The infection may progress to epididymitis, prostatitis or vesiculitis. Epididymitis is commonly unilateral. Infertility is an important sequel. Persistent or recurrent urethral symptoms may occur, often without discharge or any demonstrable microorganisms.

Most women with cervicitis present as the symptom-free contacts of men with NGU. Cervicitis may, however, present with vaginal discharge, symptoms of urethritis or lower abdominal pain. Speculum examination may reveal a cervical discharge and an inflamed cervix but the cervix commonly appears normal.

The most important complication of gonorrhoea or NGC is the spread to the upper genital tract causing endometritis, salpingitis and pelvic inflammatory disease (see chapter 6). Late sequelae are ectopic pregnancy and infertility.
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Causative organisms

Urethral and cervical inflammation are common presentations of STD. The most common STDs manifested by urethritis or cervicitis are gonorrhoea caused by Neisseria gonorrhoeae and non-gonococcal urethritis (NGU), and non-gonococcal cervicitis (NGC) caused by Chlamydia trachomatis. Other causes of these presentations include the genital mycoplasmas, candidiasis, trichomoniasis and herpes simplex infection.
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“I must say that I think of kissing you and of how sweet the kisses would taste, and I imagine you becoming wet—not because I’m such a macho man, but because I have won your trust and respect. I see you beaming at me, your intelligent eyes alive again. . . .*

The husband observes his wife throughout all this. When he is pretty sure she has become “hooked” by the Mystery Lover (let’s say he catches her looking intently for mail), then he writes a final letter:

“Dear Lady, I believe we are approaching the moment of truth. I don’t think I’m going to be able to restrain myself from revealing myself to you. Every day, every hour, I imagine our meeting. I know you’ll be gentle—even if you don’t like me, even if you don’t feel the same way I do. All I ask is that you treat me with respect. I have only tried to love you. If you can’t return that love, I’ll understand and go away.—Your Mystery Lover.”

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“No. I told you, I’m doing it for me. I like doing this, and I’m doing it for me. Okay?”

“You do have nice breasts. Especially your left one. Not that I’m discriminating against your right breast. May I squeeze it?”

“Why must you ask me everything?”

“I don’t want to be a sexist.”

“You’re not being a sexist.”

“But I’m using you as a sex object, aren’t I?”

“In a way.”

“Doesn’t that make me a sexist?”

“Not necessarily. Would you just kiss me and shut up?”

“All right. How was that?”

“That was great. Kiss me again.”

“Like that?”

“Yes.”

“You don’t think my tongue is a bit arrogant?” “Not at all.”

“Thanks. Do you mind if I put my hand down there?”

“No, I don’t mind.”

“You don’t think it’s rude?”

“No, it’s not rude.”

“You don’t feel sexually exploited?”

“Not really.”

“And if I stick my finger inside you, how would you feel about that?” “Please do.”

“You wouldn’t feel finger-raped?” “Just do it.”

“How about two fingers? Would two fingers constitute rape?”

“Try three.”

“Would you like to get on top now?” “Why?”

“I’d like to engage in nonsexist intercourse with you.”

“Just put it in!”

“But I’m lying on top of you.”

“I know. Put it in! Put it in!*

“All right—if you insist. There! Are you all right?”

“Yes, I’m fine.”

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Setting: A dwelling in the woods.

Aim: Appeal to husband’s angry self and wife’s feeling that she is married to a beast—but give her a different way of relating to that beast, designed to transform both him and her.

Game Plan: This game is for angry couples consisting of a husband who has been continually accused of being—and may actually be—a beast, bastard, abuser, or (if possible) worse; and a wife who despises him and despairs of his ever changing. Like other couples, they will have been locked into this ritualized way of relating, she hurling insults at him in an attempt to browbeat or guilt-trip him into being good, and he defying her by being even more beastly.

If possible, the couple should play this game mainly in a house or cabin in the woods. (If they can get hold of a castle, so much the better.) Once in the woods, the game should loosely follow the story line of the famous children’s story it is named after. The wife wanders into the woods one day, dressed in a virginal white gown. She encounters the Beast.

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She: (As he kisses her.) “What are you doing?”

He: “I’m not sure.”

She: “I think it’s called kissing.”

He: “That’s right. Kissing. I knew there was a name for it.” She: “Did I say you could kiss me?” He: “No. But you didn’t say I couldn’t.” She: “What are you doing with your hands?” He: “I don’t remember.”

She: “But you’re doing it right now. How can you not remember it?”

He: “I have a very bad memory sometimes.” She: “I don’t know if I want to do this.” He: “I don’t know either.”

She: “I don’t know if I’ll respect myself in the morning.” He: “The morning’s a long way off.” She: “What did you say your name was?” He: “Masterson. Hank Masterson.”

She: “Glad to meet you, Hank. What do you do, Hank?”

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When the discharge is examined under the microscope, the individual trichomonads can be seen. Often, bacterial vaginosis occurs with trichomoniasis, and this can be seen under the microscope as well. The protozoans move in a characteristic way that is apparent under the microscope. Therefore microscopic examination is the oldest and still the most common method to evaluate for trichomonas infection, although it may miss infection in about 20-30 percent of cases. If the diagnosis is in question, cultures can be trichomonads.

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For a Pap smear, a sample of cells is taken from the surface of the cervix and then sent to a laboratory to be examined by a pathologist or technician for abnormalities. Newer evaluation techniques, such as the use of computers to help diagnose abnormal Pap smears, are being employed by some laboratories. Improved Pap collection techniques are also being studied. Currently cells are rubbed onto a slide, preserved with a fixative, and sent to the laboratory for review. A newer technique involves placing them into a solution before sending them, thus allowing the cells to better retain their shape and therefore making readings more accurate.

Health care providers must take an adequate specimen, so that there are enough cells for an accurate evaluation. This step is essential, and a woman should feel entirely free to ask her health care provider about it. This will be indicated on the result of the Pap smear that the laboratory issues. If an adequate specimen was not obtained, a repeat smear will be necessary.

Two types of cells are seen on the cervix: the columnar cells line the inside of the cervix and are also found in the uterus; the squamous cells are on the outside of the cervix and are also found in the vagina. They meet on the cervix in an area called the transformation zone or squamocolumnar junction, which may be inside the cervix in a woman over the age of thirty or on the outside of the cervix in a younger woman or a woman taking birth control pills. Cells for the Pap smear are taken from this area, since these rapidly dividing cells have the highest risk for changes that can lead to cervical cancer.

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