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Key Features

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  • Common causative pathogens in males

    • Neisseria gonorrhoeae

    • Chlamydia trachomatis

    • Trichomonas vaginalis

    • Herpes simplex virus

    • Ureaplasma urealyticum

    • Mycoplasma genitalium

  • Coliforms may cause urethritis in males practicing insertive anal intercourse

  • Mechanical manipulation or contact with irritants can also cause transient urethritis

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Clinical Findings

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  • Frequently asymptomatic in both males and females

  • In females, symptoms of a urinary tract infection and "sterile pyuria" (no enteric bacterial pathogens isolated) are often present

  • In males,

    • Clear or purulent discharge from the urethra, dysuria, or urethral pruritus commonly present

    • Hematuria and inguinal adenopathy can occur

  • Most infections caused by C trachomatis and T vaginalis are asymptomatic, while 70% of males with M genitalium and 23–90% with gonococcal urethritis are symptomatic

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Diagnosis

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  • Positive leukocyte esterase test on first-void urine or microscopic examination of first-void urine demonstrating more than 10 white blood cells (WBCs) per high-power field is suggestive of diagnosis

  • Gram stain of urethral secretions demonstrating more than 5 WBCs per high-power field is also suggestive

  • Gonococcal urethritis is established by documenting the presence of WBCs containing intracellular gram-negative diplococci

  • Urethral swab or first-void urine for nucleic acid amplification testing should be sent to the laboratory to detect N gonorrhoeae and C trachomatis

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Treatment

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  • C trachomatis urethritis

    • Recommended

      • Azithromycin, 1 g orally as single dose or

      • Doxycycline, 100 mg orally twice a day for 7 days

    • Alternatives

      • Erythromycin, 500 mg orally four times a day for 7 days or

      • Erythromycin ethylsuccinate, 800 mg orally four times a day for 7 days or

      • Levofloxacin 500 mg orally once daily for 7 days or

      • Ofloxacin, 300 mg orally twice a day for 7 days

  • T vaginalis urethritis

    • Recommended

      • Metronidazole, 2 g orally as single dose or

      • Tinidazole, 2 g orally as single dose

    • Alternative: Metronidazole, 500 mg orally twice a day for 7 days

  • Nongonococcal, nonchlamydial urethritis

    • Recommended

      • Azithromycin, 1 g orally as single dose or

      • Doxycycline, 100 mg orally twice a day for 7 days

    • Alternatives

      • Erythromycin base, 500 mg orally four times a day for 7 days or

      • Erythromycin ethylsuccinate, 800 mg orally four times a day for 7 days or

      • Levofloxacin, 500 mg orally once daily for 7 days or

      • Ofloxacin, 300 mg orally twice a day for 7 days

  • Gonococcal urethritis

    • Recommended: Ceftriaxone, 250 mg IM as single dose plus azithromycin, 1 g orally as single dose

    • Alternative

      • Cefixime, 400 mg orally twice a day or

      • Cefixime suspension, 400 mg by suspension (200 mg/5 mL) orally twice a day plus azithromycin, 1 g orally as single dose

  • Recurrent or persistent urethritis

    • Metronidazole, 2 g orally as single dose or

    • Tinidazole, 2 g orally as single dose plus azithromycin, 1 g orally as single dose (if not used for initial episode)

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