Male Urethritis 

Updated: Apr 08, 2016
Author: Michael C Plewa, MD; Chief Editor: Erik D Schraga, MD 

Overview

Background

Urethral discharge, dysuria, and exposure to a sexually transmitted infection (STI) are frequent presentations of urethritis in the male population. Recent research has focused on cost-effective antibiotic therapy and concern for emergence of antibiotic resistance among both typical and atypical organisms. The goal of initial therapy is to optimize compliance and prevent recurrence of this disease, which is predominantly sexually transmitted.[1, 2, 3, 4, 5, 6, 7, 8]

Pathophysiology

Inflammation of the urethra is more frequently infectious than posttraumatic, with STIs being the most common cause. Sexually transmitted urethritis is classified as either gonococcal urethritis (GCU) following infection with Neisseria gonorrhoeae, or nongonococcal urethritis (NGU).

For cases of NGU, Chlamydia trachomatis remains a primary concern, although Mycoplasma genitalium and Trichomonas vaginalis are increasingly recognized as important pathogens, and less commonly Ureaplasma parvum, Ureaplasma urealyticum, Mycoplasma hominis, and Gardnerella vaginalis.[9, 10, 11]

In one 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 types 1 (7.1%) and 2 (2.6%) were detected.[12]

M genitalium, not routinely tested by polymerase chain reaction (PCR) in many locations, may cause up to 10-30% of NGU cases[1, 2, 13] and, like chlamydia, may be associated with human immunodeficiency virus (HIV), human papilloma virus (HPV), and herpes simplex transmission and infection. M genitalium has been associated with treatment failure to presently recommended single-dose therapy, owing to macrolide resistance,[14, 15, 3, 16, 13, 17, 4] and has potential for quinolone resistance as well.[16, 4, 18, 15] Couldwell et al describe rates of resistance of 15% for quinolones and 43% for macrolides among 143 M genitalium specimens in Australia in 2013.[16]

Idiopathic urethritis, defined as urethritis in the absence of nucleic acid amplification testing (NAAT) evidence for the most common infectious causes (N gonorrhoeae, C trachomatis, M genitalium, and T vaginalis), may be considered the largest category.[19, 20]

Unusual infectious causes of urethritis include herpes genitalis, syphilis, mycobacterium, adenovirus, cytomegalovirus, as well as typical bacteria (usually gram-negative rods) associated with cystitis in the presence of urethral stricture or following insertive anal sex.

Urethritis following trauma is less common, but it can occur with intermittent catheterization or after urethral instrumentation or foreign body insertion. Fewer than 20% of patients practicing intermittent catheterization suffer urethritis; however, use of latex instead of silicone catheters significantly increases this risk. Symptoms of urethritis (urethral syndrome) can also be due to sensitivity to chemicals in spermicidal or contraceptive jellies or foams.

Idiopathic urethritis of childhood is of uncertain cause, perhaps related to dysfunctional elimination syndrome,[21] and presents as blood-stained urethral discharge, bleeding between micturition, or dysuria in the 5- to 15-year-old male, and can result in urethral stricture.[22, 23]

Urethritis involves local mucous membrane epithelial cell damage or invasion by an infectious agent (bacterial, viral, or fungal) followed by inflammatory changes including accumulation of leukocytes and chemical mediators (antibodies, cytokines, and interleukins) with resultant swelling, discharge, and pain.

Epidemiology

Urethritis usually resolves without complication, even if untreated, yet it can result in urethral stricture, stenosis, or abscess formation in rare cases. Urethritis can occur in a continuum with concomitant seminal vesiculitis and epididymitis.[24]

Recurrent urethritis may occur from reinfection, therapeutic failure or "venereophobia," an old term describing fear of recurrence where men can induce urethral inflammation and drainage (negative by white blood cell or Gram stain criteria) by repeatedly milking the urethra checking for infection.[25] .

Urethritis is predominantly a disease of adolescent and adult men. The prevalence is greatest in men younger than 25 years.

 

Presentation

History

The majority, but certainly not all, 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%)[26] and typically nongonococcal in etiology. Patients may be detected with partner screening for STIs or with physical examination revealing unrecognized urethral discharge.[26, 27]

Gonococcal urethritis (GCU) 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 STDs, 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:

  • Fever

  • Sore throat (pharyngitis)

  • Arthritis

  • Conjunctivitis

  • Proctitis

  • Prostatitis

  • Epididymitis/orchitis

  • Pneumonia

  • Otitis media

  • Low back pain (reactive arthritis)

  • Iritis

  • Rash

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.[28]

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.[29]

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.

