Young Scientist . #8 (55) .

August 2013

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.., .., .., .. : // . 1995. 2. . 2631.

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.. : / .., .., .. // . 2005. 17. . 4347.
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Neissers Disease in the Former Soviet Union and Related Topics

Jargin S.V.
, ,
(. )

The treatment of gonorrhea in the former Soviet Union is discussed here on the basis of three typical case histories.
Some outdated methods of topical treatment and provocation, not used in other countries, are described. Being aware
of alengthy treatment, groups of risk avoided the prevention and treatment centers (dispensaries) and often practiced
self-treatment, which contributed to the spread of infection. Besides, some related problems of womens health in the
former SU are discussed heree.g. overtreatment of cervical pseudo-erosions or endocervical ectopy. Today, there are
grounds for optimism: the growing Russian economy makes it possible to acquire modern equipment and to apply new
diagnostic and treatment methods, while broadening international cooperation would attract foreign expertise.

Case Reports
The treatment of gonorrhea (Gn) in the former Soviet
Union (SU) is discussed here by the example of three typical
cases from the 197080s. Case 1. Alawyer was infected with

Gn. In compliance with the laws and regulations he went to

the dermato-venerological dispensary (prevention and treatment center) and was treated according to the official recommendations issued by the health care authorities. Thereafter
the patient declared that the treatment was lengthy and un-

512

pleasant and that he would never approach the dispensary

again.
Case 2. An unmarried man prone to moderate alcohol
consumption commissioned himself with anext military
rank every time he was infected with Gn. In this way he became ageneralissimo, which illustrates widespread irresponsibility: the patient was in fact proud of his career. The patient was one of the ringleaders of adrinking company that
among other things inveigled adolescents into alcohol consumption and young females into sexual contacts. The patient never approached the dermato-venerological dispensary and treated himself with intramuscular injections of
Bicillin (Benzathin-Benzylpenicillin). Retrospectively it is
unclear when it was aquestion of afresh infection or an exacerbation: the case was reported to the authorities after many
years of the patients activities. The informer did not conceal
the fact of denunciation; later he was battered by the perpetrators, but his civic duty he had done. The high-risk social
groups were informed about methods applied in the dispensaries and avoided them. They treated themselves with antibiotics, e.g. with the Bicillin injections, but not always adequately, thus continuing spreading the infection. Accordingly,
the official statistics has never been realistic. This case demonstrates that the society and its institutions factually permitted the spreading of sexually transmitted infections (STI).
Case 3. Afemale student residing in astudents dormitory was infected with Gn. It should be commented here that
female under- and postgraduate students were sometimes
manipulated to cohabitation by indirect use of authority,
whereas some of the perpetrators are still employede.g. as
professors at amedical school. First time the patient had not
noticed any symptoms. Shortly thereafter she met her future
spouse, and aweek later was hospitalized to agynecology
department with the diagnosis of adnexitis. In the meantime,
the partner developed an acute urethritis with abundant purulent discharge. An acquainted physician prescribed them
an imported antibiotic available at some pharmacies at that
time but absent at the hospital. The patient took it in addition
to the hospital medication. The recovery was complete; there
were no relapses. Gn had not been diagnosed at the hospital,
which permitted the couple to evade some of the procedures
described below.
Treatment and tests of cure
Here follow several quotations from instructions issued
by the Ministry of Health[13], handbooks and manuals
that contained essentially the same recommendations. If
the signs of inflammation (discharge, threads in urine) persist longer than 57 days after acourse of antibiotics, if
even there are no gonococci in the urethral smears, atopical therapy was prescribed. In the introduction to the latest
instruction[1] it is noted that the topical treatment is indicated only in case of intolerance of antibiotics, but further in
the text it is pointed out that the topical therapy is indicated
also in case of atorpid or chronic course of the disease. The

. 8 (55) . , 2013 .
sexual contacts are to be treated in the same way as the patients with chronic Gn, also if no gonococci are found in the
smears[1]. Earlier instructions[3] and handbooks[4, 5] recommended the topical treatment also for acute Gn. The following modalities of the topical treatment were specified. Irrigation of the urethra with potassium permanganate solution,
instillations into the urethra of 0.251% silver nitrate solution with additional treatment of focal lesions with 1020%
silver nitrate through the urethroscope. Bouginage, urethral
massage on the urethroscope, and tamponade of the urethra
were recommended both for soft and hard infiltration (beyond
the acute phase) with subsequent smearing of the urethral
mucosa with ichtyol[4, 6]. Even in alatest edition it is specified (verbatim from Russian): In case of amixed or hard infiltration atamponade of the urethra should be performed
Colliculitis is treated by bouginage, etc.[7] There was also
research on Gn treatment with instillation into the urethra of
different substances such as gastric juice, oxygen foam, plant
decoctions[1113] etc.
The tests of cure, recommended to all patients, included
different kinds of provocations[1]. Chemical provocations in
men included instillations of silver nitrate solution into the
urethra, in women smearing of the urethral mucosa with
12% and of the cervical canal with 25% silver nitrate solution or Lugols iodine solution with glycerol. Mechanical
provocations included urethroscopy with amassage of urethra on the urethroscope[1]. If the symptoms reappear, also
in the absence of gonococci in the smears, the treatment and
the tests of cure must be repeated. The urethral discharge is
examined 24, 48 and 72 hours after the provocation; in the
absence of discharge, secretions of the prostate and seminal vesicles were examined. If no gonococci were found after
the first provocation, acombined provocation including urethroscopy was performed amonth later[1].
In women, the topical treatment was recommended for
fresh torpid and chronic Gn[1, 14]. However, some earlier instructions and monographs recommended topical
treatment (urethra washings, instillations) in women also
for acute Gn[35]. Bimanual examination[14] and urethroscopy were recommended in women for diagnostic purposes for both acute and chronic Gn, whereas technical difficulties of urethroscope insertion were mentioned[15].
For the chronic urethritis the following was recommended
among others: urethral instillations of silver nitrate solution,
smearing of the urethral and cervical mucosa with ichthyol
(a product of oil shail)[16] and Vishnevski liniment containing birch-tar[17] (possible carcinogenicity of these substances is aseparate topic); massage of the urethra on the
urethroscope, coagulation of inflamed paraurethral glands[6,
14, 16], coagulation of so-called pseudo-erosions (cervical
ectopy, ectropion). It should be commented here that diathermocoagulation (electrocautery), cryodestruction[18] or,
later, laser vaporization[19] of the cervical ectopy without
epithelial dysplasia were performed routinely because the ectopy as such was regarded as aprecancerous[16, 20, 21] or
apredisposing lesion. Cylindrical endocervical-type epithe-

