- Symptoms usually develop 4-7 d after exposure for gonococcal urethritis and 5-8 d for nongonococcal urethritis
- Initially minimal or absent in many patients
Signs and Symptoms
- Urethral discharge, dysuria
- Cloudy first portion of urine
- Pruritus
- 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 STIs:
- 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 reagin (RPR) or Venereal Disease Research Laboratory (VDRL) should be drawn because STIs frequently occur together
- An HIV test should also be offered to the patient
- If testing is not available a presumptive diagnosis of urethritis can be made based on the history and physical
Diagnostic 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 first-void urine or urethral swab:
- Equal efficacy for diagnosing N. gonorrhoeae and Chlamydia species
- Diagnosis suggested by +ve leukocyte esterase on dipstick or ≥10 WBC/hpf on first void urine
Differential Diagnosis
- Chemical irritation from soaps or spermicides
- Epididymitis
- Orchitis
- Pelvic inflammatory disease
- Prostatitis
- Reactive arthritis (formerly Reiter syndrome)
- Urethral chancre (from syphilis)
- UTI
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:
- Recurrent infections
- Ascending UTIs, including pelvic inflammatory disease and epididymo-orchitis
- Fallopian tube damage and infertility
- Arthritis
- Conjunctivitis, uveitis, and blindness
|
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:
- M. genitalium:
- Azithromycin 1 g (peds: 10 mg/kg day 1, 5 mg/kg days 2-5) PO once
Pregnancy Prophylaxis |
- Doxycycline is 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 worldwide |
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, STIs 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
- Centers for Disease Control and Prevention (CDC). Update to CDC's sexually transmitted diseases treatment guidelines, 2010: Oralcephalosporins no longer a recommended treatment for gonococcal infections . MMWR Morb Mortal Wkly Rep. 2012; 61(31):590-594.
- ItoS, HanaokaN, ShimutaK, et al. Male non-gonococcal urethritis: From microbiological etiologies to demographic and clinical features . Int J Urol. 2016;23(4):325-331.
- ItoS, HatazakiK, ShimutaK, et al. Haemophilus influenzae isolated from men with acute urethritis: Its pathogenic roles, responses to antimicrobial chemotherapies, and antimicrobial susceptibilities . Sex Transm Dis. 2017;44(4):205-210.
- ManhartLE, GillespieCW, LowensMS, et al. Stand ard treatment regimens for nongonococcal urethritis have similar but declining cure rates: A rand omized controlled trial . Clin Infect Dis. 2013;56(7):934-942.
- RaneVS, FairleyCK, WeerakoonA, et al. Predictors and pathogens among 4,326 cases of acute non-gonoccocal urethritis . Sex Transm Infect. 2013;89:A53.
- ReadTR, FairleyCK, TabriziSN, et al. Azithromycin 1.5 g over 5 days compared to 1 g single dose in urethral mycoplasma genitalium: Impact on treatment outcome and resistance . Clin Infect Dis. 2017;64(3):250-256.
- SchwebkeJR, RompaloA, TaylorS, et al. Re-evaluating the treatment of nongonococcal urethritis: Emphasizing emerging pathogens—a rand omized clinical trial . Clin Infect Dis. 2011;52(2):163-170.
- WorkowskiKA, BolanGA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015 . MMWR Recomm Rep. 2015;64(RR-03):1-137.
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