eMedicine Specialties > Urology > Common Problems of the Urethra
Urethritis: Treatment & Medication
Updated: Aug 10, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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.
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
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
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
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.
Adult
250 mg IM single dose
Pediatric
CDC guidelines for urethritis
Children: 125 mg IM single dose
Adolescents: 125 mg IM single dose
Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
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.
Adult
400 mg PO single dose
Pediatric
CDC guidelines for urethritis
<45 kg: Not established
>45 kg: 400 mg PO single dose
Coadministration of aminoglycosides increases nephrotoxicity; probenecid may increase effects
Documented hypersensitivity
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.
Adult
500 mg PO single dose
Pediatric
CDC guidelines for urethritis
Adolescents: Administer as in adults
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)
Documented hypersensitivity
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.
Adult
400 mg PO single dose
Pediatric
<18 years: Not recommended
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)
Documented hypersensitivity
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.
Adult
100 mg PO bid for 7 d
Pediatric
CDC guidelines for urethritis
<8 years: Not recommended
>8 years: Administer as in adults
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
Documented hypersensitivity; severe hepatic dysfunction
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
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| Overview: Urethritis |
| Differential Diagnoses & Workup: Urethritis |
 Treatment & Medication: Urethritis |
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Further Reading
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
