Male Urethritis Clinical Presentation
- Author: Michael C Plewa, MD; Chief Editor: Erik D Schraga, MD more...
The majority, but certainly not all, of patients with urethritis are symptomatic and may experience any of the following symptoms:
Urethral discharge, purulent or mucopurulent
Hematuria or hemospermia
Painful intercourse or ejaculation
Asymptomatic urethritis is common (16%) and typically nongonococcal in etiology. Patients may be detected with partner screening for STIs or with physical examination revealing unrecognized urethral discharge.[26, 27]
Gonococcal urethritis (GCU) has a more abrupt onset of symptoms, commonly within 3-4 days and usually within 7 days, with opaque yellow or white discharge and significant dysuria.
In contrast, NGU has insidious onset, minimal dysuria, and scant or mucoid or clear discharge.
Systemic symptoms (eg, fever, chills, sweats, nausea) are typically absent but, if present, may suggest disseminated gonococcemia, pyelonephritis, orchitis, or other infection.
Ask about number and sex of sexual partners and condom use.
Ask about history of STDs, including previous urethritis.
Ask about recent urethral catheterization or instrumentation, either medical or self-induced (eg, foreign body).
Ask about the following systemic symptoms of disseminated gonococcal, chlamydial, or mycoplasmal infections:
Male urethritis as a localized inflammatory process would not be expected to result in the appearance of toxicity or significant abnormal vital signs, including fever. Systemic findings of sepsis such as fever or hypotension should prompt consideration of another disease process.
Examine the urethral meatus for skin lesion, stricture, or obvious urethral discharge. The urethral meatus may appear inflamed with tenderness, erythema, and possibly swelling. Urethral discharge, whether purulent or mucopurulent, secures the diagnosis.
Palpate along the urethra for areas of fluctuance, tenderness, or warmth suggestive of abscess or for firmness suggestive of foreign body.
Have the patient strip (milk) the urethra outwards to express discharge.
Physical examination is important in men at risk for STIs, especially those previously treated for urethritis, even if without symptoms, since as many as 10% of asymptomatic cases will have findings.
Examine the testes and epididymis for swelling, tenderness, or warmth suggestive of orchitis or epididymitis.
Examine the foreskin and glans for evidence of balanitis or posthitis, which may be associated with M genitalium infection.
Palpate the prostate for tenderness or bogginess suggestive of prostatitis.
In patients with symptoms suggestive of disseminated gonococcal, chlamydial, or mycoplasmal disease, the remainder of the physical examination should assess the pharynx, joints, skin, conjunctivae, tympanic membranes, and lungs.
Promiscuous or unprotected sex is a significant risk factor for urethritis or other sexually transmitted diseases (STIs).
N gonorrhoeae, the cause of gonococcal urethritis (GCU) is a gram-negative intracellular diplococcus, which can also be involved in epididymitis, prostatitis, proctitis, septic arthritis, disseminated infection, pharyngitis, osteomyelitis, as well as pelvic inflammatory disease, infertility, endometritis, Bartholin gland abscess in women and conjunctivitis in neonates. GCU typically causes a discharge.
Nongonococcal urethritis (NGU) can be caused by various organisms (see list below). A recent study of 293 symptomatic young heterosexual men with NGU detected C trachomatis in 44%, M genitalium in the 31%, T vaginalis in 13%, and no detectable pathogen in 28% (Ureasplasma screening not available).
In one study of 424 men with signs and symptoms of acute urthritis, 127 (30%) were found to be infected with N gonorrhoeae. In 297 men with nongonococcal urethritis, C trachomatis was detected in 143 (48.1%). In 154 men with nonchlamydial nongonococcal urethritis, M genitalium (22.7%), M hominis (5.8%), U parvum (9.1%), U urealyticum (19.5%), H influenzae (14.3%), N meningitidis (3.9%), T vaginalis (1.3%), human adenovirus (16.2%), and herpes simplex virus types 1 (7.1%) and 2 (2.6%) were detected.
The etiology of nongonococcal urethritis often cannot be determined in 30-40% of patients, according to some studies. In a Swedish study, the etiology in at least 24% of patients with acute nongonococcal urethritis could not be identified.
C trachomatis, an obligate intracellular organism, is likely the most common nongonococcal cause of urethritis, present in as many as 43% of NGU cases. This organism can also be involved in prostatitis, proctitis, epididymitis, lymphogranuloma venereum as well as pelvic inflammatory disease, chronic pelvic pain and infertility in women, and trachoma and neonatal pneumonia.