Causes

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

GCU

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

NGU

Nongonococcal urethritis (NGU) can be caused by various organisms (see list below). A recent study of 293 symptomatic young heterosexual men with NGU detected C trachomatis in 44%, M genitalium in the 31%, T vaginalis in 13%, and no detectable pathogen in 28% (Ureasplasma screening not available).[2]

In one 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 types 1 (7.1%) and 2 (2.6%) were detected.[12]

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.[30]

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, lymphogranuloma venereum as well as pelvic inflammatory disease, chronic pelvic pain and infertility in women, and trachoma and neonatal pneumonia.

Mycoplasma 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 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.[31]

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 recently been determined to be associated with urethritis, especially when present in high numbers.[32]

Trichomonas is a single-celled, motile parasite, easily visible on wet mount, which infects the squamous epithelium of the genital tract. 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 vaginali s 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), cervical neoplasia, and, during pregnancy, 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% in 2007 to 5% in 2012 in South Africa.[33]

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, balanoposthitis, as well as sepsis, pulmonary abscess, perinephric abscess or osteomyelitis in rare cases. 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, 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 gonorrhea, C trachomatis, T vaginalis, and M genitalium),[19] is a common classification of urethritis in young men.[34]

 

DDx

 

Workup

Laboratory Studies

Because gonorrhea and chlamydia are reportable to the state health departments in the United States,[35, 36, 37] confirmatory diagnostic testing is recommended. Options include Gram stain, culture, direct immunofluorescence, enzyme immunoassay, polymerase chain reaction, nucleic acid hybridization, or nucleic acid amplification testing (NAAT), with the latter being the most sensitive.

When urine testing (see below) is not available, urethral swab specimen may be obtained by inserting a Dacron or calcium alginate swab a centimeter into the urethra and gently twisting. Testing of the discharge itself is less sensitive and not recommended. The sensitivity of urethral swab testing is diminished by recent voiding.

Gram stain microscopy may not be necessary if the patient will be treated empirically for both GCU and NGU. Gram stain microscopy with gram-negative intracellular diplococci indicates gonococcal infection. A negative Gram stain usually indicates NGU, but it does not completely exclude gonococcal infection.[38]

The presence of more than 5 WBC per oil immersion field on Gram stain of urethral secretions secures the diagnosis of urethritis. However, this classic cutoff of 5 WBC has sensitivity for infection by Neisseria gonorrhoeae, Chlamydia trachomatis, and Ureaplasma urealyticum of 80%, 23%, and 11%, respectively.[38] Some suggest the use of the presence of 2 or more polymorphonucleocytes per high-power field to diagnose urethritis.[39]

Urine Testing

Nucleic acid amplification testing (NAAT) of a urine specimen is the most sensitive test (in a male) for gonorrhea or chlamydia. Sensitivity of NAAT testing for chlamydia is optimized by waiting a minimum of 20 minutes after a recent void,[40] although prior experts recommended a 1-hour wait.

A first-void urine specimen with positive leukocyte esterase or ≥10 white blood cells per high power field is sensitive for urethritis, but this result may also occur with cystitis, pyelonephritis, and prostatitis. Leukocytes are commonly absent in midstream specimens in patients with GCU as well as even first-void specimens from patients with NGU. Leukocyte esterase testing may be as accurate as a urethral smear in asymptomatic partners in STD clinics.

Urinalysis may also visibly identify T vaginalis infection, although culture or PCR assay are more sensitive, and multiple specimens may be necessary for confirmation.[41] Because of the high transmission rate, male sex partners of infected women can be presumed to also carry T vaginalis. PCR testing for M genitalium may be available in research settings and some countries,[16] but is not yet universally available.[7]

Screen for HIV and syphilis serology (Venereal Disease Research Laboratory [VDRL] test or rapid plasma reagin test).

For refractory urethritis, consider culture of urethral secretions or first-void urine for T vaginalis.

Procedures

Gram stain of the urethral discharge is useful to secure the diagnosis as well as to determine GCU, but this test may no longer be considered essential, since the results usually do not alter therapy.

 

Treatment

Emergency Department Care

History and physical examination should focus on exclusion of the following other disorders:

  • Cystitis

  • Pyelonephritis

  • Epididymitis/orchitis

  • Prostatitis

  • Pneumonia

  • Otitis media

  • Conjunctivitis

  • Arthritis

  • Reactive arthritis

  • Foreign body

  • Trauma

  • Other STDs, such as syphilis, herpes simplex, condyloma acuminatum, chancroid, or lymphogranuloma venereum

  • Urinalysis may be necessary to exclude cystitis or pyelonephritis.

