- Symptoms usually develop 1–2 wk after exposure but can take up to 4–6 wk.
- Initially minimal or absent in many patients
SIGNS AND SYMPTOMS 
- Urethral discharge, dysuria
- Cloudy 1st portion of urine
- Pyuria
- Inguinal adenopathy may be present.
History
- Color, consistency, and quantity of urethral discharge.
- Associated symptoms of dysuria, urgency, frequency, hematuria, and hematospermia
- Risk factors for STDs:
- Recent new partner or multiple sexual partners
- Symptoms of partner
- Anal/oral practices
- Young age
- Lower socioeconomic status
Physical Exam
- Urethral discharge
- Staining on undergarments
- Meatal crusting
- Genital lesions
- Lymphadenopathy
- Palpate testes, epididymis, and spermatic cord:
ESSENTIAL WORKUP
- Urethral swabs for N. gonorrhoeae and Chlamydia species will confirm the diagnosis.
- DNA amplification, DNA probe, and testing of urine specimens via polymerase chain reaction (PCR) have shown good sensitivity and are acceptable tests
- A rapid plasma regain (RPR) or Venereal Disease Research Laboratory (VDRL) should be drawn because STDs frequently occur together.
- An HIV test should also be offered to the patient.
DIAGNOSIS TESTS & INTERPRETATION
Lab
- Gram stain and cultures from urethral swabs should be reviewed when the patient is re-evaluated by his or her physician after treatment.
- DNA amplification (ligase chain reaction [LCR] or PCR) can be used on 1st-void urine or urethral swab:
- Equal efficacy for diagnosing N. gonorrhoeae and Chlamydia species
- UA should be performed after urethral swabs to identify UTIs.
DIFFERENTIAL DIAGNOSIS
Pediatric Considerations
- Urethritis in children should arouse suspicion of child abuse.
- Because N. gonorrhoeae infects the entire vaginal vault in prepubescents, a speculum exam is not required:
- External exam and cultures are sufficient.
- Potential complications:
[Outline]
INITIAL STABILIZATION/THERAPY
Most patients will not require significant stabilization.
ED TREATMENT/PROCEDURES
- Treatment may be given empirically based on probable etiology.
- Patients should be treated for both N. gonorrhoeae and C. trachomatis.
MEDICATION
- Gonorrhea:
- Chlamydia:
- Azithromycin 1 g (peds: 10 mg/kg day 1, 5 mg/kg days 2–5) PO once
- Doxycycline 100 mg PO BID for 7 days
- Erythromycin base 500 mg (peds: 40 mg/kg/d div. QID) PO QID for 7 days
- Erythromycin ethyl succinate 800 mg (peds: 30–50 mg/kg/d div. QID) PO QID for 7 days
- Levofloxacin 500 mg PO QD for 7 days
- Ofloxacin: 300 mg PO BID for 7 days
- M. genitalium:
- Azithromycin 1 g (peds: 10 mg/kg day 1, 5 mg/kg days 2–5) PO once
Pregnancy Considerations
- Fluoroquinolones and doxycycline are contraindicated in pregnancy
- Azithromycin is safe and effective
- Repeat testing 3 wk after treatment is recommended to ensure cure.
ALERT
Increasing incidence of quinolone-resistant N. gonorrhoeae nationwide.
[Outline]
DISPOSITION
Admission Criteria
Patients should not require admission for urethritis unless there are other complaints or infections.
Discharge Criteria
All patients should be discharged with follow-up arranged at an outside clinic or with PCP.
Issues for Referral
- If child abuse is suspected, child protective services must be involved; the child should be admitted if a safe home situation cannot be ensured.
- Sexual partners should be evaluated.
- In many states, STDs require reporting.
FOLLOW-UP RECOMMENDATIONS
- All patients should follow up with primary care to ensure adequate treatment of the infection.
- All patients with suspected or confirmed urethritis should be referred for HIV testing.
- Patients should be given information regarding safe sexual practices.
[Outline]
- Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2006. Atlanta: U.S. Department of Health and Human Services; 2007.
- Mandell GL, Bennett JE, Dolin R (eds). Principles and Practice of Infectious Diseases. 6th ed. Philadelphia, PA: Churchill Livingstone; 2004.
- Merchant RC, Depalo DM, Stein MD, et al. Adequacy of testing, empiric treatment, and referral for adult male emergency department patients with possible chlamydia and/or gonorrhea urethritis. Int J STD AIDS. 2009;20(8):534–539.
- Takahashi S, Matsukawa M, Kurimura Y, et al. Clinical efficacy of azithromycin for male nongonococcal urethritis. J Infect Chemother. 2008;14(6):409–412.
- Update to CDC's 2010 Sexually Transmitted Disease Treatment Guidelines: Oral Cephalosporins No Longer Recommended Treatment for Gonococcal Infections – MMWR. August 10, 2012.
- Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1–110.
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