Young Scientist . #8 (55) . August 2013

lium and glands within an ectopy were designated as pathological tissue that must be removed[22]. It occurred
under the motto of prophylaxis priority endorsed by the official directives of the Soviet time[21]. It was also speculated,
as ajustification for cryotherapy, that cervical pseudo-erosions are conductive to infertility and complications of pregnancy[23]. Routine electrocoagulation or cryodestruction of
cervical ectopy without epithelial dysplasia is at variance with
the scientific evidence, which does not support the hypothesis that treatment of the ectopy provides protection against
cervical cancer[24]. For example, cervical pseudo-erosions
were diagnosed at mass prophylactic checkups (so called dispenserizations) and treated by electro- or thermocautery[25,
26]; complications of such practice were noticed at alater
date[19, 27, 28]. It was recommended to start the treatment of the pseudo-erosions possibly early, whereas large
lesions were to be treated by diathermoconization (conization by means of an electrocautery electrode[16]), aprocedure associated with complications[29]. It should be noted
that according to the internationally used literature, in most
women during the reproductive period, the mucin-secreting
columnar epithelium of the endocervix is present on the cervical portio, forming the endocervical ectropion or cervical
ectopy.[30]
If at the first appointment no gonococci are found in the
urethral smears, aprovocation by means of silver nitrate solution treatment of the urethra and cervical canal was recommended[14]. The test of cure included urethroscopy[2].
The combined provocation in women was performed 710
days after the completed treatment, then repeated after the
next menstruation, and then again after 23 menstrual periods. The thrice-repeated combined provocations have been
recommended also for Gn in female adolescents and children[1113]. If the symptoms persist, but no gonococci are
found in the smears, the treatment as for chronic Gn is prescribed. In consequence of such approach, non-gonococcal
urethritis was sometimes treated by means of the topical procedures described above. For women with urogenital inflammatory conditions of unclear etiology some manuals recommended the same treatment as for chronic Gn[14].
Discussion
The methods of local treatment and provocation described
above were inherited from the pre-antibiotic epoch; they
were mentioned neither in the internationally used handbooks[3134] nor in review articles of that time[3538],
while the bouginage was recommended only for strictures [34].
Nevertheless the topical treatment and repeated tests of cure
could have been meaningful in some cases because of limited availability of modern antibiotics in the former SU. Fur-

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513

thermore it is not entirely clear for apathologist, which morphological equivalent corresponds to the hard infiltration,
where the bouginage was firmly recommended[2, 3]. Obviously, an inflamed and edematous mucosa can be traumatized, possibly contributing to the scarring and formation of
strictures. An overview of the earlier literature has shown that
similar methods were applied during the World War I, when
instrumentation, tamponades etc., were used for the treatment of Gn[39]. However, during the 1930s, agentler, observant tactics were advocated[40]. After the discovery of
sulfonamides[39] and especially of penicillin[41] the topical
treatment of Gn and the rigorous tests of cure have largely
lost their significance. Note that excessive instrumentation
might have contributed to the spread of blood-borne infections such as viral hepatitis. In some countriese.g. Egypt repeated use of needles in conditions of suboptimal sterilization is believed to have contributed to the high prevalence of
HCV infection[42].
The STI were under the state control in the former SU;
and corresponding instructions had legal validity. At the
same time, some STI experts understood obsoleteness of instructions and did not strictly adhere to them. Vague and incomprehensive recommendations in some handbooks[e.g.,
6, 11, 43, 44] left space for personal judgment. Under these
circumstances, personal judgment, sometimes coupled with
conscious or subconscious ideation of punishment, have
been obviously involved in some cases[45]. Some patients
witnessed that abortions and gynecological manipulations
were quite unpleasant, especially in women considered to
be socially unprotected or immoral. At the same time, cytological tests (Pap-smears) for precancerous lesions of the
cervix have been rare and not up to the international standards[46, 47], cervical cancer being therefore diagnosed relatively late[48].
Conclusion
Today the situation is changing. The instruction[1] is still
valid; but at least in central dermato-venerological dispensaries no mechanical provocations are performed, and instillations are done only occasionally. The tests for Chlamydia
and other pathogens are available today. Modern diagnostics
and therapies are offered by some private institutions. In the
newly edited Russian-language handbooks[49, 50], antibiotic therapy of Gn is extensively discussed, while the provocations and topical therapy are not mentioned at all. Hopefully,
this article will be only of historical interest in the near future.
What is important, however, is the ethical aspect mentioned
in the preceding paragraph, which pertains also to other fields
of medicine. Some other outdated therapies were discussed
in[51]; this topic is significant and should be further studied.

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