Classification & Causes
Gonococcal Urethritis
- Causative agent: Neisseria gonorrhoeae
- Gram-negative diplococcus
- Incubation: 2-7 days
- Purulent discharge typical
- Often more symptomatic than NGU
Non-Gonococcal Urethritis (NGU)
- No identifiable cause in >50%
- Common pathogens:
- Chlamydia trachomatis (20-40%)
- Mycoplasma genitalium (10-25%)
- Less common infectious causes:
- Ureaplasma urealyticum
- Trichomonas vaginalis
- Urinary tract pathogens
- Adenoviruses
- Herpes simplex virus
Persistent/Recurrent Urethritis
- Occurs 30-90 days after treatment
- Usually no identifiable cause
- Consider treatment failure
- Possible reinfection
- Antibiotic resistance possible
- Non-infectious causes possible
Non-Infectious Causes
Traumatic Causes
- Catheterization
- Urethral instrumentation
- Trauma during sexual activity
- Foreign bodies
Irritant Causes
- Soaps and lotions
- Spermicide creams
- Deodorants
- Chemical irritants
Other Causes
- Urethral stricture
- Urinary calculi
- Autoimmune conditions
- Idiopathic causes
Common Pathogens in Urethritis
Distribution of common causative organisms in urethritis cases
Clinical Features
Key Diagnostic Features
- Urethral discharge (minimal to copious)
- Dysuria (painful urination)
- Discharge may only be visible after urethral massage
- Patient may not notice discharge initially
Associated Symptoms
Local Symptoms
- Penile irritation or itching
- Urethral discomfort
- Balanoposthitis
- Meatal redness or swelling
Systemic Symptoms
- Usually absent in uncomplicated cases
- Fever (if complicated)
- Malaise
- Arthralgia (reactive arthritis)
Asymptomatic Cases
Up to 25% of urethral infections are asymptomatic, particularly with chlamydial infections. Asymptomatic carriers can still transmit infection to partners.
Sexual History Assessment
High-Risk Factors for STI
- Multiple partners in the last year
- Recent new partner
- Previous STI history
- Age 25 years or younger
- Unprotected sexual intercourse
- Partners with STI symptoms
Differential Diagnosis
| Condition | Key Differentiating Features |
|---|---|
| Physiological Discharge | Small clear/mucoid discharge with sexual excitement, no dysuria |
| Balanitis | Glans penis infection, often candidal, erythema, itching |
| Acute Prostatitis | Fever, perineal pain, tender prostate, may have blood-tinged discharge |
| Cystitis | Severe dysuria, frequency, urgency, haematuria, nocturia |
| Urinary Tract Infection | Positive urine culture, systemic symptoms possible |
| Meatitis | Localized meatal inflammation, often post-instrumentation |
Diagnostic Approach
- Assess STI risk factors
- Examine for discharge after urethral massage
- Consider non-STI causes if low risk
- Urinalysis and culture if UTI suspected
- Refer to GUM for definitive diagnosis
Management
Referral Recommendation
Refer all men with suspected urethritis to a genitourinary medicine (GUM) clinic or local specialist sexual health service for confirmation of diagnosis and appropriate treatment.
GUM Clinic Management
Diagnostic Testing
- NAAT for chlamydia and gonorrhoea
- Microscopy of urethral smear
- Culture for gonorrhoea
- Testing for other STIs
- Partner notification services
Treatment Principles
- Empirical antibiotics based on local guidelines
- Cover for chlamydia in all NGU cases
- Dual therapy if gonorrhoea suspected
- Test of cure if indicated
- Advise abstinence until treatment complete
Expected Response
Treatment Timeline
- Symptoms generally resolve within 3 days of appropriate antibiotic treatment
- Persistent symptoms require re-evaluation
- Consider treatment failure or reinfection
- Test of cure may be indicated
Complications
Prevention
Complications are rare with appropriate treatment but can occur with untreated or inadequately treated urethritis.
Non-Gonococcal Urethritis Complications
Epididymo-orchitis
- Scrotal pain and swelling
- Testicular tenderness
- Fever possible
- Common with chlamydial infection
Reactive Arthritis
- Also known as Reiter's syndrome
- Triad: arthritis, conjunctivitis, urethritis
- Asymmetric joint involvement
- Mucocutaneous lesions
Gonococcal Urethritis Complications
Local Spread
- Epididymitis
- Penile lymphangitis
- Periurethral abscess
- Acute prostatitis
- Seminal vesiculitis
- Tyson's and Cowper's gland infection
Disseminated Infection
- Skin lesions (pustules)
- Arthralgia and arthritis
- Tenosynovitis
- Fever and malaise
- Rare but serious complication
Complications Timeline
Progression of untreated urethritis to complications
Prevention & Patient Education
STI Prevention
- Consistent condom use
- Regular STI screening
- Partner communication
- Reducing number of partners
Patient Advice
- Complete full course of antibiotics
- Abstain from sex until treatment complete
- Ensure partner(s) get treated
- Attend follow-up if symptoms persist
- Seek prompt care for recurrence
Public Health
- Partner notification services
- Contact tracing
- Health education programs
- Access to sexual health services