Mycoplasma are non–cell-walled organisms associated with mucosal surfaces. Both Mycoplasma and Ureaplasma species can cause urethritis, pyelonephritis, pelvic inflammatory disease, infertility and endometritis in women, and chorioamnionitis, neonatal pneumonia, bacteremia, and meningitis in infants. Rarely, these can result in infectious arthritis, osteomyelitis, abscess, and even struvite kidney stones. They each can be transmitted sexually as well as vertically from mother to infant. These organisms are not routinely tested for in urethritis since PCR is not yet clinically available in most settings. Specialized culture media and growing conditions are required, and use of a calcium alginate swab is necessary for isolation.
With M genitalium and M hominis, special techniques, such as NAAT, may be necessary to differentiate between Mycoplasma and Ureaplasma species and are not typically available in the clinical setting. M genitalium may be the second most common cause of NGU and should be considered in cases of refractory NGU and in NGU testing negative for N gonorrhoea and C trachomatis.
With regard to U parvum and U urealyticum, Ureaplasma, previously thought to be nonpathogenic, and part of normal genital flora in as many as 70% of sexually active humans, have recently been determined to be associated with urethritis, especially when present in high numbers.
Trichomonas is a single-celled, motile parasite, easily visible on wet mount, which infects the squamous epithelium of the genital tract. As many as 70% of male sexual partners of women with T vaginalis will also be transiently colonized. Although commonly transmitted sexually, T vaginalis can also be transmitted via fomites. Men with T vaginalis are more often asymptomatic carriers, but T vaginali s can cause urethritis and may also be involved in prostatitis, epididymitis, and balanoposthitis. In women, vaginitis is typical, but T vaginalis can coexist with other organisms in pelvic inflammatory disease, endometritis, Bartholin gland abscess, postoperative infections (cuff cellulitis), cervical neoplasia, and, during pregnancy, can also result in preterm delivery and low birth weight infants.
The prevalence of T vaginalis may be decreasing in some regions. Lewis et al reported T vaginalis prevalence decreased from 13% in 2007 to 5% in 2012 in South Africa.
Gardnerella is a gram-negative anaerobic organism existing in a biofilm on mucosal surfaces. Previously considered nonpathogenic in males, G vaginalis is now thought to be associated with male urethritis, cystitis, balanoposthitis, as well as sepsis, pulmonary abscess, perinephric abscess or osteomyelitis in rare cases. As many as 80% of male sexual partners of women with bacterial vaginosis are colonized. In women, G vaginalis is involved in pelvic inflammatory disease, endometritis, infertility, postoperative infections (cuff cellulitis), preterm labor (and low birth weight infants), chorioamnionitis, and cervical neoplasia.
Rare infectious causes of urethritis include herpes genitalis, syphilis, mycobacterium, N meningitidis, H influenzae, Streptococcus species , Candida species, adenovirus, cytomegalovirus, as well as typical bacteria (usually gram-negative rods) associated with cystitis in the presence of urethral stricture or following insertive anal sex.
Idiopathic urethritis, which is defined by some as urethral symptoms without NAAT evidence of the 4 most common causes (N gonorrhea, C trachomatis, T vaginalis, and M genitalium), is a common classification of urethritis in young men.
Schwebke JR, Rompalo A, Taylor S, Seña AC, Martin DH, Lopez LM, et al. Re-evaluating the treatment of nongonococcal urethritis: emphasizing emerging pathogens--a randomized clinical trial. Clin Infect Dis. 2011 Jan 15. 52(2):163-70. [Medline]. [Full Text].
Seña A, Lensing S, Rompalo A, Taylor S, Martin D, Lopez L. Chlamydia trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis infections in men with non-gonococcal urethritis: predictors and persistence after therapy. J Infect Dis. 2012 May 21. [Medline].
Pond MJ, Nori AV, Witney AA, Lopeman RC, Butcher PD, Sadiq ST. High Prevalence of Antibiotic-Resistant Mycoplasma genitalium in Nongonococcal Urethritis: The Need for Routine Testing and the Inadequacy of Current Treatment Options. Clin Infect Dis. 2014 Jan 2. [Medline].
Manhart LE, Gillespie CW, Lowens MS, Khosropour CM, Colombara DV, Golden MR, et al. Standard treatment regimens for nongonococcal urethritis have similar but declining cure rates: a randomized controlled trial. Clin Infect Dis. 2013 Apr. 56(7):934-42. [Medline]. [Full Text].
Takahashi S, Ichihara K, Hashimoto J, Kurimura Y, Iwasawa A, Hayashi K, et al. Clinical efficacy of levofloxacin 500 mg once daily for 7 days for patients with non-gonococcal urethritis. J Infect Chemother. 2011 Jun. 17(3):392-6. [Medline].
