Male Urethritis Guidelines

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

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.