eMedicine Specialties > Urology > Common Problems of the Urethra

Urethritis

Martha K Terris, MD, FACS, Professor, Department of Surgery, Medical College of Georgia
Kamran P Sajadi, MD, Staff Physician, Division of Urology, Medical College of Georgia Health System

Updated: Aug 10, 2009

Introduction

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).

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 genitalis, 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 epididymitis, orchitis, prostatitis, proctitis, reactive arthritis, iritis, pneumonia, otitis media, and urinary tract infection.

Frequency

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 has declined steadily since 2000, and the incidence of NGU is increasing. 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.

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 less than 1% of female patients with urethritis.
• 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.
• 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.
• Mortality rates are minimal in patients with gonococcal urethritis or NGU.

Race

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

Sex

• 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. Homosexual males are at a greater risk for urethritis than are (1) heterosexual males or (2) females in general.

Age

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

Clinical

History

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).

Physical

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.

Causes

• 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.

Differential Diagnoses

Other Problems to Be Considered

Trichomonal vaginitis
Candidal vaginitis
Alcohol ingestion
Contact dermatitis secondary to spermicides
Guilt over sexual behavior likely to be perceived as deviant
Guilt over infidelity
Dried semen mistaken for discharge
Stevens-Johnson syndrome
Foreign body
Fungal infections of the genitourinary tract

Workup

Laboratory Studies

Urethritis can be diagnosed based on the presence of one or more of the following: (1) a mucopurulent or purulent urethral discharge, (2) urethral smear that demonstrates at least 5 leukocytes per oil immersion field on microscopy, and (3) first-voided urine specimen that demonstrates leukocyte esterase on dipstick test or at least 10 white blood cells (WBCs) per high-power field on microscopy.

All patients with urethritis should be tested for N gonorrhoeae and C trachomatis.

• Gram stain
  • Traditionally, treatment was based on Gram stain results. Patients with gram-negative intracellular diplococci on urethral smear received treatment for gonococcal urethritis, and those without gram-negative intracellular diplococci received treatment for nongonococcal urethritis (NGU).
  • Because current recommendations suggest patients receive concomitant treatment for both, and with the success of nucleic acid amplification tests (NAATs), a Gram stain may be unnecessary.
• Urethral culture for N gonorrhoeae and C trachomatis
  • Endourethral culture (obtained by gently inserting a malleable cotton-tipped swab 1-2 cm into the urethra), rather than culture of the expressible discharge, is necessary to test for C trachomatis infection. Endocervical cultures should also be obtained in women.
  • This culture may be a useful screening tool for penicillinase-producing N gonorrhoeae or chromosomally mediated resistance to multiple antibiotics; however, the results do not influence the initial antibiotic therapy, and performing this screening may not be cost-effective.
• Urine
  • Urinalysis is not a useful test in patients with urethritis, except for helping exclude cystitis or pyelonephritis, which may be necessary in cases of dysuria without discharge. Patients with gonococcal urethritis may have leukocytes in a first-void urine specimen and fewer or none in a midstream specimen. More than 30% of patients with NGU do not have leukocytes in urine specimens.
  • Many nucleic acid–based tests for C trachomatis and N gonorrhoeae can be performed on urine specimens (see below). These require a first-voided specimen. For Chlamydia species, endourethral samples are more accurate.
• Nucleic acid amplification tests
  • Polymerase chain reaction assays are available for gonococcal urethritis and Chlamydia infection. NAATs are also available for Mycoplasma species, Ureaplasma species, and T vaginalis, but these are not recommended, as they are expensive and do not alter the choice of treatment.
  • NAATs are the preferred test for Chlamydia and are more sensitive than traditional culture methods. Chlamydia DNA probe results are 60%-70% sensitive and nearly 100% specific. Obtain samples on swabs at least 2 hours after micturition, using a calcium-alginate swab on a nonwooden stick inserted at least 1 cm in depth to help prevent false-negative findings. Chlamydia ligase chain reaction is 90%-95% sensitive and nearly 100% specific. Obtain samples on swabs at least 2 hours after micturition, using a calcium-alginate swab on a nonwooden stick inserted at least 1 cm in depth to help prevent false-negative results.
  • DNA-based tests, unlike culture, do not allow for antibiotic susceptibility testing, but this is unnecessary in most patients.
• Potassium hydroxide preparation: This is used to evaluate for fungal organisms.
• Wet preparation: Secretions reveal the movement of trichomonal organisms, if present.
• STD testing: Patients with urethritis should be counseled about the risk for more serious STDs. They should be offered syphilis serology (Venereal Disease Research Laboratory test or Rapid Plasma Reagin test) and HIV serology.
• Nasopharyngeal and/or rectal swabs: Men who have sex with men (and perhaps other patients) should undergo gonorrhea screening with nasopharyngeal and/or rectal swabs. Validation of NAATs for these specimens is still in progress.¹
• Pregnancy testing: Women who have had unprotected intercourse should be offered pregnancy testing.
• Other tests: Patients with reactive arthritis are diagnosed based on the presence of NGU and clinical findings of uveitis and arthritis. HLA-B27 testing is of limited value. More readily available laboratory findings, such as elevated erythrocyte sedimentation rate (ESR) in the absence of rheumatoid factor, may be helpful.