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].
Horner P, Blee K, O'Mahony C, Muir P, Evans C, Radcliffe K, et al. 2015 UK National Guideline on the management of non-gonococcal urethritis. Int J STD AIDS. 2016 Feb. 27 (2):85-96. [Medline].
Gaydos CA, Maldeis N, Hardick A, Hardick J, Quinn TC. Mycoplasma genitalium Compared to Chlamydia, Gonorrhea, and Trichomonas as an Etiologic Agent of Urethritis in Men Attending STD Clinics. Sex Transm Infect. 2009 Apr 20. [Medline].
Iser P, Read TH, Tabrizi S, Bradshaw C, Lee D, Horvarth L, et al. Symptoms of non-gonococcal urethritis in heterosexual men: a case control study. Sex Transm Infect. 2005 Apr. 81(2):163-5. [Medline].
Moi H, Reinton N, Moghaddam A. Mycoplasma genitalium is associated with symptomatic and asymptomatic non-gonococcal urethritis in men. Sex Transm Infect. 2009 Feb. 85(1):15-8. [Medline].
Ito S, Hanaoka N, Shimuta K, Seike K, Tsuchiya T, Yasuda M, et al. Male non-gonococcal urethritis: From microbiological etiologies to demographic and clinical features. Int J Urol. 2016 Feb 4. [Medline].
Hamasuna R. Mycoplasma genitalium in male urethritis: diagnosis and treatment in Japan. Int J Urol. 2013 Jul. 20(7):676-84. [Medline].
Chrisment D, Charron A, Cazanave C, Pereyre S, Bébéar C. Detection of macrolide resistance in Mycoplasma genitalium in France. J Antimicrob Chemother. 2012 Nov. 67(11):2598-601. [Medline].
Horner P, Blee K, Adams E. Time to manage Mycoplasma genitalium as an STI: but not with azithromycin 1?g!. Curr Opin Infect Dis. 2014 Feb. 27(1):68-74. [Medline].
Couldwell DL, Tagg KA, Jeoffreys NJ, Gilbert GL. Failure of moxifloxacin treatment in Mycoplasma genitalium infections due to macrolide and fluoroquinolone resistance. Int J STD AIDS. 2013 Oct. 24(10):822-8. [Medline].
Ito S, Yasuda M, Seike K, Sugawara T, Tsuchiya T, Yokoi S, et al. Clinical and microbiological outcomes in treatment of men with non-gonococcal urethritis with a 100-mg twice-daily dose regimen of sitafloxacin. J Infect Chemother. 2012 Jun. 18(3):414-8. [Medline].
Weinstein SA, Stiles BG. Recent perspectives in the diagnosis and evidence-based treatment of Mycoplasma genitalium. Expert Rev Anti Infect Ther. 2012 Apr. 10(4):487-99. [Medline].
Wetmore CM, Manhart LE, Golden MR. Idiopathic urethritis in young men in the United States: prevalence and comparison to infections with known sexually transmitted pathogens. J Adolesc Health. 2009 Nov. 45(5):463-72. [Medline]. [Full Text].
Wetmore CM, Manhart LE, Lowens MS, Golden MR, Whittington WL, Xet-Mull AM, et al. Demographic, behavioral, and clinical characteristics of men with nongonococcal urethritis differ by etiology: a case-comparison study. Sex Transm Dis. 2011 Mar. 38(3):180-6. [Medline].
Herz D, Weiser A, Collette T, Reda E, Levitt S, Franco I. Dysfunctional elimination syndrome as an etiology of idiopathic urethritis in childhood. J Urol. 2005 Jun. 173(6):2132-7. [Medline].
Eradi B, Ninan GK. Intravesical steroid instillation--a novel therapeutic intervention for idiopathic urethritis of childhood. Eur J Pediatr Surg. 2009 Apr. 19(2):105-7. [Medline].
Henderson L, Farrelly P, Dickson AP, Goyal A. Management strategies for idiopathic urethritis. J Pediatr Urol. 2016 Feb. 12 (1):35.e1-5. [Medline].
Furuya R, Takahashi S, Furuya S, Saitoh N, Ogura H, Kurimura Y, et al. Is urethritis accompanied by seminal vesiculitis?. Int J Urol. 2009 Jul. 16(7):628-31. [Medline].
Shahmanesh M, Moi H, Lassau F, Janier M. 2009 European guideline on the management of male non-gonococcal urethritis. Int J STD AIDS. 2009 Jul. 20(7):458-64. [Medline].
