Urethritis Treatment & Management

Updated: Dec 12, 2018
  • Author: Martha K Terris, MD, FACS; Chief Editor: Edward David Kim, MD, FACS  more...
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Treatment

Medical Care

Symptoms of urethritis spontaneously resolve over time, regardless of treatment. Administer antibiotics to prevent morbidity and to reduce disease transmission to others. Treating sexual contacts also prevents reinfection of the index patient.

Antibiotic therapy should cover both gonococcal urethritis and nongonococcal urethritis (NGU). If concomitant treatment for NGU is not provided, the risk of postgonococcal urethritis is approximately 50%. The choice of antibiotics should be based on cost, adverse effects, effectiveness, and compliance. In most situations, optimal treatment is with single-dose therapy administered in the emergency department or the physician's office.

For treatment of NGU, the Centers for Disease Control and Prevention (CDC) currently recommends azithromycin, 1 g orally in a single dose, or doxycycline, 100 mg orally twice a day for 7 days. [8, 9] Alternative regimens include any of the following:

  • Erythromycin base 500 mg orally four times a day for 7 days
  • Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days
  • Levofloxacin 500 mg orally once daily for 7 days
  • Ofloxacin 300 mg orally twice a day for 7 days

For uncomplicated gonococcal urethritis, the CDC recommends single doses of ceftriaxone, 250 mg IM, and azithromycin, 1 g orally; preferably, the two antibiotics should be administered simultaneously and under direct observation. If ceftriaxone is unavailable, cefixime, 400 mg orally in a single dose, can be substituted. [8]

Gonorrhea treatment guidelines issued by the World Health Organization (WHO) in 2016 recommend determining the choice of therapy on the basis of local antibiotic resistance data, but in settings where local resistance data are not available, the WHO recommends the same dual-therapy regimens as the CDC for treatment of genital gonorrhea. [11]

Because of widespread high levels of resistance, the WHO guidelines do not recommend quinolones for the treatment of gonorrhea. For monotherapy of genital gonorrhea, the WHO guidelines recommend a single dose of one of the following, with the choice based on recent local resistance data confirming susceptibility [11] :

  • Ceftriaxone 250 mg IM
  • Cefixime 400 mg orally
  • Spectinomycin 2 g IM

Patients with persistent symptoms should be reevaluated. In patients with a repeat diagnosis of NGU after treatment with doxycycline, the most common organism is Mycoplasma genitalium. Men in whom a treatment regimen of doxycycline fails should be treated with azithromycin 1 g orally in a single dose; if azithromycin fails, recommended treatment is with moxifloxacin, 400 mg once daily for 7 days, as studies have shown this dosing is highly effective against M genitalium. [9]

Trichomonas vaginalis infection should be considered in heterosexual patients with persistent symptoms. In regions where T vaginalis is prevalent, patients with urethritis should be treated empirically with metronidazole 2 g orally in a single dose or tinidazole 2 g orally in a single dose. [9]

See also Urethritis Empiric Therapy and Urethritis Organism-Specific Therapy.

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Activity

See the list below:

  • Instruct the patient to refrain from intercourse until all partners are treated.

  • Educate the patient about always using barrier devices when engaging in intercourse with multiple partners.

  • Inform patients that infections can spread by orogenital or genitoanal intercourse, even in the absence of penovaginal intercourse.

  • If symptoms persist or recur after treatment, patients should be instructed to return for re-evaluation

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Consultations

Consider urology consultation in patients with persistent or recurrent NGU after presumptive treatment for gonococcal urethritis, NGU, and M genitalium or T vaginalis  [9]

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