Summary![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
Urethritis is an inflammation of the urethral mucosa that may be caused by various pathogens, most notably C. trachomatis, N. gonorrhea, and M. genitalium. Transmission primarily occurs as a result of unprotected sexual intercourse and it is especially prevalent in young, sexually active men. Patients typically present with urethral discharge, dysuria, and/or itching of the urinary meatus, although asymptomatic infections are common. Diagnostics include urine dipstick (pyuria, positive leukocyte esterase), staining of a urethral sample, and nucleic acid amplification testing of first-void urine. In gonococcal urethritis, Gram staining of the urethral swab demonstrates gram-negative diplococci and patients are treated with ceftriaxone; otherwise patients are treated with azithromycin or doxycycline for nongonococcal urethritis. Evaluation and treatment of all recent sexual partners is necessary to prevent recurrent infections.
Etiology![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
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Typically a sexually transmitted infection
- Gonococcal urethritis (GU): Neisseria gonorrhoeae
- Nongonococcal urethritis (NGU) [1]
- Chlamydia trachomatis (most common)
- Mycoplasma genitalium
- Trichomonas vaginalis
- Gram-positive cocci
- Herpes simplex virus types 1 and 2
- Adenovirus
- Coinfection is also common
- Most common in young, sexually active men
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Risk factors
- Unprotected sexual intercourse
- Multiple sexual partners
- History of other sexually transmitted infections [2]
References:[1][2][3][4][5]
Clinical features![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
- Dysuria
- Burning or itching of the urethral meatus
- Urethral discharge: purulent , cloudy, blood-tinged, or clear
- Initial hematuria
- General symptoms (e.g., fever, chills, or myalgia) are uncommon in urethritis and should raise suspicion for complications (see “Complications” below).
Urethritis, especially nongonococcal urethritis, may also be asymptomatic.
Diagnostics![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
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Confirming urethritis
- Urine dipstick; of first-void urine: positive leukocyte esterase
- Pyuria (≥ 5–10 WBC per high power field )
- Urethral smear: ≥ 2 leukocytes per oil immersion field
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Identifying the causative pathogen
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Gram stain of urethral swab or discharge :
- Gram-negative diplococci: GU
- Otherwise NGU
- Nucleic acid amplification testing (NAAT) of first-void urine without prior precleaning of the urethra for N. gonorrhea and C. trachomatis
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Gram stain of urethral swab or discharge :
- Offer to test for HIV, syphilis, and hepatitis B. [6]
Dysuria with urethral discharge and no organism on Gram staining of a urethral specimen suggest urethritis by C. trachomatis or M. genitalium.
References:[7]
Differential diagnoses![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
Because coinfection with other genitourinary tract infections is possible, the presence of one infection does not rule out urethritis.
The differential diagnoses listed here are not exhaustive.
Treatment![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
- The initial therapy is usually empiric and, according to prior distinction based on microscopic urethral specimen evaluation, divided into either a GU or NGU regimen. [1]
- Nongonococcal urethritis: single dose azithromycin or doxycycline PO for seven days
- Gonococcal urethritis: single dose of ceftriaxone IM [8]
- If T. vaginalis infection is suspected: metronidazole
- Patients should refrain from sexual activity for 1 week after initiation of therapy.
- All sexual partners from the 2 months prior to diagnosis should be notified, evaluated for urethritis, and offered empiric treatment.
- Repeat NAAT 3–6 months after completion of therapy.
Sexual partners should be treated simultaneously to avoid reinfection!
Complications![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
- Other genitourinary tract infections, e.g., cystitis, epididymitis, prostatitis, cervicitis, pelvic inflammatory disease
- Urethral stricture or stenosis
- Infertility
- Disseminated gonococcal infection
- Reactive arthritis
We list the most important complications. The selection is not exhaustive.
Prevention![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
- Barrier protection during sexual intercourse
- Chlamydia and gonorrhea are reportable diseases.