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Urethritis

  • Author: Martha K Terris, MD, FACS; Chief Editor: Edward David Kim, MD, FACS  more...
 
Updated: Jul 05, 2016
 

Practice Essentials

Urethritis is defined as infection-induced inflammation of the urethra. The term is typically reserved to describe urethral inflammation caused by an STD, and the condition is normally categorized into either gonococcal urethritis (GU) or nongonococcal urethritis (NGU).

Signs and symptoms

Many patients with urethritis, including approximately 25% of those with NGU, are asymptomatic and present to a clinician following partner screening.[1] Up to 75% of women with Chlamydia trachomatis infection are asymptomatic.

Signs and symptoms in patients with urethritis may include the following:

  • Urethral discharge: May be yellow, green, brown, or tinged with blood; production unrelated to sexual activity
  • Dysuria (in men): Usually localized to the meatus or distal penis, worst during the first morning void, and made worse by alcohol consumption; typically not present are urinary frequency and urgency
  • Itching: Sensation of urethral itching or irritation between voids
  • Orchalgia: Heaviness in the male genitals
  • Worsens during menstrual cycle (occasionally).
  • Systemic symptoms (eg, fever, chills, sweats, nausea): Typically absent

See Clinical Presentation for more detail.

Diagnosis

Most patients with urethritis do not appear ill and do not present with signs of sepsis. The primary focus of the examination is on the genitalia.

Examination in male patients with urethritis includes the following:

  • Inspect the underwear for secretions
  • Penis: Examine for skin lesions that may indicate other STDs (eg, condyloma acuminatum, herpes simplex, syphilis); in uncircumcised men, retract the foreskin to assess for lesions and exudate
  • Urethra: Examine lumen of the distal urethral meatus for lesions, stricture, or obvious urethral discharge; palpate along urethra for areas of fluctuance, tenderness, or warmth suggestive of abscess or for firmness suggesting foreign body
  • Testes: Examine for evidence of mass or inflammation; palpate the spermatic cord, looking for swelling, tenderness, or warmth suggestive of orchitis or epididymitis
  • Lymphatics: Check for inguinal adenopathy
  • Prostate: Palpate for tenderness or bogginess suggestive of prostatitis
  • Rectal: During the digital rectal examination, note any perianal lesions

Examine female patients in the lithotomy position. Include the following evaluation:

  • Skin: Assess for lesions that may indicate other STDs
  • Urethra: Strip the urethra for any discharge
  • Pelvis: Complete pelvic examination, including the cervix

Testing

Urethritis can be diagnosed based on the presence of one or more of the following:

  • A mucopurulent or purulent urethral discharge
  • Urethral smear that demonstrates at least 5 leukocytes per oil immersion field on microscopy
  • First-voided urine specimen that demonstrates leukocyte esterase on dipstick test or at least 10 WBCs/hpf on microscopy

All patients with urethritis should be tested for Neisseria gonorrhoeae and C trachomatis. Laboratory studies may include the following:

  • Gram stain
  • Endourethral and/or endocervical culture for N gonorrhoeae and C trachomatis
  • Urinalysis: Not useful test in urethritis, except to help exclude cystitis or pyelonephritis
  • Nucleic acid–based tests: For C trachomatis and N gonorrhoeae (urine specimens) and other Chlamydia species (endourethral samples)
  • Nucleic acid amplification tests (eg, PCR for N gonorrhoeae, Chlamydia species)
  • KOH preparation: to evaluate for fungal organisms
  • Wet mount preparation: To detect the movement/presence of Trichomonas
  • STD testing for syphilis serology (VDRL) and HIV serology
  • Nasopharyngeal and/or rectal swabs: For gonorrhea screening in men who have sex with men
  • Pregnancy testing: In women who have had unprotected intercourse

Imaging studies

Imaging studies, specifically retrograde urethrography, are unnecessary in patients with urethritis, except in cases of trauma or possible foreign body insertion.

Procedures

Patients with urethritis may undergo the following procedures:

  • Catherization: In cases of urethral trauma; to avoid urinary retention and tamponade urethral bleeding
  • Cystoscopy: In cases when catherization is not possible, for placement of a catheter; to remove foreign body or stone in the urethra
  • Dilation of urethral strictures with filiforms and followers
  • Placement of suprapubic tube: In severe cases of urethral trauma that prevent placement of urethral catheters or in the absence of adequate facilities for emergent cystoscopy; temporizing measure to divert urine and relieve patient discomfort

See Workup for more detail.

Management

Symptoms of urethritis spontaneously resolve over time, regardless of treatment. Administer antibiotics that cover both GU and NGU. Regardless of symptoms, administer antibiotics to the following individuals:

  • Patients with positive Gram stain or culture results
  • All sexual partners of the above patients
  • Patients with negative Gram stain results and a history consistent with urethritis who are not likely to return for follow-up and/or are likely to continue transmitting infection

Antibiotics used in the treatment of urethritis include the following:

  • Azithromycin
  • Ceftriaxone
  • Cefixime
  • Ciprofloxacin
  • Ofloxacin
  • Doxycycline
  • Moxifloxacin

See Treatment and Medication for more detail.

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Background

Urethritis is defined as infection-induced inflammation of the urethra. Although various clinical conditions may result in irritation of the urethra, the term urethritis is typically reserved to describe urethral inflammation caused by a sexually transmitted disease (STD). Urethritis is normally categorized into one of two forms, based on etiology: gonococcal urethritis (GU) and nongonococcal urethritis (NGU).

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Pathophysiology

Urethritis is an inflammatory condition that can be infectious or posttraumatic in nature. Infectious causes of urethritis are typically sexually transmitted and categorized as either gonococcal urethritis (ie, due to infections with Neisseria gonorrhoeae) or NGU (ie, due to infections with Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma hominis, Mycoplasma genitalium, or Trichomonas vaginalis).

