Male Urethritis Clinical Presentation

Updated: Nov 29, 2021
  • Author: Michael C Plewa, MD; Chief Editor: Erik D Schraga, MD  more...
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Presentation

History

The majority 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 urethritis is common (16%) [33] and typically nongonococcal in etiology. Patients may be detected with partner screening for STIs or with physical examination revealing unrecognized urethral discharge. [33, 34]

Gonococcal urethritis (GU) 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 STIs, 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:

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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.

Have the patient strip (milk) the urethra outwards to express discharge.

Physical examination is important in men at risk for STIs, especially those previously treated for urethritis, even if without symptoms, since as many as 10% of asymptomatic cases will have findings. [35]

Examine the testes and epididymis for swelling, tenderness, or warmth suggestive of orchitis or epididymitis.

Examine the foreskin and glans for evidence of balanitis or posthitis, which may be associated with M genitalium infection. [36]

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 STIs, 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.

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Causes

Promiscuous or unprotected sex is a significant risk factor for urethritis or other sexually transmitted infections (STIs).

Gonococcal urethritis

N gonorrhoeae, the cause of gonococcal urethritis (GU), is a gram-negative intracellular diplococcus, which can also be involved in epididymitis, prostatitis, proctitis, septic arthritis, disseminated infection, pharyngitis, and osteomyelitis, as well as pelvic inflammatory disease, infertility, endometritis, Bartholin gland abscess in women, and conjunctivitis in neonates. GU typically causes a discharge.

Nongonococcal urethritis

Nongonococcal urethritis (NGU) can be caused by various organisms (see list below). A study of 293 symptomatic young heterosexual men with NGU detected C trachomatis in 44%, M genitalium in 31%, T vaginalis in 13%, and no detectable pathogen in 28%. [2]

In a study of 424 men with signs and symptoms of acute urthritis, 127 (30%) were found to be infected with N gonorrhoeae. In 297 men with nongonococcal urethritis, C trachomatis was detected in 143 (48.1%). In 154 men with nonchlamydial nongonococcal urethritis, M genitalium (22.7%), M hominis (5.8%), U parvum (9.1%), U urealyticum (19.5%), H influenzae (14.3%), N meningitidis (3.9%), T vaginalis (1.3%), human adenovirus (16.2%), and herpes simplex virus type 1 (7.1%) and type 2 (2.6%) were detected. [21]

The etiology of nongonococcal urethritis often cannot be determined in 30-40% of patients, according to some studies. In a Swedish study, the etiology in at least 24% of patients with acute nongonococcal urethritis could not be identified. [37]

C trachomatis, an obligate intracellular organism, is likely the most common nongonococcal cause of urethritis, present in as many as 43% of NGU cases. [1] This organism can also be involved in prostatitis, proctitis, epididymitis, and lymphogranuloma venereum, as well as pelvic inflammatory disease, chronic pelvic pain and infertility in women, and trachoma and neonatal pneumonia.

Mycoplasma organisms 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.

With M genitalium and M hominis, special techniques, such as nucleic acid amplification test (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 and in NGU testing negative for N gonorrhoea and C trachomatis. [38]

With regard to 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 been determined to be associated with urethritis, especially when present in high numbers. [39]

Trichomonas is a single-celled, motile parasite, easily visible on wet mount, which infects the squamous epithelium of the genital tract. Trichomonas is the most common non-viral cause of STI worldwide. Prevalence may be underestimated due to low sensitivity of wet mount testing or culture results. 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 vaginalis 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), and cervical neoplasia; and during pregnancy, T vaginalis can also result in preterm delivery and low birth weight infants.

The prevalence of T vaginalis may be decreasing in some regions. Lewis et al reported T vaginalis prevalence decreased from 13% to 5% in South Africa. [40]

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, and balanoposthitis, as well as sepsis, pulmonary abscess, perinephric abscess, or osteomyelitis. 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.

Other

Rare infectious causes of urethritis include herpes genitalis, syphilis, mycobacterium, N meningitidis, H influenzae, Streptococcus species , Candida species, adenovirus, and 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 gonorrhoeae, C trachomatis, T vaginalis, and M genitalium), [28] is a common classification of urethritis in young men. [41]

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