Types
Urethritis can be classified as either:
- gonococcal
- non-gonococcal urethritis (NGU)
Causes
Gonococcal urethritis
Gonococcal urethritis is caused by the bacteria Neisseria gonorrhoeae
Non-gonococcal urethritis
NGU is most commonly caused by Chlamydia trachomatis or Mycoplasma genitalium.
Herpes simplex virus, adenovirus and Trichomonas vaginalis are less common causes.
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.
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.
Clinical presentation
Symptoms of urethritis in men include:
- urethral discomfort
- discharge
- dysuria
Some men will report only dysuria or discomfort without discharge.
Gonococcal urethritis is usually purulent.
Clinical features that suggest a viral aetiology include:
- marked and persistent dysuria. Consider herpes or adenoviral urethritis when dysuria is severe.
- an inflamed meatus
- concurrent conjunctivitis (in the case of adenovirus)
Diagnosis
| Test | Site/ specimen | Comments |
|---|---|---|
|
NAAT Nucleic acid amplification test |
First pass urine: does not have to be early morning specimen, time since previous urination is irrelevant or Urethral swab smear: swab of discharge is sufficient, does not have to be a urethral swab |
Test for gonorrhoea, chlamydia and Mycoplasma genitalium. Suspect 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. |
| Gram stain | Urethral swab smear |
Urethral polymorphs and gram-negative intracellular diplococci are indicative of gonorrhoea. May also assist 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 Mycoplasma 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. |
| Culture | Urethral swab smear |
Test for gonorrhoea. Culture prior to treatment is important for surveillance for gonorrhoea resistance. |
Management
Treat empirically. Don’t wait for results.
Index patient
| Condition | Recommended | Comments |
|---|---|---|
| Non-gonococcal urethritis | Doxycycline 100 mg PO, twice daily for 1 week |
Alternative is azithromycin 1 g as a single dose. If trichomonas is suspected add tinidazole or metronidazole 2 gram as a single dose. |
| Non-gonococcal urethritis - viral cause suspected | Consider antiviral for herpes | Antivirals will only benefit individuals with herpes urethritis and are not effective for adenovirus. |
| Gonococcal urethritis |
If patient presents with thick, purulent discharge and gonorrhoea is suspected. Ceftriaxone 500 mg in 2 ml of 1% lignocaine IM, stat PLUS Azithromycin 1 g PO, stat |
Refer to gonorrhoea treatment guidelines |
Follow up
If a specific pathogen is confirmed on testing, refer to the relevant treatment guideline for specific treatment, advice on tests of cure or tests for reinfection, and management of sexual partners:
- Chlamydia treatment guidelines
- Gonorrhoea treatment guidelines
- Mycoplasma genitalium treatment guidelines
- Trichomonas treatment guidelines
NGU usually improves within a few days but occasionally takes 2-3 weeks to resolve completely. With persistent symptoms, consider:
- non-compliance with medication
- reinfection with a specific pathogen such as chlamydia or Mycoplasma genitalium from untreated sexual partner(s)
- Mycoplasma 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.
Contact tracing & partner management
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.
Clinical education: Urethral symptoms in men
This presentation on urethral symptoms in men includes discussion on clinical presentations and case studies, laboratory confirmation and treatment options.
Disclaimer
We recognise that gender identity is fluid. In our treatment guidelines, the words and language we use to describe genitals and gender are based on the sex assigned at birth.
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.