Gillespie CW, Manhart LE, Lowens MS, Golden MR. Asymptomatic urethritis is common and is associated with characteristics that suggest sexually transmitted etiology. Sex Transm Dis. 2013 Mar. 40(3):271-4. [Medline].
Kim SJ, Lee DS, Lee SJ. The prevalence and clinical significance of urethritis and cervicitis in asymptomatic people by use of multiplex polymerase chain reaction. Korean J Urol. 2011 Oct. 52(10):703-8. [Medline]. [Full Text].
Tuddenham S, Ghanem KG. Toward enhancing sexually transmitted infection clinic efficiency in an era of molecular diagnostics: the role of physical examination and risk stratification in men. Sex Transm Dis. 2013 Nov. 40(11):886-93. [Medline].
Horner PJ, Taylor-Robinson D. Association of Mycoplasma genitalium with balanoposthitis in men with non-gonococcal urethritis. Sex Transm Infect. 2011 Feb. 87(1):38-40. [Medline].
Frolund M, Lidbrink P, Wikstrom A, Cowan S, Ahrens P, Skov Jensen J. Urethritis-associated Pathogens in Urine from Men with Non-gonococcal Urethritis: A Case-control Study. Acta Derm Venereol. 2015 Dec 11. [Medline].
Mezzini TM, Waddell RG, Douglas RJ, Sadlon TA. Mycoplasma genitalium: prevalence in men presenting with urethritis to a South Australian public sexual health clinic. Intern Med J. 2013 May. 43(5):494-500. [Medline].
Shimada Y, Ito S, Mizutani K, Sugawara T, Seike K, Tsuchiya T, et al. Bacterial loads of Ureaplasma urealyticum contribute to development of urethritis in men. Int J STD AIDS. 2013 Sep 18. [Medline].
Lewis DA, Marsh K, Radebe F, Maseko V, Hughes G. Trends and associations of Trichomonas vaginalis infection in men and women with genital discharge syndromes in Johannesburg, South Africa. Sex Transm Infect. 2013 Sep. 89(6):523-7. [Medline].
Henderson L, Farrelly P, Dickson AP, Goyal A. Management strategies for idiopathic urethritis. J Pediatr Urol. 2016 Feb. 12 (1):35.e1-5. [Medline].
Kirsch TD, Shesser R, Barron M. Disease surveillance in the ED: factors leading to the underreporting of gonorrhea. Am J Emerg Med. 1998 Mar. 16(2):137-40. [Medline].
[Guideline] CDC. 2006 guidelines for treatment of sexually transmitted diseases. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 55(RR-11):1-94. [Full Text].
[Guideline] CDC, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. 2006 Aug 4. 55(RR-11):1-94. [Medline].
Orellana MA, Gómez-Lus ML, Lora D. Sensitivity of Gram stain in the diagnosis of urethritis in men. Sex Transm Infect. 2012 Feb 2. [Medline].
Rietmeijer CA, Mettenbrink CJ. Recalibrating the Gram stain diagnosis of male urethritis in the era of nucleic acid amplification testing. Sex Transm Dis. 2012 Jan. 39(1):18-20. [Medline].
Kwan B, Ryder N, Knight V, Kenigsberg A, McNulty A, Read P, et al. Sensitivity of 20-minute voiding intervals in men testing for Chlamydia trachomatis. Sex Transm Dis. 2012 May. 39(5):405-6. [Medline].
Hobbs MM, Lapple DM, Lawing LF, Schwebke JR, Cohen MS, Swygard H, et al. Methods for detection of Trichomonas vaginalis in the male partners of infected women: implications for control of trichomoniasis. J Clin Microbiol. 2006 Nov. 44(11):3994-9. [Medline].
Yasuda M, Ito S, Kido A, Hamano K, Uchijima Y, Uwatoko N, et al. A single 2 g oral dose of extended-release azithromycin for treatment of gonococcal urethritis. J Antimicrob Chemother. 2014 Nov. 69 (11):3116-8. [Medline].
Costa LM, Pedroso ER, Vieira Neto V, Souza VC, Teixeira MJ. Antimicrobial susceptibility of Neisseria gonorrhoeae isolates from patients attending a public referral center for sexually transmitted diseases in Belo Horizonte, State of Minas Gerais, Brazil. Rev Soc Bras Med Trop. 2013 May-Jun. 46(3):304-9. [Medline].
Yuan LF, Yin YP, Dai XQ, Pearline RV, Xiang Z, Unemo M, et al. Resistance to azithromycin of Neisseria gonorrhoeae isolates from 2 cities in China. Sex Transm Dis. 2011 Aug. 38(8):764-8. [Medline].