Imaging Studies

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

Procedures

• Catheterization
  • In cases of urethral trauma, urethral catheter placement can hold the urethra open to avoid urinary retention caused by edema or a flap of elevated mucosa.
  • The catheter also serves to tamponade urethral bleeding.
• Cystoscopy
  • When urethral catheter placement is not possible after urethral trauma, careful negotiation of the urethra with a flexible cystocope can allow passage of a guidewire, over which the Council tip urethral catheter can be placed. This can generally be performed in the emergency department or outpatient clinic with local anesthesia (lidocaine jelly). However, if not easily accomplished on the initial attempt, this procedure should be aborted to avoid further urethral trauma, and a suprapubic tube should be placed.
  • A foreign body or stone in the urethra, which may mimic urethritis, can be removed cystoscopically. Unless the object is very small and very distal, this procedure probably should be undertaken in the operating suite while the patient is under anesthesia. A rigid cystoscope with a larger lumen sheath and working port allows utilization of more secure endoscopic graspers. The object can often be removed through the large lumen of the cystoscope sheath, rather than pulling it through the distal urethra (which may cause further trauma).
• Filiforms and followers: Filiforms and followers can also be used by experienced urologists but are being used less frequently in cases of urethral trauma because of the wide availability of flexible cystoscopes. In addition, this technique can lead to more severe urethral trauma if not used correctly.
• Suprapubic tube placement: With more severe urethral trauma preventing urethral catheter placement or inadequate facilities for emergent cystoscopy in patients with urethral obstruction due to trauma or foreign bodies, a suprapubic catheter is an excellent temporizing measure to divert urine and relieve patient discomfort until definitive therapy can be undertaken.

Treatment

Medical Care

Symptoms of urethritis spontaneously resolve over time, regardless of treatment. Administer antibiotics to prevent morbidity and to reduce disease transmission to others. Treating sexual contacts also prevents reinfection of the index patient.

Antibiotic therapy should cover both gonococcal urethritis and nongonococcal urethritis (NGU). If concomitant treatment for NGU is not provided, the risk of postgonococcal urethritis is approximately 50%. The choice of antibiotics should be based on cost, adverse effects, effectiveness, and compliance. In most situations, optimal treatment is with single-dose therapy administered in the emergency department or the physician's office.

Activity

• Instruct the patient to refrain from intercourse until all partners are treated.
• Educate the patient about always using barrier devices when engaging in intercourse with multiple partners.
• Inform patients that infections can spread by orogenital or genitoanal intercourse, even in the absence of penovaginal intercourse.

Medication

Administer antibiotics to patients with positive Gram stain or culture results and to all sexual partners of those patients, regardless of symptoms. Also treat 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 (eg, prostitutes, persons who abuse drugs, homeless persons). The latter group may best be served with single-dose therapies (see below).

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

The antimicrobial options in the treatment of urethritis include parenteral ceftriaxone, oral azithromycin, oral ofloxacin, oral ciprofloxacin, oral cefixime, oral doxycycline, and parenteral spectinomycin. Azithromycin and doxycycline have been proven equally efficacious in treating C trachomatis infections. Ofloxacin and azithromycin are effective for nongonococcal urethritis (NGU), whereas ciprofloxacin is ineffective against chlamydial infection. Combinations of probenecid with penicillin, amoxicillin, or ampicillin are no longer used because of resistance. Conversely, the macrolides, including erythromycin, and tetracyclines all have similar effectiveness in NGU. The incidence of quinolone-resistant N gonorrhea is high in Asian and Pacific nations and is rising in the West Coast of the United States. Obtaining a recent travel history may help direct therapy.

