Urethritis

Key Features

• 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

Clinical Findings

• 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

Diagnosis

• 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

Treatment

• 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)