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Basic Information ⬇

Author: Lauren C. Roby, MD

Definition

Urethritis is a well-defined clinical syndrome manifested by dysuria, a urethral discharge, or both.

Synonyms

  • Gonococcal urethritis
  • GCU
ICD-10CM CODE
A54.00Gonococcal infection of lower genitourinary tract, unspecified
Epidemiology & Demographics

  • •Urethritis commonly is divided into two major categories based on etiology: Gonococcal urethritis (GCU, Neisseria gonorrhoeae spp.) and nongonococcal urethritis (NGU, all other pathogens, most commonly Chlamydia trachomatis and Mycoplasma genitalium).1
  • •This differentiation is based historically on N. gonorrhoeae’s easy visualization on Gram stain as gram-negative, kidney-shaped diplococci or laboratory diagnosis by nucleic acid amplification testing (NAAT).
  • •Approximately 4 million people in the U.S. will be affected by urethritis each year, with gonococcal urethritis accounting for over 600,000 of them.2
Physical Findings & Clinical Presentation

  • •Symptoms of GCU: Dysuria is the most common chief complaint in patients with GCU, which is often accompanied by discharge and pruritus. Acute-onset purulent discharge is a hallmark of this infection. Additionally, meatal edema and urethral tenderness to palpation may occur. However, many patients with GCU may be asymptomatic, especially women.2
  • •GCU may spread to other parts of the genitourinary system. Prostatic involvement can cause urinary frequency, urgency, and nocturia and may present with mucopurulent discharge. Epididymal involvement can result in unilateral testicular pain and edema.
  • •Time frame: The incubation period of GCU is variable but is commonly 4 to 7 days. Without treatment, urethritis will persist for 3 to 7 wk, with 95% of men becoming asymptomatic after 3 mo.
  • •Complications: Periurethritis leading to urethral stenosis can occur. Additionally, disseminated infection can lead to tenosynovitis and arthritis. Rarely, hepatitis, myocarditis, endocarditis, and meningitis can occur.

Diagnosis ⬆ ⬇

Differential Diagnosis (Table 1

  • •NGU
  • •Herpes simplex virus

TABLE 1 Etiology of Urethritis

InfectiousNoninfectious
Sexually Transmitted InfectionsVasculitides
  • Neisseria gonorrhoeae
  • Chlamydia trachomatis
  • Trichomonas vaginalis
  • Herpes simplex virus type 2
  • Mycoplasma spp.
  • Reiter syndrome
  • Erythema multiforme
  • Kawasaki disease
Nonsexually Transmitted InfectionsMechanical
  • Staphylococcus saprophyticus
  • Enterobacteriaceae
  • Gardnerella vaginalis
  • Streptococcus spp.
  • Enterobius vermicularis
  • Masturbation
  • Foreign body
  • Trauma
  • Dysfunctional elimination
Chemical
  • Soaps
  • Detergents
  • Drugs

From Cherry JD: Feigin and Cherry’s pediatric infectious diseases, ed 8, Philadelphia, 2019, Elsevier.

