Urethritis Clinical Presentation

Obtaining a careful patient history often helps differentiate between an STD and other causes of urethritis. The questions can be quite personal, and the physician should take care to not appear disgusted, amused, or judgmental regarding the patient's sexual history. If patients feel uncomfortable, they may not be forthcoming with essential information that may be helpful in their treatment or the treatment of any sexual partners, ie, including the chain of partners that may be linked to the patient (eg, partners of partners and so on).

• Sexual history: Certain sexual practices may increase or decrease the likelihood of contracting urethritis secondary to an STD.

  • Contraceptive use: Using condoms helps substantially decrease the chance of STD transmission. Other types of birth control either do not improve or worsen the chance of transmitting urethritis. The use of spermicides may cause a chemical urethritis, with associated dysuria findings that mimic those of infectious urethritis.
  • Age at first intercourse: With the exception of some religious groups who encourage marriage and monogamy at an early age, a younger age at first intercourse is correlated with increased risk of contracting STDs.
  • Number of sexual partners: Individuals with multiple partners are more likely to have contracted an STD. Long-term monogamous couples are extremely unlikely to contract an STD. A married patient should not be informed of the diagnosis (or possible diagnosis) in the presence of his or her spouse, but the spouse should be treated once the patient has had the opportunity to explain the situation.
  • Sexual preference: Homosexual men have the highest rate of STDs. They are followed, in order of occurrence rates, by heterosexual men, heterosexual women, and homosexual women.
  • Previous STDs: Patients with a prior history of STDs are at an increased risk of contracting another STD. Concurrent STDs may also occur. A high level of suspicion for other more sinister STDs, such as syphilis and HIV infection, should be maintained. In addition, urethritis can increase viral shedding of HIV and can increase the likelihood of transmission.
• Symptoms: Many patients, including approximately 25% of those with NGU, are asymptomatic and present following partner screening. Up to 75% of women with C trachomatis infection are asymptomatic.

  • Timing: Symptoms generally begin 4 days to 2 weeks after contact with an infected partner, or the patient may be asymptomatic.
  • Urethral discharge: Fluid may be yellow, green, brown, or tinged with blood, and production is unrelated to sexual activity.
  • Dysuria: Dysuria is usually localized to the meatus or distal penis, worst during the first morning void, and made worse by alcohol consumption. Urinary frequency and urgency are typically absent. If present, either should suggest prostatitis or cystitis.
  • Itching: A sensation of urethral itching or irritation may persist between voids, and some patients have itching instead of pain or burning.
  • Orchalgia: Men sometimes complain of heaviness in the genitals. Associated pain in the testicles should suggest epididymitis, orchitis, or both.
  • Menstrual cycle: Women occasionally complain of worsening symptoms during menses.
  • Foreign body or instrumentation: The patient should be questioned about recent urethral catheterization or instrumentation, either medical or self-induced (eg, foreign body). These procedures may cause traumatic urethritis.
• Systemic symptoms: Systemic symptoms (eg, fever, chills, sweats, nausea) are typically absent but, if present, may suggest disseminated gonococcemia, pyelonephritis, arthritis, conjunctivitis, proctitis, prostatitis, epididymitis or orchitis, pneumonia, otitis media, low back pain (ie, reactive arthritis), iritis, or rash (characteristically involving the palms of hands and soles of feet).

Most patients with urethritis do not appear ill and do not present with signs of sepsis, such as fever, tachycardia, tachypnea, or hypotension. The primary focus of the examination is on the genitalia.

• Men

  • The best plan is to avoid examining the patient immediately after micturition because urination temporarily washes away discharge and potentially culturable organisms. Because urine culture is an important component of the evaluation, advise the patient to urinate approximately 2 hours before the examination so that culture and examination results are optimal and the patient can comfortably provide a urine specimen after the examination.
  • Ensure that the patient is standing, is completely undressed, and that the room is warm and has good lighting. When the patient is undressed, inspecting the underwear for secretions may yield additional information.
  • Examine the patient for skin lesions that may indicate other STDs, such as condyloma acuminatum, herpes simplex, or syphilis. The examiner must retract the foreskin of uncircumcised men. Lesions and exudate may be hiding beneath.
  • Examine the lumen of the distal urethral meatus for lesions, stricture, or obvious urethral discharge.
  • Strip the urethra by gently milking from the base of the penis to the glans. Any discharge may then be seen exuding from the urethral meatus. Palpate along the urethra for areas of fluctuance, tenderness, or warmth suggestive of abscess or for firmness suggestive of foreign body.
  • Examine the testes for evidence of mass or inflammation. Palpate the spermatic cord, looking for swelling, tenderness, or warmth suggestive of orchitis or epididymitis.
  • Check for inguinal adenopathy.
  • Palpate the prostate for tenderness or bogginess suggestive of prostatitis. During the digital rectal examination, note any lesions around the anus.
• Women

  • The best plan is to avoid examining the patient immediately after micturition because urination temporarily washes away discharge and potentially culturable organisms. Because urine culture is an important component of the evaluation, advise the patient to urinate approximately 2 hours before the examination so that culture and examination results are optimal and the patient can comfortably provide a urine specimen after the examination.
  • The patient should be in the lithotomy position.
  • Inspect the skin for any lesions that may indicate the presence of other STDs.
  • Strip the urethra by inserting a finger into the anterior vagina and stroking forward along the urethra. Any discharge should be sampled for examination.
  • Follow the urethral examination with a complete pelvic examination, including cervical cultures.
• General: Fever, palmar rash, joint tenderness, and conjunctivitis are indications of systemic disease.

• Gonococcal urethritis

  • Gonococcal urethritis (80% of cases) is caused by N gonorrhoeae, which is a gram-negative intracellular diplococcus.
  • Patients with gonococcal urethritis have a shorter incubation period than those with NGU, and the onset of dysuria and purulent discharge is abrupt.
• Nongonococcal urethritis

  • Patients with NGU (50% of cases) have a longer incubation period than those with gonococcal urethritis, and the onset of either dysuria or, less commonly, a mucopurulent discharge, is subacute. Patients with NGU are much more likely to be asymptomatic than patients with gonococcal urethritis.
  • NGU is caused by C trachomatis (15-55% of cases), U urealyticum (40-60% of cases), M hominis (5-10% of cases), and T vaginalis (< 5% of cases). The number of fastidious organisms implicated in NGU is increasing and includes several Ureaplasma and Mycoplasma species. The causative organism cannot be identified in most patients with NGU.
  • Rare cases may be related to lymphogranuloma venereum, herpes simplex, syphilis, mycobacteria, or urinary tract infection with urethral stricture. Other rare but reported causes of NGU include anaerobes, adenovirus, cytomegalovirus, and streptococcus.
  • Urethritis following catheterization occurs in 2-20% of patients practicing intermittent catheterization and is 10 times more likely to occur with latex catheters than with silicone catheters.
• Urethritis of mixed etiology: Polymicrobial NGU and cases of urethritis due to both gonococcal infection and nongonococcal factors are possible and can explain some treatment failures. This should also be considered in patients with HIV infection.