Urethritis Summary

Classification

  • Gonococcal: Neisseria gonorrhoeae
  • Non-gonococcal: Chlamydia, Mycoplasma
  • Persistent: 30-90 days post-treatment

Key Symptoms

  • Urethral discharge
  • Dysuria
  • Penile irritation
  • 25% asymptomatic

Investigations

  • NAAT testing essential
  • Test for gonorrhea & chlamydia
  • Consider HIV/syphilis testing
  • GUM clinic referral

Treatment

  • GC: Ceftriaxone + Azithromycin
  • NGU: Doxycycline 7 days
  • Alternative: Azithromycin single dose

Management

  • Partner notification
  • Abstinence until treated
  • Test-of-cure if persistent
  • Document advice given

Urethritis

Inflammation of the Urethra - Diagnosis and Management

Definition

Urethritis is inflammation of the urethra, usually caused by sexually transmitted infections (STIs), though non-infectious causes also exist.

Causes and Classification

Gonococcal Urethritis

  • Caused by Neisseria gonorrhoeae
  • Typically produces purulent discharge
  • Incubation period 2-5 days

Non-Gonococcal Urethritis (NGU)

  • No identifiable cause in >50% cases
  • Common pathogens:
    • Chlamydia trachomatis (most common)
    • Mycoplasma genitalium
  • Other causes include Ureaplasma, Trichomonas, adenovirus, HSV

Persistent/Recurrent Urethritis

  • Occurs 30-90 days after treatment
  • Often no identifiable cause
  • May represent treatment failure or reinfection

Non-Infectious Causes

Clinical Features

Common Symptoms

  • Urethral discharge (may be minimal or copious)
  • Dysuria
  • Penile irritation
  • Urethral discomfort

Important Notes

  • Up to 25% of cases are asymptomatic
  • Discharge may only be visible after urethral massage
  • Sexual history is crucial for STI risk assessment

STI Risk Factors

Higher risk of STI if patient has:

  • Multiple partners in past year
  • Recent new partner
  • Previous STI history
  • Age ≤25 years

Differential Diagnosis

Condition Distinguishing Features
Physiological Discharge Clear/mucoid, associated with sexual excitement
Balanitis Glans infection, often candidal, with erythema
Acute Prostatitis Fever, perineal pain, tender prostate on exam
Cystitis Frequency, urgency, nocturia, often without discharge

Management

Referral Guidelines

All men with suspected urethritis should be referred to a genitourinary medicine (GUM) clinic or specialist sexual health service for:

  • Confirmatory testing (NAATs for gonorrhea/chlamydia)
  • Appropriate antibiotic treatment
  • Partner notification services
  • Follow-up testing

Typical Treatment Regimens

Gonococcal Urethritis
  • Single dose ceftriaxone IM plus
  • Azithromycin 1g orally (covers possible chlamydia co-infection)
Non-Gonococcal Urethritis
  • First-line: Doxycycline 100mg BD for 7 days
  • Alternative: Azithromycin 1g single dose
  • For persistent cases: Moxifloxacin 400mg OD for 7-14 days

Complications

NGU Complications

  • Epididymo-orchitis
  • Reactive arthritis (Reiter's syndrome)
  • Urethral stricture (chronic cases)

Gonococcal Complications

  • Epididymitis
  • Periurethral abscess
  • Prostatitis
  • Disseminated gonococcal infection (arthritis-dermatitis syndrome)

Key Practice Points

  • Always test for both gonorrhea and chlamydia
  • Consider HIV and syphilis testing in STI cases
  • Advise abstinence until treatment completed and partners treated
  • Arrange test-of-cure if symptoms persist
  • Document partner notification advice given