Patients with proven gonococcal urethritis should be empirically treated for C trachomatis infection. Empiric treatment is less expensive than culture in any population whose coinfection rate is at least 10%. Single-dose empiric treatments offer an advantage in patients who are noncompliant or unlikely to return for follow-up. Single-dose regimens include azithromycin for C trachomatis and cefixime, ceftriaxone, ciprofloxacin, ofloxacin, or levofloxacin for N gonorrhea.

A single dose of metronidazole plus a 7-day course of erythromycin is recommended for NGU recurrence. Antibiotic therapy is recommended for affected individuals and sexual partners of individuals with documented trichomonal infection, even if asymptomatic.

Azithromycin (Zithromax)

In 2-g dose, treats both gonococcal urethritis and NGU. Treatment of choice and is well tolerated by most patients. Eight large tabs are required, and liquid is also available.

Dosing

Adult

2 g PO single dose

Pediatric

CDC guidelines for urethritis
<45 kg: Not recommended
<8 years and >45 kg: 1 g PO single dose
>8 years: 1 g PO single dose
Adolescent: 1 g PO single dose

Interactions

May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine

Contraindications

Documented hypersensitivity; hepatic impairment; do not administer with pimozide

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

1-g dose treats only gonococcal urethritis, 2 g required for NGU; site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, elderly, or debilitated patients

Ceftriaxone (Rocephin)

Used for gonococcal urethritis only. Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to 1 or more penicillin-binding proteins.

Dosing

Adult

250 mg IM single dose

Pediatric

CDC guidelines for urethritis
Children: 125 mg IM single dose
Adolescents: 125 mg IM single dose

Interactions

Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in impaired hepatic function; adult 125-mg dose no longer recommended; adjust dose in renal impairment; caution in breastfeeding and allergy to penicillin

Cefixime (Suprax)

Treats gonococcal urethritis only. By binding to 1 or more of the penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial growth.

Dosing

Adult

400 mg PO single dose

Pediatric

CDC guidelines for urethritis
<45 kg: Not established
>45 kg: 400 mg PO single dose

Interactions

Coadministration of aminoglycosides increases nephrotoxicity; probenecid may increase effects

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment

Ciprofloxacin (Cipro)

Treats gonococcal urethritis only. Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, Staphylococcus epidermidis, and most gram-negative organisms but offers no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth.

Dosing

Adult

500 mg PO single dose

Pediatric

CDC guidelines for urethritis
Adolescents: Administer as in adults

Interactions

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy

Ofloxacin (Floxin)

Treats gonococcal urethritis only. Penetrates prostate well and is effective against N gonorrhea and C trachomatis. A derivative of pyridine carboxylic acid with broad-spectrum bactericidal effect.

Dosing

Adult

400 mg PO single dose

Pediatric

<18 years: Not recommended

Interactions

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy; may cause tendon pain or rupture

Doxycycline (Vibramycin)

Treats NGU only. Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.

Dosing

Adult

100 mg PO bid for 7 d

Pediatric

CDC guidelines for urethritis
<8 years: Not recommended
>8 years: Administer as in adults

Interactions

Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy

Contraindications

Documented hypersensitivity; severe hepatic dysfunction

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines

Follow-up

Further Outpatient Care

• Only patients who remain symptomatic require follow-up cultures to ensure eradication of infection.
• If symptoms persist following adequate treatment, the disease is most likely nongonococcal urethritis (NGU). Prior to improved culture methods and increased awareness of the causes of NGU, symptom recurrences were thought to be psychological in nature. This is usually not the case, and most cases of recurrent NGU are related to persistent chlamydial, ureaplasmal, or mycoplasmal infection. These patients benefit from prolonged (14-28 d) therapy with erythromycin. Consider also quinolone resistance in gonococcal urethritis, based on local epidemiologic data.
• Most infections after treatment are due to reinfection by the same or a new partner, stressing the need to educate patients and to treat partners.