Chen PL, Hsieh YH, Lee HC, et al. Suboptimal therapy and clinical management of gonorrhoea in an area with high-level antimicrobial resistance. Int J STD AIDS. 2009 Apr. 20(4):225-8. [Medline].
CDC. Update to CDC’s Sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR. Apr 13 2007. 56(14):332-334. [Full Text].
Mena LA, Mroczkowski TF, Nsuami M, Martin DH. A randomized comparison of azithromycin and doxycycline for the treatment of Mycoplasma genitalium-positive urethritis in men. Clin Infect Dis. 2009 Jun 15. 48(12):1649-54. [Medline].
Falk L, Fredlund H, Jensen JS. Tetracycline treatment does not eradicate Mycoplasma genitalium. Sex Transm Infect. 2003 Aug. 79(4):318-9. [Medline].
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. 2008 Dec 15. 47(12):1546-53. [Medline].
Lau A, Bradshaw CS, Lewis D, Fairley CK, Chen MY, Kong FY, et al. The Efficacy of Azithromycin for the Treatment of Genital Mycoplasma genitalium: A Systematic Review and Meta-analysis. Clin Infect Dis. 2015 Nov 1. 61 (9):1389-99. [Medline].
Moi H, Blee K, Horner PJ. Management of non-gonococcal urethritis. BMC Infect Dis. 2015 Jul 29. 15:294. [Medline].
Maeda S, Yasuda M, Ito S, Seike K, Ito S, Deguchi T. Azithromycin treatment for nongonococcal urethritis negative for Chlamydia trachomatis, Mycoplasma genitalium, Mycoplasma hominis, Ureaplasma parvum, and Ureaplasma urealyticum. Int J Urol. 2009 Feb. 16(2):215-6. [Medline].
Takahashi S, Matsukawa M, Kurimura Y, et al. Clinical efficacy of azithromycin for male nongonococcal urethritis. J Infect Chemother. 2008 Dec. 14(6):409-12. [Medline].
Bradshaw CS, Jensen JS, Tabrizi SN, Read TR, Garland SM, Hopkins CA, et al. Azithromycin failure in Mycoplasma genitalium urethritis. Emerg Infect Dis. 2006 Jul. 12(7):1149-52. [Medline].
Jernberg E, Moghaddam A, Moi H. Azithromycin and moxifloxacin for microbiological cure of Mycoplasma genitalium infection: an open study. Int J STD AIDS. 2008 Oct. 19(10):676-9. [Medline].
Khosropour CM, Manhart LE, Colombara DV, Gillespie CW, Lowens MS, Totten PA, et al. Suboptimal adherence to doxycycline and treatment outcomes among men with non-gonococcal urethritis: a prospective cohort study. Sex Transm Infect. 2013 Oct 8. [Medline].
Deguchi T, Ito S, Hagiwara N, Yasuda M, Maeda S. Antimicrobial chemotherapy of Mycoplasma genitalium-positive non-gonococcal urethritis. Expert Rev Anti Infect Ther. 2012 Jul. 10(7):791-803. [Medline].
Hamasuna R, Takahashi S, Uehara S, Matsumoto T. Should urologists care for the pharyngeal infection of Neisseria gonorrhoeae or Chlamydia trachomatis when we treat male urethritis?. J Infect Chemother. 2012 Feb 4. [Medline].
Shigehara K, Kawaguchi S, Sasagawa T, Furubayashi K, Shimamura M, Maeda Y, et al. Prevalence of genital Mycoplasma, Ureaplasma, Gardnerella, and human papillomavirus in Japanese men with urethritis, and risk factors for detection of urethral human papillomavirus infection. J Infect Chemother. 2011 Aug. 17(4):487-92. [Medline].
Hamasuna R, Yasuda M, Ishikawa K, Uehara S, Takahashi S, Hayami H, et al. Nationwide surveillance of the antimicrobial susceptibility of Neisseria gonorrhoeae from male urethritis in Japan. J Infect Chemother. 2013 Aug. 19(4):571-8. [Medline].
Lau CY, Qureshi AK. Azithromycin versus doxycycline for genital chlamydial infections: a meta-analysis of randomized clinical trials. Sex Transm Dis. 2002 Sep. 29(9):497-502. [Medline].
Lyss SB, Kamb ML, Peterman TA, et al. Chlamydia trachomatis among patients infected with and treated for Neisseria gonorrhoeae in sexually transmitted disease clinics in the United States. Ann Intern Med. 2003 Aug 5. 139(3):178-85. [Medline].