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Urethritis

BASICS

Description

  • Urethritis is a common manifestation of sexually transmitted infection (STI).
  • Frequently associated with dysuria, pruritus, and/or urethral discharge.
  • Classified as:
  • Gonococcal urethritis (commonly due to Neisseria gonorrhoeae).
  • Nongonococcal urethritis (due to other pathogens or noninfectious causes such as Reiter syndrome, trauma, or chemical irritation).

EPIDEMIOLOGY

  • Chlamydia: 1.64 million cases in 2021; 4.1% increase from 2020.
  • Gonorrhea: 710,151 cases in 2021; 118% increase since 2009.
  • Syphilis: 176,713 cases in 2021; primary/secondary cases increased by 28.6%.
  • Highest prevalence in age group 14–25 years.
  • Affects both sexes across multiple demographics and risk groups.

ETIOLOGY AND PATHOPHYSIOLOGY

Common Infectious Causes

  • Neisseria gonorrhoeae
  • Chlamydia trachomatis
  • Mycoplasma genitalium
  • Trichomonas vaginalis
  • Ureaplasma urealyticum
  • Herpes simplex virus (rare)
  • Adenovirus (rare)

Noninfectious Causes

  • Chemical irritants (soaps, spermicides, etc.)
  • Foreign bodies
  • Urethral instrumentation

RISK FACTORS

  • Age 15–24 years
  • New or multiple sex partners
  • History of STIs
  • Inconsistent condom use
  • High-risk populations (e.g., incarcerated individuals, military recruits)

PREVENTION

  • Consistent condom use
  • Reducing number of sexual partners
  • Behavioral counseling
  • Abstinence

COMMONLY ASSOCIATED CONDITIONS

  • Annual chlamydia and gonorrhea screening is recommended for:
  • All sexually active women ≤24 years
  • Women >25 years with risk factors
  • Insufficient evidence for routine screening in men

DIAGNOSIS

Clinical Features

  • Urethral discharge (especially mucopurulent in gonorrhea)
  • Dysuria
  • Erythema of urethral meatus
  • Symptom onset 2–8 days post-exposure

History and Physical Exam

  • Detailed sexual history
  • Exam for discharge, testicular tenderness, scrotal swelling
  • Female exam: vaginal/cervical discharge, signs of PID

Pediatric Considerations

  • STI in children (outside neonates) strongly suggests sexual abuse

DIFFERENTIAL DIAGNOSIS

  • UTI, cystitis, pyelonephritis
  • Epididymitis, prostatitis
  • Vaginal atrophy
  • Reiter syndrome
  • Stevens-Johnson syndrome
  • Wegener granulomatosis
  • Urethral syndrome

DIAGNOSTIC TESTS

Initial Tests

  • NAAT (Nucleic Acid Amplification Test): preferred for C. trachomatis and N. gonorrhoeae
  • Gram stain: ≥2 WBCs per oil immersion or ≥10 WBCs per HPF in first-void urine sediment
  • MB/GV stain: alternative to Gram stain
  • Wet mount or culture for Trichomonas

Follow-Up and Special Tests

  • Test of cure in pregnant women or suspected treatment noncompliance
  • Repeat testing in 3 months due to high reinfection risk
  • Screen for other STIs: HIV, syphilis (RPR), hepatitis B and C

TREATMENT

General Principles

  • Outpatient management preferred
  • Treat both gonorrhea and chlamydia empirically if suspected
  • Single-dose, directly observed therapies preferred

Chlamydia

  • Preferred: Doxycycline 100 mg PO BID × 7 days
  • Alternative: Azithromycin 1 g PO single dose (preferred in pregnancy), Amoxicillin 500 mg TID × 7 days (pregnancy)

Gonorrhea

  • Preferred: Ceftriaxone 500 mg IM (if <150 kg) or 1 g IM (if >150 kg)
  • Alternative: Gentamicin 240 mg IM + Azithromycin 2 g PO

Trichomonas

  • Men: Metronidazole 2 g PO single dose
  • Women: Metronidazole 500 mg PO BID × 7 days

Recurrent/Persistent Urethritis

  • If doxycycline used initially, repeat or switch to:
  • Moxifloxacin 400 mg QD × 7 days
  • Azithromycin 1 g PO single dose

PREGNANCY CONSIDERATIONS

  • Screen all pregnant women for chlamydia and gonorrhea.
  • Test of cure at 3 weeks; retest at 3 months
  • Chlamydia:
  • Azithromycin 1 g PO single dose
  • Amoxicillin alternative
  • Gonorrhea:
  • Ceftriaxone 500 mg IM
  • Avoid tetracyclines; ID consult if allergic to cephalosporins

ONGOING CARE

Follow-Up

  • Avoid sexual activity for 7 days or until completion of therapy
  • Refer all partners within 60 days for evaluation and treatment
  • EPT (Expedited Partner Therapy) is an acceptable alternative

Patient Monitoring

  • Return if symptoms persist
  • Screen all patients again in 3 months

PATIENT EDUCATION

  • Behavior counseling improves STI prevention
  • Focus on condom use, communication skills, goal setting

PROGNOSIS

  • Generally good with treatment
  • Symptom resolution within days
  • Reinfection is common without partner treatment

COMPLICATIONS

  • Stricture formation
  • Epididymitis, prostatitis
  • PID, tubo-ovarian abscess
  • Disseminated gonococcal infections (meningitis, endocarditis)
  • Reiter syndrome
  • Neonatal complications: chlamydial conjunctivitis, pneumonia

CLINICAL PEARLS

  • NAAT is the preferred diagnostic test
  • Treat both chlamydia and gonorrhea empirically
  • Always screen for other STIs when urethritis is diagnosed
  • Reinfection is common; retest at 3 months
  • Same treatment applies to HIV-positive individuals
  • Report all cases to public health authorities