Laboratory Tests

  • •Urethritis is diagnosed when a symptomatic male has any of the following characteristics:
    1. 1.Mucopurulent/purulent discharge on examination (Fig. E1)
    2. 2.Urethral swab showing:
      1. a.≥2 white blood cells (WBCs) per field in high-prevalence settings or ≥5 WBCs per field in lower prevalence settings
      2. b.Gram-negative diplococci seen within WBCs (Fig. E2)
  • •Urethritis can be diagnosed by culture or by NAATs.3 The performance of NAATs with respect to overall sensitivity, specificity, and ease of specimen transport is better than that of any of the other tests available for the diagnosis of chlamydial and gonococcal infections. NAATs should be used as first line to detect Chlamydia and gonorrhea, except in cases of child sexual assault, rectal and oropharyngeal infections in prepubescent girls, and when evaluating a potential gonorrhea treatment failure, in which case culture and susceptibility testing might be required.
  • •Of note, a presumptive diagnosis can be made without the earlier diagnostic criteria for males who are at high risk for sexually transmitted infections (i.e., more than one partner and >25 yr) and who are unlikely to return for follow-up. In these patients, empirical treatment to cover both gonococcal and nongonococcal infections can be given before the results of a nucleic acid amplification test (NAAT).
  • •If Gram staining is available, it is indicated and should be performed with modified Thayer-Martin media, as this helps differentiate GCU from NGU.
  • •NAATs have largely replaced culture in many health care settings. They are not more sensitive than culture for detecting N. gonorrhoeae in cervical or urethral specimens; however, they have specificities of >99% and retain sensitivity when used to test first-catch urine.
  • •For culture and susceptibility testing: Rayon, Dacron, or calcium alginate tips with plastic or wire shafts should be used (not cotton-tipped swabs, which are bactericidal). A swab of the urethra should be performed within 2 to 4 h after voiding to prevent bacterial washout with urination. Collect cultures of the pharynx and rectum when indicated for concomitant Chlamydia testing on all patients.
  • •Concomitant serologic testing for syphilis and HIV infections should be offered to all patients.

Figure E1 Purulent urethral discharge from a man with gonococcal urethritis.

(From Bennett JE et al: Mandell, Douglas, and Bennett’s principles and practice of infectious diseases, ed 9, Philadelphia, 2020, Elsevier.)

Figure E2 Gram stain of urethral exudate from a man with gonorrhea.

Several neutrophils contain many gram-negative cell-associated diplococci.

(From Bennett JE et al: Mandell, Douglas, and Bennett’s principles and practice of infectious diseases, ed 9, Philadelphia, 2020, Elsevier.)

Treatment ⬆ ⬇

Treatment (Table 2)

Uncomplicated adults and adolescents with GCU:

TABLE 2 Recommended Treatment of Gonococcal Infections

Age GroupInfectionTreatment RegimenLength of Therapy
NeonatesOphthalmia neonatorumCeftriaxone* 25-50 mg/kg IV or IM OR cefotaxime 100 mg/kg IV or IMOnce
Disseminated infection
Scalp abscess
Meningitis		Ceftriaxone 25-50 mg/kg IV or IM every day
OR OR cefotaxime 25-50 mg/kg IV or IM q8-12h†		7 days
MeningitisCeftriaxone 25-50 mg/kg IV or IM every day
OR cefotaxime 25-50 mg/kg IV or IM q8-12h		10-14 days
Endocarditis
  • Ceftriaxone 25-50 mg/kg IV or IM every day
  • OR cefotaxime 25-50 mg/kg IV or IM q8-12h
Minimum 28 days
Children ≤45 kg
  • Pharyngeal infection
  • Anorectal infection
  • Urogenital infection
Ceftriaxone 25-50 mg/kg IV or IM (max 500 mg)Once
ConjunctivitisCeftriaxone 50 mg/kg IM (max 1 g) plus consider lavage of infected eye with saline solutionOnce
Disseminated infection
Septic arthritis		Ceftriaxone 50 mg/kg IV or IM every day (max 1 g daily)7 days
MeningitisCeftriaxone 50 mg/kg IV or IM q12-24h (max 4 g daily)10-14 days
EndocarditisCeftriaxone 50 mg/kg IV or IM q12-24h (max 4 g daily)Minimum 28 days
Adults, adolescents, and children >45 kg
  • Pharyngeal infection
  • Anorectal infection
  • Urogenital infection
Ceftriaxone 500 mg IM (or 1 g IM for persons ≥150 kg)Once
ConjunctivitisCeftriaxone 1 g IM plus consider lavage of infected eye with saline solutionOnce
Disseminated infection
Septic arthritis		Ceftriaxone 1 g IV or IM every day7 days
MeningitisCeftriaxone 1-2 g IV q12-24h10-14 days
EndocarditisCeftriaxone 1-2 g IV q12-24hMinimum 28 days

IM, Intramuscularly; IV, intravenously; max, maximum; PO, orally.

* Ceftriaxone should be administered cautiously to neonates with hyperbilirubinemia, especially those born prematurely. Cefotaxime can be administered for those neonates unable to receive ceftriaxone because of simultaneous administration of IV calcium. Consult neonatal dosing references.

