About the treatment of gonorrhea in the former Soviet Union

The treatment of gonorrhea in the former Soviet Union is discussed in this report with the examples of three typical cases from the 1980s. Some outdated methods of topical treatment and provocation, not used in other countries at that time, are listed. Being aware of lengthy and unpleasant treatment methods, high-risk groups avoided the government-run dermato-venereological dispensaries (prevention and treatment centers) and often practiced self-treatment, which, in some cases, contributed to the spread of STI. The future is therefore optimistic: the growing Russian economy today enables access to modern equipment and new methods of treatment, and broadening international cooperation has attracted foreign expertise into the country.


Report
Some aspects of gonorrhea (Gn) treatment in the former Soviet Union are discussed in this letter in the example of three typical cases from the 1980s. The facts follow: Case 1. A lawyer, about 30 years old, who spent much time on study and work, was infected with Gn. In compliance with the law at the time, he went to a dermatovenereological dispensary (prevention and treatment center), where he was registered and treated according to the instructions issued by the health care authorities [1,2]. The patient said that the treatment had been lengthy and unpleasant and subsequently would never return to the dispensary. Case 2. A bachelor, about 35 years old, awarded himself a next highest military rank whenever he contracted Gn; in this way he became a generalissimo (which demonstrates widespread irresponsibility: the patient was, in fact, proud of his "career"). He never visited the dermatovenereological dispensary and treated himself with intramuscular injections of Bicillin (benzathine benzylpenicillin).
High-risk groups were informed about methods applied in the dispensaries and avoided them. They also had general knowledge about how to treat Gn with antibiotics; more responsible individuals administered themselves regular courses of Bicillin injections, but others treated themselves incompletely and continued spreading infection. These cases show that the society de facto permitted many infected people, including those from higher classes, to spread sexually transmitted infections (STI). Case 3. A female student was infected with Gn in a students' dormitory. Initially, no symptoms were noticed. Shortly thereafter, she met her future husband and a week later was admitted to a gynecology department with a diagnosis of "adnexitis"; while the fiancée developed an acute urethritis with a massive discharge of creamy pus. An acquainted physician gave them several tablets of an overseas antibiotic (unavailable in Russian hospitals at that time), which ended their disease; there were no relapses. Bacteriology laboratories in hospitals were sometimes unreliable, which allowed the couple to avoid some of the procedures described below.
Following are several citations from official manuals legally in force at that time [1,2] and from standard publications such as the Medical Encyclopedia [3] and the Manual of Dermatovenereology [4]: "If inflammation persists 5-7 days after a course of antibiotic therapy, even if gonococci have disappeared from the urethral smears, topical therapy is recommended." [3] In the introductory part of the latest manual available [1], it is stated that topical therapy was indicated only in case of intolerance of antibiotics, but further in the text it recommended them for torpid and chronic Gn, and sexual contacts were to be treated in the same way as the patients with chronic Gn, even if no gonococci had been found in the smears [1].
Some earlier handbooks recommended topical treatment for all patients with Gn [5]. Among other things, topical therapy included the following: In case of a "soft" infiltration,  [7]. The test of cure included urethroscopy [1]. As a test of cure for women, a combined provocation 7-10 days after the treatment was applied with a repeat treatment during the next menstrual period, and then again after 2-3 periods. If clinical symptoms were persisting, but no gonococci were found, the same treatment as for chronic Gn was recommended [7]. As a consequence of this approach, non-gonococcal inflammatory conditions were sometimes treated by the topical procedures (among them must have been cases of chlamydia infection because of its relatively high incidence) [8]. If no clinical symptoms were present, and no gonococci were found at two months after the last treatment, a registration with the dispensary is cancelled.
The methods of topical therapy and provocations, inherited from the pre-antibiotic era, were mentioned neither in foreign handbooks of that time [9,10] nor in review articles [11][12][13][14]; while bouginage was recommended only for strictures [10]. Nevertheless, topical therapy and repeated tests of cure were probably useful in some cases because of the limited availability of modern antibiotics in the former Soviet Union. For a pathologist, it is not entirely clear which morphological substrate corresponds to the "firm infiltration," where bouginage was strongly recommended [1,3]; but it is obvious that inflamed and edematous mucosa can be traumatized, which might contribute to scarring and formation of strictures. At the same time, diagnostic tests for non-gonococcal urethritis, such as direct immunofluorescence for chlamydia infection, were unavailable to the public until the late 1980s or the 1990s. The outdated approach has persisted partly due to the limited access to foreign professional literature [15].
The treatment of venereal diseases, including gonorrhea, was under strict official control in the USSR. Challenging the guidelines, that had remained unchanged for a long time, was equivalent to challenging legal instructions and was difficult. Some STI experts understood that the instructions were obsolete. Others witness that the guidelines were not always strictly adhered to; in other words, some personal judgment was involved. Apparently, a psychological mechanism, including conscious or subconscious ideation of punishment, on the part of medical personnel possibly fueled in some cases by personal frustrations, obesity etc., played a role in it. Some patients witnessed that abortions and gynecological manipulations, especially in women considered to be socially unprotected or "immoral," had been quite unpleasant. There are no reliable statistics, but the abortion rate in the former Soviet Union was reported to be the highest in the world, which was caused not only by insufficient availability of modern contraception [16] but also by irresponsibility of some men (the author of this letter not excluded, which he today sincerely regrets). Alcohol misuse was a contributing factor [17]. Of oral contraceptives, mainly Infecundin and Bisecurin (both produced in Hungary), were known in the 1980s; these pills required a prescription and were used infrequently. Condoms were of poor quality then: imported ones were scarce, while the Soviet-made condoms were notoriously thick and at the same time tore easily. There may have been a policy in place aimed at an increase of the birth rate [18]. Furthermore, as mentioned above, cervical "pseudo-erosions" (endocervical ectopia, ectropion), independent of the presence of epithelial dysplasia, have been treated with electrocoagulation. This practice is at variance with scientific evidence that does not support the hypothesis that coagulation of an ectopy provides protection against cervical cancer [19].
Today, however, the attitude is changing. The instructions Tests for chlamydia and other pathogens are available today.
Some private institutions offer modern diagnostics and treatment. In the recently edited Russian-language manuals, antibiotic therapy of Gn is broadly discussed, while the provocations and topical treatment are not mentioned at all [20,21].
The future is therefore optimistic: the growing Russian economy today enables access to modern equipment and new methods of treatment, and broadening international cooperation has attracted foreign expertise into the country.

Summary
The treatment of gonorrhea in the former Soviet Union is discussed in this report with the examples of three typical cases from the 1980s. Some outdated methods of topical treatment and provocation, not used in other countries at that time, are listed. Being aware of lengthy and unpleasant treatment methods, high-risk groups avoided the government-run dermato-venereological dispensaries (prevention and treatment centers) and often practiced self-treatment, which, in some cases, contributed to the spread of STI. The future is therefore optimistic: the growing Russian economy today enables access to modern equipment and new methods of treatment, and broadening international cooperation has attracted foreign expertise into the country.