Male Urethritis Guidelines

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

Center for Disease Control and Prevention (CDC)

According to the CDC, urethritis can be documented on the basis of any of the following signs or laboratory tests [11] :

  • Mucoid, mucopurulent, or purulent discharge on examination.

  • Gram stain is highly sensitive and specific for documenting both urethritis and the presence or absence of gonococcal infection; methylene blue (MB) or gentian violet (GV) stain of urethral secretions is an alternative POC diagnostic test with performance characteristics similar to Gram stain; thus, the cutoff number for WBCs per oil immersion field should be the same.

    • Presumed gonococcal infection is established by the presence of WBCs containing gram-negative intracellular diplococci (GNID) in Gram stain or intracellular purple diplococci in MB or GV smears; men should be tested for C trachomatis and N gonorrhoeae by nucleic acid amplification testing (NAATs) and presumptively treated and managed accordingly for gonococcal infection.

    • If no intracellular gram-negative or purple diplococci are present, men should receive  (NAATs) for C trachomatis and N gonorrhoeae and can be managed for NGU as recommended.

    • Gram stain of urethral secretions with ≥2 WBCs per oil immersion field. The microscopy diagnostic cutoff might vary, depending on background prevalence (≥2 WBCs/high power field [HPF] in high-prevalence settings [STI clinics] or ≥5 WBCs/HPF in lower-prevalence settings).

  • Positive leukocyte esterase test on first-void urine or microscopic examination of sediment from a spun first-void urine demonstrating ≥10 WBCs/HPF.

Recommended Regimen for Gonococcal Urethritis

Recommended regimen for GU is ceftriaxaone 500 mg IM single dose, or 1 g IM for persons ≥ 150 kg. [11] Alternative choices include a single-dose of cefixime 800 mg orally, or gentamicin 240 mg IM single dose with azithromycin 2 g orally in a single dose for patients with cephalosporin allergy.

Recommended Regimen for Nongonococcal Urethritis

Recommended regimen for NGU is doxycycline 100 mg orally 2 times/day for 7 days; [11] alternative regimens are (1) azithromycin 500 mg orally in a single dose, followed by 250 mg orally daily for 4 days, or (2) azithromycin 1 g orally in a single dose.

Erythromycin is no longer recommended for NGU because of gastrointestinal side effects and dosing frequency. Levofloxacin is no longer recommended for NGU because of inferior efficacy, especially for M genitalium.