• Clinical science

Urethritis

Abstract

Urethritis is an inflammation of the urethral mucosa that may be caused by various pathogens, most notably C. trachomatis, N. gonorrhea, and M. genitalium. Transmission primarily occurs as a result of unprotected sexual intercourse and it is especially prevalent in young, sexually active men. Patients typically present with urethral discharge, dysuria, and/or itching of the urinary meatus, although asymptomatic infections are common. Diagnostics include urine dipstick (pyuria, positive leukocyte esterase), staining of a urethral sample, and nucleic acid amplification testing of first-void urine. In gonococcal urethritis, Gram staining of the urethral swab demonstrates gram-negative diplococci and patients are treated with ceftriaxone and azithromycin; otherwise patients are treated with azithromycin or doxycycline for nongonococcal urethritis. Evaluation and treatment of all recent sexual partners is necessary to prevent recurrent infections.

Etiology

  • Typically a sexually-transmitted infection
  • Noninfectious etiologies: repeated urethral manipulation or chemical irritation
  • Coinfection is also common
  • Most common in young, sexually active men
  • Risk factors

References:[1][2][3][4][5][6][7]

Clinical features

  • Dysuria
  • Burning or itching of the urethral meatus
  • Urethral discharge: purulent , cloudy, blood-tinged, or clear
  • Initial hematuria
  • Systemic findings such as fever, chills, or myalgia are absent in urethritis.

Urethritis, especially nongonococcal urethritis, may also be asymptomatic!
References:[8][2][5]

Diagnostics

  • Confirming urethritis
    • Urine dipstick; of first-void urine: pyuria; (≥ 5-10 WBC per high power field ) or positive leukocyte esterase
    • Urethral smear: ≥ 2 leukocytes per oil immersion field
  • Identifying the causative pathogen
    • Gram stain of urethral swab or discharge :
      • Gram-negative diplococci: GU
      • Otherwise NGU
    • Nucleic acid amplification testing (NAAT) of first-void urine without prior precleaning of the urethra for N. gonorrhea and C. trachomatis

Dysuria with urethral discharge and no organism on Gram staining of a urethral specimen suggest urethritis by C. trachomatis or M. genitalium!
References:[2][9]

Differential diagnoses

Because coinfection with other genitourinary tract infections is possible, the presence of one does not rule out urethritis.

The differential diagnoses listed here are not exhaustive.

Treatment

  • The initial therapy is usually empiric and, according to prior distinction based on microscopic urethral specimen evaluation, divided into either a GU or NGU regimen.
  • Patients should refrain from sexual activity for 1 week after initiation of therapy.
  • All sexual partners from the 2 months prior to diagnosis should be notified, evaluated for urethritis, and offered empiric treatment.
  • Repeat NAAT 3–6 months after completion of therapy.

Sexual partners should be treated simultaneously to avoid reinfection!
References:[1][2][9]

Complications


References:[2][5]

We list the most important complications. The selection is not exhaustive.

Prevention

  • Barrier protection during sexual intercourse
  • Chlamydia and gonorrhea are reportable diseases.
  • 1. Moi H, Blee K, Horner PJ. Management of non-gonococcal urethritis. BMC Infect Dis. 2015; 15: p. 294. doi: 10.1186/s12879-015-1043-4.
  • 2. Seña AC, Cohen MS, Swygard H. Urethritis in adult men. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/urethritis-in-adult-men. Last updated October 24, 2016. Accessed March 29, 2017.
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  • 6. Gaydos C, Maldeis NE, Hardick A, Hardick J, Quinn TC. Mycoplasma genitalium compared to chlamydia, gonorrhoea and trichomonas as an aetiological agent of urethritis in men attending STD clinics. Sex Transm Infect. 2009; 85(6): pp. 438–440. doi: 10.1136/sti.2008.035477.
  • 7. Centers for Disease Control and Prevention. Sexually Transmitted Diseases in the United States, 2008. https://www.cdc.gov/std/stats08/trends.htm. Updated November 16, 2009. Accessed March 29, 2017.
  • 8. Kasper DL, Fauci AS, Hauser SL, Longo DL, Lameson JL, Loscalzo J. Harrison's Principles of Internal Medicine. New York, NY: McGraw-Hill Education; 2015.
  • 9. Centers for Disease Control and Prevention. 2015 Sexually Transmitted Diseases Treatment Guidelines: Diseases Characterized by Urethritis and Cervicitis. https://www.cdc.gov/std/tg2015/urethritis-and-cervicitis.htm. Updated June 4, 2015. Accessed March 29, 2017.
last updated 11/09/2018
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