Urethritis

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.

• 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
• Risk factors
  • Unprotected sexual intercourse
  • Multiple sexual partners
  • History of other sexually transmitted infections ^[2]

References:^{[1][2][3][4][5]}

• 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.

• 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
• Identifying the causative pathogen
  • 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
• 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]

Because coinfection with other genitourinary tract infections is possible, the presence of one infection does not rule out urethritis.

• Acute cystitis
• Epididymitis
• Prostatitis

The differential diagnoses listed here are not exhaustive.

• 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!

• 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.

• Barrier protection during sexual intercourse
• Chlamydia and gonorrhea are reportable diseases.