Male Urethritis in Emergency Medicine Clinical Presentation

• 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
  • Dysuria
  • Urethral pruritus
  • Hematuria or hemospermia
  • Painful intercourse or ejaculation
• Asymptomatic patients may be detected with partner screening for STDs, and are usually nongonococcal in etiology.
• 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.
• Urinary frequency and urgency typically are absent. If present, either should suggest prostatitis or cystitis.
• 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:

  • Fever
  • Sore throat (pharyngitis)
  • Arthritis
  • Conjunctivitis
  • Proctitis
  • Prostatitis
  • Epididymitis/orchitis
  • Pneumonia
  • Otitis media
  • Low back pain (reactive arthritis)
  • Iritis
  • Rash

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.
• Examine the testes and epididymis for swelling, tenderness, or warmth suggestive of orchitis or epididymitis.
• Palpate the prostate for tenderness or bogginess suggestive of prostatitis.
• Look at the skin of the penis, scrotum, and groin for lesions indicative of other STDs, such as herpes simplex, syphilis (including condyloma acuminatum), lymphogranuloma venereum, or chancroid.
• 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 (STDs).

• 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 the following:

  • C trachomatis, an obligate intracellular organism, is likely the most common nongonococcal cause of urethritis and 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.
    • 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.
    • 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.
  • T vaginalis: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.
  • G vaginalis: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),^[4] is a common classification of urethritis in young men.