

• the danger of transmission of infection to the marital partner

• the danger of disabilities such as chronic illness, arthritis, blindness.

• The danger of sterility or barren marriage being imposed

• The danger of ophthalmia neonatorum in the new born leading to blindness

The factors which govern fitness for marriage are:-

• the duration of infection

• the age and sex of the patient

• the anatomical extent of infection

• the type and amount of treatment

• the personal habits such as alcoholic drinks,

• the additional syphilitic infection and

• the economic responsibilities involved.

Earlier the disease is diagnosed and treated, less the chances of complications and quicker and easier is the cure obtained. It is easier to procure in the male than in the female. Younger the patient and less prepares financially, greater and more taxing will be the difficulties of early married life. When the disease becomes old and spreads high up in the uro-genital tract or involves accessory sexual glands, it then becomes difficult to effect bacteriologic cure and still more difficult to undo the changes that have taken place in the organs of the body. The treatment must be proper, regular and in adequate dosage over an adequate period so as to maintain an effective blood level for the requisite time. The majority of strains of gonococci are sensitive to penicillin concentrations of 0.3 to 0.25 units per ml. maintained over a period of 3 to 4 days. Under or irregular treatment especially in the early stages of infection only alleviates the symptoms temporarily and makes the organisms drug-resistant. Such a patient falls victim to an occasional acute exacerbation of infection and late sequelae. Persons who are habitually promiscuous or given to alcoholic drinks are hard to cure; they are often subject to relapses. The presence of concomittent syphilis is likely to add more difficulties to the problem. (Please refer to the issue of June 1967.)

Similarly, the difficulty in determining the adequacy of the treatment will be apparent. The treatment, its type and its amount depend on the sex of the patient and whether the disease is fresh and uncomplicated or old and complicated. The routine amounts of treatment for gonorrhoea in the female is usually double that of the male. As a general rule, complicated or old gonorrhoea requires probably three times the amount of treatment that is considered adequate in the uncomplicated fresh gonorrhoea. In addition, it requires local therapeutic and supportive measures. A case of acute fresh uncomplicated gonorrhoea in the male needs minimum of 1.2 mega units of procain penicillin-G parenterally or sulphadiazine 4 to 5 gms daily by mouth for 5 to 6 days, while that in the female needs 2.4 mega units of penicillin or two courses of sulpha drugs at a week’s interval. A case of old or complicated gonorrhoea in the male needs minimum of 3.6 mega units and that in the female 6.0 mega units in addition to local and supportive therapy. The resistant organism will need a change of antibiotic. Today there are numerous effective alternatives.

Tests of cure in the male:

• Absence of urethral discharge especially on rising.

• Urine retained for 4/5 hours should be free from pus and gonococci. Presence of threads or pus cells more than five per microscopic field under 1/6 objective is an indication of continued inflammation.

• Accessory sexual glands such as the prostate, seminal vesicles, Cowper’s glands, Tyson’s glands and paraurethral ducts should be free from any evidence of infection.

• Negative microscopic and cultural examination of the centrifugalised deposit fro m the fresh urine retained for about four to five hours.

• Negative microscopic and cultural examination of the secretions from accessory sexual glands.

• These tests should be repeated after provocative procedures such as the passage of full size urethral dilator or instillation of 2ml of 0.5 to 1.0% freshly prepared silver nitrate solution into the urethra.

• Negative serologic tests for syphilis at the beginning and at the end of the observation period.

• Urethroscopy.

• Observation must extend over three months in case sulpha drugs are used, and six months where penicillin is used.

Tests of cure in Female:

• Negative clinical examination, absence of signs and symptoms of gonorrhoea, normal appearance of the cervix, urethra; Skene’s ducts, Bartholin’s glands and their ducts. Bimanual examination of the pelvic contents to exclude involvement of the ovaries and fallopian tubes at each session

• Gram-stained smears taken from the urethra, cervix and ducts of Bartolini should be negative for gonococci. Since a large number of smears from symptom-free carriers of gonorrhoea are missed by this technique, a more effective method, the fluorescent antibody technique, is now-a-days employed for detection of gonococci. Immunofluorescene technique yields better results even than culture.

• Negative microscopical and cultural studies of the secretions from the urethra, cervix and the accessory sexual glands, taken especially after the cessation of the menstrual period.

• Absence of clinical and bacteriological evidence after provocation i.e. retention of a glycerine plug high up in the vagina for 24 hours.

• Negative complement fixation test.

• Negative serologic test for syphilis at the beginning and during the observation period.

The above tests should be repeated monthly for a period of six months.

If all these tests are found satisfactory after the completion of treatment, a provisional assurance that the disease is cured can be given. If any doubt arises as to the presence of infection, further course of treatment and repetition of series of tests have to be considered. A complete failure to demonstrate any evidence of the presence of infection in the patient after these elaborate tests can be taken as a reasonable proof of a complete and permanent cure. Though the evidence is circumstantial after all and can be relied on cent percent from the bacteriologic point of view, one can not afford to be casual and impatient with the pronouncement of the cure of gonorrhoea. The disease is infectious and as it is one’s duty to exhaust all the means that are available to achieve a reasonable standard of bacteriologic cure. Failure to fulfill these obligations will only help to increase and enlarge the pool of reservoir of infection in the society. It is the responsibility of the practitioner to warn such a patient against contracting a marriage or his or her resumption of normal marital relations unless the patient has fulfilled the necessary tests of cure to eliminate any possible risk of transmission of disease to others.