Deterrence/Prevention

• Educate at-risk patients on how to prevent disease recurrence.
• Educate patients on risks of other sexually-transmitted infections, including HIV.
• Try to find asymptomatic patients and symptomatic patients who are unlikely to seek treatment.
• Early diagnosis and treatment of infected individuals is essential.
• Evaluate and treat sexual partners of known infected persons.

Complications

• Complications, such as stricture, stenosis, or abscess formation, are quite rare. Concomitant epididymitis or prostatitis is not uncommon.
• PID and tubo-ovarian abscess are known complications of urethritis in females that may predispose to infertility. In addition, increasing evidence shows that genital chlamydial infection in males may predispose to infertility. In addition, both Chlamydia and U urealyticum can impair sperm and adversely affect semen parameters.^2,3

Prognosis

• All patients with uncomplicated urethritis spontaneously recover with or without treatment.

Patient Education

• Instruct patients to avoid the following high-risk behaviors are associated with STDs:
  • Intercourse at a young age, with rare exception, is associated with multiple sex partners and unprotected intercourse.
  • Intercourse with multiple partners
  • Drug abuse
  • Unprotected sex
  • Intercourse with partners known to have infections
• Instruct patients to use barrier devices with all partners at all times.
• For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center and Pregnancy and Reproduction Center. Also, see eMedicine's patient education articles Urinary Tract Infections, Birth Control Spermicides, Birth Control FAQs, and Birth Control Overview.

Miscellaneous

Medicolegal Pitfalls

• Failure to detect or treat co-infections
• Failure to identify and treat partners
• Failure to screen for other STDs

References

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3. Gunn RA, O'Brien CJ, Lee MA, Gilchick RA. Gonorrhea screening among men who have sex with men: value of multiple anatomic site testing, San Diego, California, 1997-2003. Sex Transm Dis. Oct 2008;35(10):845-8. [Medline].

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6. Centers for Disease Control and Prevention. CDC Division of AIDS, STD, and TB. Gonococcal Isolation Surveillance Project (GISP) Annual Report - 2007. Atlanta, Ga: Centers for Disease Control and Prevention. [Full Text].

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12. Jensen JS, Bradshaw CS, Tabrizi SN, Fairley CK, Hamasuna R. Azithromycin Treatment Failure in Mycoplasma genitalium-Positive Patients with Nongonococcal Urethritis Is Associated with Induced Macrolide Resistance. Clin Infect Dis. Dec 15 2008;47(12):1546-1553. [Medline].

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Keywords

urethritis, gonococcal urethritis, nongonococcal urethritis, NGU, GU, urethral inflammation, urethra inflammation, infected urethra, STD, sexually transmitted disease, Neisseria gonorrhoeae, N gonorrhoeae, Chlamydia trachomatis, C trachomatis, Ureaplasma urealyticum, U urealyticum, Mycoplasma hominis, M hominis, Trichomonas vaginalis, T vaginalis, Mycobacterium, lymphogranuloma venereum, herpes genitalis, genital herpes, syphilis, mycobacteria, cystitis, urethral stricture, post-traumatic urethritis, posttraumatic urethritis, foreign body insertion, epididymitis, orchitis, prostatitis, proctitis, Reiter syndrome, iritis, pneumonia, otitis media, urinary tract infection, UTI, pelvic inflammatory disease, PID, disseminated gonococcal infection, DGI, infectious urethritis

Contributor Information and Disclosures

Author

Martha K Terris, MD, FACS, Professor, Department of Surgery, Medical College of Georgia
Martha K Terris, MD, FACS is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Institute of Ultrasound in Medicine, American Urological Association, New York Academy of Sciences, and Society of University Urologists
Disclosure: Nothing to disclose.

Coauthor(s)

Kamran P Sajadi, MD, Staff Physician, Division of Urology, Medical College of Georgia Health System
Kamran P Sajadi, MD is a member of the following medical societies: American Urological Association, Endourological Society, and National Association for Continence
Disclosure: Nothing to disclose.

Medical Editor

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, 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, and Society of Urologic Oncology
Disclosure: GSK Consulting fee Consulting; Astra Zeneca Honoraria Speaking and teaching; Watson Pharmaceuticals Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

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, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

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