†Dose or dosing frequency changes after postnatal age >7 days of life: consult neonatal dosing references.

From Wangu Z, Hsu KK: Neisseria gonorrhoeae. In Long SS et al (eds): Principles and practice of pediatric infectious diseases, ed 6, Philadelphia, 2023, Elsevier, Table 126.1.

Alternative regimens if ceftriaxone is not available:

Regimen for infants and children weighing ≤45 kg:

Follow-Up

It is imperative to appropriately counsel patients on the avoidance of intercourse or use of barrier protection until a cure has been obtained and sexual partners have been evaluated. Once treated, patients should be advised to abstain from sex for 7 days.

In cases of suspected cephalosporin treatment failure, clinicians should obtain relevant clinical specimens for culture and antimicrobial susceptibility testing, consult an infectious disease specialist or STD clinical expert (https://www.stdccn.org/) for guidance in clinical management, and report the case to the Centers for Disease Control and Prevention (CDC) through state and local public health authorities within 24 h. Health departments should prioritize notification and culture evaluation for the patient’s sex partner(s) from the preceding 60 days for those with suspected cephalosporin treatment failure or persons whose gonococcal isolates demonstrate reduced susceptibility to cephalosporins.

A test of cure (repeat testing 1 to 3 wk after initial treatment) is unnecessary for persons with uncomplicated GCU treated with any of the recommended or alternative regimens. However, for persons with pharyngeal gonorrhea, a test of cure is recommended, using culture or NAATs 7 to 14 days after initial treatment, regardless of the treatment regimen.

Alternatively, repeat testing 3 mo after treatment is recommended for all persons diagnosed with GCU, regardless of treatment, because reinfections rates are so high: Reinfection within 12 mo ranges from 7% to 12% among persons previously treated for gonorrhea. If retesting at 3 mo is not possible, clinicians should retest within 12 mo after initial treatment.

Chronic Infection

  • •Reinfection is the most common cause of recurrence.
  • •Repeat swab and culture of the urethra, pharynx, and rectum (where applicable) are mandatory.
  • •Persistence of N. gonorrhoeae by smear or culture requires treatment for N. gonorrhoeae.
  • •Postgonococcal urethritis (PGU): Persistence of polymorphonuclear cells (PMNs) in the absence of gram-negative intracellular diplococci. This occurs when GCU is treated with a regimen that is ineffective against coincident nongonococcal infection; it represents NGU after GCU and should be treated as such.
  • •For Doxycycline pre-exposure prophylaxis (PEP), please refer to "Gonorrhea" chapter.

Pearls & Considerations ⬆ ⬇

Comments

  • •Partner notification: The names and contact information of sexual partners should be gathered at the time of diagnosis and referred to the health department, or the patient can notify the contact directly.
  • •Expedited partner treatment is recommended by the CDC and is approved in most states. This consists of giving prescriptions to the infected patient for their partner(s) who has not been evaluated by a physician and for whom health department partner-management strategies are impractical or unavailable.1
  • •On examination of the urethral smear, the presence of small numbers of PMNs provides objective evidence of urethritis. The complete absence of PMNs on a urethral smear argues against urethritis. If in addition to the PMNs there are gram-negative, intracellular diplococci, the diagnosis of gonorrhea is established.
Related Content

  • Gonococcal Urethritis (Patient Information)
  • Gonorrhea (Related Key Topic)

Reference(s) ⬆

  1. Centers for Disease Control and Prevention: Sexually transmitted infections treatment guidelines, 2021. Available at https://www.cdc.gov/std/treatment-guidelines/default.htm. Accessed August 16, 2024.
  2. Young A et al: Urethritis. [Updated 2024 Apr 26.] In: StatPearls [Internet]. Treasure Island, 2024, StatPearls Publishing. Available at https://www.ncbi.nlm.nih.gov/books/NBK537282/
  3. Centers for Disease Control and Prevention: Sexually transmitted diseases. Available at https://www.cdc.gov/std/default.htm. Accessed September 12, 2022.