Urethritis Clinical Presentation

Updated: Dec 18, 2020
  • Author: Dustin L Whitaker, MD; Chief Editor: Edward David Kim, MD, FACS  more...
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Presentation

History

Obtaining a careful patient history often helps differentiate between a sexually transmitted disease (STD) and other causes of urethritis. The questions can be quite personal, and the physician should take care to remain objective regarding the patient's sexual history. If the patient is made to feel uncomfortable, they may not be forthcoming with essential information necessary to guide further diagnosis and treatment. This can delay or impede treatment altogether for the patient and their sexual partners, including the chain of partners that may be linked to the patient (eg, partners of partners and so on).

Sexual history

Certain sexual practices may increase or decrease the likelihood of contracting infectious urethritis.

Contraceptive use

Condom use substantially decreases the chance of STD transmission. Other forms of contraception either do not improve or worsen the chance of transmitting infectious urethritis. The use of spermicides may cause a chemical urethritis which can mimic the symptoms of infectious urethritis.

Age at first intercourse

Apart from certain religious groups that encourage marriage and monogamy at an early age, early age at first intercourse correlates with an increased risk of STD.

Number of sexual partners

Individuals with multiple sexual partners are more likely to contract an STD. Long-term monogamous couples are extremely unlikely to contract an STD. A married patient should not be informed of the diagnosis (or possible diagnosis) in the presence of his or her spouse, but the spouse should be treated once the patient has had the opportunity to discuss further with their spouse.

Sexual preference

Men who have sex with men have the highest rate of STDs. They are followed, in order of occurrence rates, by men who have sex with women, women who have sex with men, and women who have sex with women. 

Previous STDs

Patients with a prior history of STDs are at an increased risk of contracting another STD. Concurrent STDs may also occur. A high level of suspicion for more sinister STDs, such as syphilis and HIV infection, should be maintained. In addition, urethritis can increase viral shedding of HIV and can increase the likelihood of transmission. [22]

Symptoms

Many patients, including approximately 25% of those with nongonococcal urethritis (NGU), are asymptomatic and present following partner screening. Up to 75% of women with Chlamydia trachomatis infection are asymptomatic.

The clinician should specifically address the following manifestations:

  • Timing: Symptoms generally begin 4 days to 2 weeks after contact with an infected partner, or the patient may be asymptomatic.

  • Urethral discharge: Fluid may be yellow, green, brown, or tinged with blood, and production is unrelated to sexual activity.

  • Dysuria: Typically localized to the meatus or distal penis, worst during the first morning void, and worsened with alcohol consumption. Urinary frequency and urgency are typically absent. If present, either should suggest prostatitis or cystitis.

  • Itching: A sensation of urethral itching or irritation may persist between voids, and some patients have itching instead of pain or burning.

  • Orchalgia: Men sometimes complain of heaviness in the genitals. Associated pain in the testicles should suggest epididymitis, orchitis, or both.

  • Menstrual cycle: Women occasionally complain of worsening symptoms during menses.

  • Foreign body or instrumentation: The patient should be questioned about recent urethral catheterization or instrumentation, either medical or self-induced (eg, foreign body), which may cause traumatic urethritis.

Systemic symptoms

Systemic symptoms (eg, fever, chills, sweats, nausea) are typically absent but, if present, may suggest disseminated gonococcemia, pyelonephritis, arthritis, conjunctivitis, proctitis, prostatitis, epididymitis or orchitis, pneumonia, otitis media, or reactive arthritis (eg, low back pain, iritis, or rash [characteristically involving the palms of hands and soles of feet]).

Next:

Physical Examination

Most patients with urethritis do not appear ill and do not present with signs of sepsis, such as fever, tachycardia, tachypnea, or hypotension. The primary focus of the examination is on the genitalia.

Men

It is best to avoid examination immediately following micturition as urination temporarily washes away discharge and potentially culturable organisms. Since urine culture is an important component of the evaluation, advise the patient to urinate approximately 2 hours before the examination so that culture and examination results are optimal and the patient can comfortably provide a urine specimen after the examination.

Ensure that the patient is standing, completely undressed from the waist down, and that the room is warm and with good lighting. Inspect the underwear for secretions which may yield information.

Examine the patient for skin lesions that may indicate other STDs, such as condyloma acuminatumherpes simplex, or syphilis. The examiner must retract the foreskin of uncircumcised men to fully examine the penis and urethra.

Examine the lumen of the distal urethral meatus for lesions, stricture, or obvious urethral discharge.

Strip the urethra by gently palpating from the base of the penis to the glans to reveal any urethral discharge. Any discharge should be sampled and sent for analysis and culture. Palpate along the urethra for areas of fluctuance, tenderness, or warmth or for firmness, which may suggest abscess or foreign body, respectively.

Examine the testes for masses or inflammation. Palpate the spermatic cord, examining for swelling, tenderness, or warmth suggestive of orchitis or epididymitis.

Check for inguinal adenopathy.

Palpate the prostate for tenderness or bogginess suggestive of prostatitis. Note any lesion around the external anus during digital rectal exam.

Women

As with male patients, it is best to avoid examination immediately following micturition. Advise the patient to urinate approximately 2 hours before the examination so that culture and examination results are optimal and the patient can comfortably provide a urine specimen after the examination.

The patient should be in the lithotomy or frog leg position.

Inspect the skin for any lesions that may indicate the presence of other STDs.

Strip the urethra by inserting a finger into the anterior vagina and gently palpating forward along the urethra. Any discharge should be sampled and sent for analysis and culture.

Follow the urethral examination with a complete pelvic examination, including cervical cultures.

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