Rare infectious causes of urethritis include lymphogranuloma venereum, herpes simplex virus types 1 and 2, adenovirus, syphilis, mycobacterial infection, and bacterial infections that are typically associated with cystitis (usually gram-negative rods) in the presence of urethral stricture. Other rare but reported causes of urethritis include viral, streptococcal, anaerobic, and meningococcal infections.

Posttraumatic urethritis can occur in 2%-20% of patients practicing intermittent catheterization and following instrumentation or foreign body insertion. Urethritis is 10 times more likely to occur with latex catheters than with silicone catheters.

Urethritis may be associated with other infectious syndromes, such as the following:

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Epidemiology

United States

Urethritis occurs in 4 million Americans each year. The incidence of gonococcal urethritis is estimated at over 700,000 new cases annually, and the incidence of NGU is approximately 3 million new cases annually. Both infections are significantly underreported. The incidence of gonococcal urethritis declined steadily from 2000 to 2009, but then began an intermittent rise, and the incidence of NGU is increasing.[2] NGU incidence is highest in the summer months.

International

Worldwide, approximately 62 million new cases of gonococcal urethritis and 89 million new cases of NGU are reported each year.

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Mortality/Morbidity

Approximately 10%-40% of women with urethritis eventually develop pelvic inflammatory disease (PID), which may subsequently cause infertility and ectopic pregnancy secondary to postinflammatory scar formation in the fallopian tubes. PID can occur even in women with asymptomatic infections.

Children born to mothers with Chlamydia infection may develop conjunctivitis, iritis, otitis media, or pneumonia if exposed to the organism while passing through the birth canal. Performing cesarean delivery in patients with known chlamydial infections and routine treatment of all newborns with antichlamydial eyedrops has decreased the incidence of this problem in developed countries.

Disseminated gonococcal infection (DGI) and reactive arthritis develop in fewer than 1% of female patients with urethritis. Reactive arthritis is characterized by NGU, anterior uveitis, and arthritis and is strongly associated with the gene for HLA-B27. Rare but serious complications of DGI include arthritis, meningitis, and endocarditis.

Morbidity due to urethritis in males is less common (1%-2%), typically taking the form of urethral stricture or stenosis due to postinflammatory scar formation. Other potential complications of urethritis in males include prostatitis, acute epididymitis, abscess formation, proctitis, infertility, abnormal semen, DGI, and reactive arthritis.

Mortality rates are minimal in patients with gonococcal urethritis or NGU.

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Race-, Sex-, and Age-related Demographics

Urethritis has no racial predilection. However, persons of low socioeconomic class are affected more often than persons of higher socioeconomic class.

Urethritis has no sexual predilection; however, data may be skewed because urethritis is underrecognized in women. Up to 75% of females with the condition can be asymptomatic or may instead present with cystitis, vaginitis, or cervicitis.[3] Homosexual males are at a greater risk for urethritis than are heterosexual males or females in general.

Urethritis may occur in any sexually active person, but incidence is highest among people aged 20-24 years.

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Contributor Information and Disclosures
Author

Martha K Terris, MD, FACS Professor, Department of Surgery, Section of Urology, Director, Urology Residency Training Program, Medical College of Georgia; Professor, Department of Physician Assistants, Medical College of Georgia School of Allied Health; Chief, Section of Urology, Augusta Veterans Affairs Medical Center

Martha K Terris, MD, FACS is a member of the following medical societies: American Cancer Society, Association of Women Surgeons, American Society of Clinical Oncology, Society of Urology Chairpersons and Program Directors, Society of Women in Urology, Society of Government Service Urologists, American College of Surgeons, American Institute of Ultrasound in Medicine, American Urological Association, New York Academy of Sciences, Society of University Urologists

Disclosure: Nothing to disclose.

Coauthor(s)

Kamran P Sajadi, MD Assistant Professor, Urology, Oregon Health & Science University

Kamran P Sajadi, MD is a member of the following medical societies: American Urological Association, Endourological Society, Oregon Medical Association, Western Section of the American Urological Association, American Urogynecologic Society, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

Additional Contributors

Leonard Gabriel Gomella, MD, FACS The Bernard W Godwin Professor of Prostate Cancer Chairman, Department of Urology, Associate Director of Clinical Affairs, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University

Leonard Gabriel Gomella, MD, FACS is a member of the following medical societies: American Association for Cancer Research, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Urological Association, Sigma Xi, Society for Basic Urologic Research, Society of University Urologists, Society of Urologic Oncology

Disclosure: Received consulting fee from GSK for consulting; Received honoraria from Astra Zeneca for speaking and teaching; Received consulting fee from Watson Pharmaceuticals for consulting.

References
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  2. CDC Fact Sheet: Reported STDs in the United States: 2014. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/std/stats14/default.htm. November 2015; Accessed: June 14, 2016.

  3. Berntsson M, Tunbäck P. Clinical and microscopic signs of cervicitis and urethritis: correlation with Chlamydia trachomatis infection in female STI patients. Acta Derm Venereol. 2013 Mar 27. 93(2):230-3. [Medline].

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  11. Manhart LE, Gillespie CW, Lowens MS, Khosropour CM, et al. Standard Treatment Regimens for Nongonococcal Urethritis Have Similar but Declining Cure Rates: A Randomized Controlled Trial. Clin Infect Dis. 2013 Jan 3. [Medline].

  12. Bachmann LH, Manhart LE, Martin DH, Seña AC, Dimitrakoff J, Jensen JS, et al. Advances in the Understanding and Treatment of Male Urethritis. Clin Infect Dis. 2015 Dec 15. 61 Suppl 8:S763-9. [Medline].

 
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