Introduction
Background
Urethral discharge, dysuria, and exposure to a sexually transmitted disease (STD) are frequent presentations of urethritis in the male population presenting to the ED. Recent research has focused on cost-effective antibiotic therapy with minimal adverse effects and dosing; the goal is to optimize compliance and prevent recurrence of this disease, which is predominantly sexually transmitted.
Pathophysiology
Inflammation of the urethra is more frequently infectious than posttraumatic, with sexually transmitted diseases (STDs) the most common cause. Sexually transmitted urethritis is classified as either gonococcal urethritis (GCU) following infection with Neisseria gonorrhoeae, or nongonococcal urethritis (NGU) from Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma hominis, Mycoplasma genitalium, or Trichomonas vaginalis.1
Unusual infectious causes of urethritis include herpes genitalis, syphilis, mycobacterium, 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.
Urethritis following trauma is less common, but it can occur with intermittent catheterization or after urethral instrumentation or foreign body insertion. Fewer than 20% of patients practicing intermittent catheterization suffer urethritis; however, use of latex instead of silicone catheters significantly increases this risk. Symptoms of urethritis (urethral syndrome) can also be due to sensitivity to chemicals in spermicidal or contraceptive jellies or foams.
Urethritis involves local mucous membrane epithelial cell damage or invasion by an infectious agent (bacterial, viral, or fungal) followed by inflammatory changes including accumulation of leukocytes and chemical mediators (antibodies, cytokines, and interleukins) with resultant swelling, discharge, and pain.
Mortality/Morbidity
Urethritis usually resolves without complication, even if untreated, yet it can result in urethral stricture, stenosis, or abscess formation in rare cases.
Sex
This article discusses male urethritis.
Age
Urethritis is predominantly a disease of adolescent and adult men. The prevalence is greatest in men younger than 25 years.
Clinical
History
- 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
- Arthritis
- Conjunctivitis
- Proctitis
- Prostatitis
- Epididymitis/orchitis
- Pneumonia
- Otitis media
- Low back pain (reactive arthritis)
- Iritis
- Rash
Physical
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.
- 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 joints, skin, conjunctivae, tympanic membranes, and lungs.
Causes
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.
- Nongonococcal urethritis (NGU) can be caused by the following:
- U urealyticum
- C trachomatis
- M genitalium
- M hominis
- T vaginalis (typically in association with other agents)
- Rare infectious causes of urethritis include herpes genitalis, syphilis, mycobacterium, 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.
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| References |
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References
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[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. Aug 4 2006;55(RR-11):1-94. [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. Apr 2009;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 [serial online]. Apr 13 2007;56(14):332-334. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5614a3.htm?s_cid=mm5614a3_e.
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. Jun 15 2009;48(12):1649-54. [Medline].
Falk L, Fredlund H, Jensen JS. Tetracycline treatment does not eradicate Mycoplasma genitalium. Sex Transm Infect. Aug 2003;79(4):318-9. [Medline].
Lau CY, Qureshi AK. Azithromycin versus doxycycline for genital chlamydial infections: a meta-analysis of randomized clinical trials. Sex Transm Dis. Sep 2002;29(9):497-502. [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. Feb 2009;16(2):215-6. [Medline].
Takahashi S, Matsukawa M, Kurimura Y, et al. Clinical efficacy of azithromycin for male nongonococcal urethritis. J Infect Chemother. Dec 2008;14(6):409-12. [Medline].
Bradshaw CS, Chen MY, Fairley CK. Persistence of Mycoplasma genitalium following azithromycin therapy. PLoS One. 2008;3(11):e3618. [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. Aug 5 2003;139(3):178-85. [Medline].
Wikström A, Jensen JS. Mycoplasma genitalium: a common cause of persistent urethritis among men treated with doxycycline. Sex Transm Infect. Aug 2006;82(4):276-9. [Medline].
Further Reading
Keywords
urethritis, inflammation of the urethra, urethritis symptoms, urethritis treatment, urethral discharge, dysuria, sexually transmitted disease, STD, infectious urethritis, posttraumatic urethritis, gonococcal urethritis, GC urethritis, GCU, nongonococcal urethritis, NG urethritis, NGU, Neisseria gonorrhoeae, N gonorrhoeae, Chlamydia trachomatis, C trachomatis, Ureaplasma urealyticum, U urealyticum, Mycoplasma hominis, M hominis, Mycoplasma genitalium, Trichomonas vaginalis, T vaginalis, lymphogranuloma venereum, herpes genitalis, syphilis, mycobacterium, epididymitis, orchitis, prostatitis, proctitis, Reiter syndrome, urinary tract infection, pyelonephritis, arthritis, conjunctivitis, iritis, urethral stricture, reactive arthritis, Mycoplasma Infections
