Male Urethritis in Emergency Medicine Workup

  • Author: Michael C Plewa, MD; Chief Editor: Erik D Schraga, MD   more...
 
Updated: May 11, 2012
 

Laboratory Studies

  • Because gonorrhea and chlamydia are reportable to the state health departments in the United States,[10, 11, 12] confirmatory diagnostic testing is recommended. Options include Gram stain, culture, direct immunofluorescence, enzyme immunoassay, polymerase chain reaction, nucleic acid hybridization, or nucleic acid amplification testing (NAAT), with the latter being the most sensitive.
    • Urethral swab specimen may be obtained by inserting a Dacron or calcium alginate swab a centimeter into the urethra and gently twisting. Testing of the discharge itself is less sensitive. The sensitivity of urethral swab testing is diminished by recent voiding.
    • Gram stain microscopy may not be necessary if the patient will be treated empirically for both GCU and NGU. Gram stain microscopy with gram-negative intracellular diplococci indicates gonococcal infection. A negative Gram stain usually indicates NGU, but it does not completely exclude gonococcal infection.[13]
    • The presence of more than 5 WBC per oil immersion field on Gram stain of urethral secretions secures the diagnosis of urethritis. However, this classic cutoff of 5 WBC has sensitivity for infection by Neisseria gonorrhoeae, Chlamydia trachomatis, and Ureaplasma urealyticum of 80%, 23%, and 11%, respectively.[13] Some suggest the use of the presence of 2 or more polymorphonucleocytes per high-power field to diagnose urethritis.[14]
  • Urine testing
    • Nucleic acid amplification testing (NAAT) of a urine specimen is the most sensitive test (in a male) for gonorrhea or chlamydia.
    • A first-void urine specimen with positive leukocyte esterase or ≥10 white blood cells per high power field is sensitive for urethritis, but this result may also occur with cystitis, pyelonephritis, and prostatitis.
      • Leukocytes are commonly absent in midstream specimens in patients with GCU as well as even first-void specimens from patients with NGU.
      • Leukocytes esterase testing may be as accurate as a urethral smear in asymptomatic partners in STD clinics.
    • Urinalysis may also visibly identify T vaginalis infection, although culture or PCR assay are more sensitive, and multiple specimens may be necessary for confirmation.[15] Because of the high transmission rate, male sex partners of infected women can be presumed to also carry T vaginalis.
  • Patients should be screened for HIV and syphilis serology (Venereal Disease Research Laboratory [VDRL] test or rapid plasma reagin test) should be obtained.
  • For refractory urethritis, consider culture of urethral secretions or first-void urine for T vaginalis.
Next

Procedures

  • Gram stain of the urethral discharge is useful to secure the diagnosis as well as to determine GCU, but this test may no longer be considered essential, since the results usually do not alter therapy.
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Contributor Information and Disclosures
Author

Michael C Plewa, MD  Research Coordinator, Consulting Staff, Department of Emergency Medicine, Lucas County Emergency Physicians, Inc, and Mercy Saint Vincent Medical Center

Michael C Plewa, MD, is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Physicians for Social Responsibility, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

David S Howes, MD  Professor of Medicine and Pediatrics, Emergency Medicine Residency Program Director Emeritus, Head, Phemister Society, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

David S Howes, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Richard H Sinert, DO  Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD  Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

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