Symptoms of urethritis in men include: urethral discomfort, discharge and dysuria. Some men will report only dysuria or discomfort without discharge. Urethritis can be classified as gonococcal or non- gonococcal urethritis (NGU). Gonococcal urethritis is usually purulent.
NGU is caused most commonly by Chlamydia trachomatis and Mycoplasma genitalium. Herpes simplex virus, adenovirus and Trichomonas vaginalis are less common causes. Clinical features that suggest a viral aetiology include marked and persistent dysuria, an inflamed meatus and in the case of adenovirus concurrent conjunctivitis. Occasionally coliforms (such as E. coli acquired through anal sex) and bacteria found in the respiratory tract (such Haemophilus influenzae and Neisseria meningitidis from oral sex) will be detected as a cause of NGU. However, in the majority of cases of NGU no pathogen is identified. Some organisms can be present in the normal urethra and detection does not necessarily indicate infection or the need for treatment. These include Mycoplasma hominis and Ureaplasma urealyticum.
The following tests are useful in the assessment of NGU:
- Gram stain of urethral swab smear for urethral polymorphs and to detect Gram-negative intracellular diplococci indicative of gonorrhoea1
- Gonorrhoea testing either by culture and nucleic acid amplification test (e.g. PCR) of first void urine. Culture prior to treatment Is important for surveillance for gonorrhoea resistance.
- Nucleic acid amplification testing (e.g. PCR) of first void urine for chlamydia
- M. genitalium test if available
- Depending on the presentation, consider tests for: 2
- Adenovirus by urine or swab PCR
- Herpes by urine or swab PCR
- Trichomonas by wet preparation and culture from urethral swab OR urine PCR
1If available, the urethral Gram stain can provide information at the initial visit to assist with presumptive treatment of gonorrhoea. It also assists with the diagnosis of NGU: a raised urethral polymorph count will be present in the majority but not in about 30% of cases of urethritis where chlamydia and M. genitalium are detected. Therefore men with suspected urethritis based on risk and symptoms should be treated for NGU even where there are no polymorphs present on urethral smear.
2Suspect adenovirus and herpes if NGU persists despite antibiotic treatment. Adenovirus is typically associated with conjunctivitis. Herpes may be present in the absence of ulceration. Trichomonas is uncommon in Australian cities but should be suspected if there has been sex overseas or if NGU persists despite initial antibiotic treatment. Wet preparation for trichomonas from a urethral swab is insensitive: PCR is more sensitive.
- Doxycycline 100mg twice daily for one week
- Azithromycin 1 gram as a single dose
Add ceftriaxone 500mg in 2ml of 1% lignocaine by intramuscular injection if gonorrhoea is suspected or cannot be excluded e.g. if there is purulent discharge and risk factors for gonorrhoea such as sex overseas or men who have sex with men.
If a viral cause is suspected consider an antiviral for herpes: refer to MSHC treatment guideline for herpes. Antivirals will only benefit individuals with herpes urethritis and are not effective for adenovirus.
If trichomonas is suspected add tinidazole or metronidazole 2 gram as a single dose.
Female partners of men with NGU should be recalled for assessment and STI testing (regardless of the STI results of the man), as these women may have an increased risk for pelvic inflammatory disease. Symptomatic female partners should be managed according to their symptoms, see relevant MSHC treatment guidelines. Asymptomatic female partners should be treated presumptively with Doxycycline 100 mg twice daily for 7 days.
If a specific pathogen (chlamydia, gonorrhoea or M. genitalium) is confirmed on testing please refer to the relevant MSHC treatment guideline for specific treatment, advice on tests of cure or tests for re-infection, and management of sexual partners.
NGU usually improves within a few days but occasionally takes 2-3 weeks to resolve completely. With persistent symptoms consider:
- non-compliance with medication
- re-infection with a specific pathogen e.g. with chlamydia or M. genitalium from untreated sexual partner(s)
- M. genitalium resistant to doxycycline or azithromycin
- Testing for other less common causes of NGU: adenovirus, herpes and trichomonas
Men with persistent NGU who did not comply with the treatment regimen or who have been re-exposed to an untreated sex partner can be retreated with the same regimen.
In men who have persistent symptoms after treatment but without a confirmed pathogen or objective signs of urethritis, the value of extending the duration of antimicrobials has not been demonstrated. Urologic examinations usually do not reveal a specific aetiology. Underlying anxiety may be present and if present should be discussed.
The content of these treatment guidelines is for information purposes only. The treatment guidelines are generic in character and should be applied to individuals only as deemed appropriate by the treating practitioner on a case by case basis. Alfred Health, through MSHC, does not accept liability to any person for the information or advice (or the use of such information or advice) which is provided through these treatment guidelines. The information contained within these treatment guidelines is provided on the basis that all persons accessing the treatment guidelines undertake responsibility for assessing the relevance and accuracy of the content and its suitability for a particular patient. Responsible use of these guidelines requires that the prescriber is familiar with contraindications and precautions relevant to the various pharmaceutical agents recommended herein.
Last Updated January 2017