  • VDRL assay should be performed to screen for syphilis.

  • Antibiotic therapy is discussed in Medication.

Consultations

Urologic consultation may be beneficial in cases of urethral foreign body or postinstrumentation urethritis.

 

Medication

Medication Summary

In the emergency department, single-dose antibiotic therapy for urethritis is administered to cover both gonococcal urethritis (GCU) and nongonococcal urethritis (NGU), since results of NAAT testing may not be immediately available, and compliance with outpatient treatment and follow-up may be uncertain. Consider presumptive treatment for T vaginalis, or base treatment on evidence of this organism on urine microscopy.

Therapy for GCU

The antimicrobial options in the treatment of GCU include ceftriaxone 125 mg IM single dose or cefixime 400 mg PO single dose. Alternative choices include a single-dose cephalosporin, such as ceftizoxime 500 mg IM or cefoxitin 2 g IM with probenecid 1 g PO, or cefotaxime 500 mg IM, or single-dose spectinomycin 2 g IM (reserved for patients with allergies to cephalosporins and not currently available in the United States). Single-dose azithromycin 2 g PO is also an alternative,[42] but it may cause gastrointestinal distress and has a resistance rate of 5%[43, 44] in some regions.

Quinolone resistance has increase worldwide, now approximately 21%,[43] and is common in Asia, the Pacific, Europe, and the Middle East as well as in some parts of the United States.[45] Quinolone-resistant GCU is also more prevalent in men who have sex with men. Because of increasing resistance, quinolones (eg, ciprofloxacin 500 mg PO single dose, levofloxacin 250 mg PO single dose, or ofloxacin 400 mg PO single dose) are not currently recommended by the Centers for Disease Control and Prevention (CDC) for routine or alternative regimens.[36, 37, 46]

The recommendation was based on analysis of new data from the CDC's Gonococcal Isolate Surveillance Project (GISP). The data from GISP showed the proportion of gonorrhea cases in heterosexual men that were fluoroquinolone-resistant (QRNG) reached 6.7%, an 11-fold increase from 0.6% in 2001. The data were published in the April 13, 2007, issue of the Morbidity and Mortality Weekly Report.[46] This limits treatment of gonorrhea to drugs in the cephalosporin class (eg, ceftriaxone 125 mg IM once as a single dose).

Fluoroquinolones may be an alternative treatment option for disseminated gonococcal infection if antimicrobial susceptibility can be documented. For more information see, the CDC's Antibiotic-Resistant Gonorrhea Web site; CDC Updated Gonococcal Treatment Recommendations (April 2007); or Medscape Medical News on CDC Issues - New Treatment Recommendations for Gonorrhea.

Therapy for NGU

A single dose of azithromycin 1 g orally or doxycycline 100 mg orally twice daily for 7 days has been recommended for treatment of NGU by the CDC,[36, 37] and both have similar clinical cure rates, 76% and 80%, respectively.[4] Doxycycline may have a higher clearance rate for Chlamydia than azithromycin[1, 2] ; however, azithromycin may be more effective than doxycycline for M genitalium[47, 48, 1, 2] and U urealyticum infections. A recent follow-up study of 293 young heterosexual NGU patients detected by NAAT persistent organisms of C trachomatis in 23% after azithromycin and 5% after doxycycline, whereas M genitalium was present in 68% after doxycycline and 33% after azithromycin.[2]

Caution has been expressed about single-dose azithromycin 1 g inducing macrolide resistance in M genitalium,[49, 50, 51] despite ensuring compliance and successful treatment of cases of NGU in which test results are negative for Chlamydia, Mycoplasma, and Ureaplasma species.[52, 53] Because of this concern for induced macrolide resistance of M genitalium after single-dose azithromycin 1 g, some recommend initial treatment with 7 days of doxycycline 100 mg orally twice daily[15] or the extended azithromycin regimen (500 mg initially, then 250 mg daily for 4 days orally).[18, 51] For patients who fail initial doxycycline therapy, the extended azithromycin regimen can then be given, with less concern for macrolide resistance. Failures of the extended azithromycin regimen should be treated with moxifloxacin 400 mg daily for 10 days.

Alternative initial regimens for NGU include 10 days of moxifloxacin 400 mg daily (which may be more effective than azithromycin for M genitalium,[54, 55, 56] although there is concern for emerging quinolone resistance[5, 18, 15, 16] ). Other choices could include 7 days of erythromycin base 500 mg 4 times daily, erythromycin ethylsuccinate 800 mg 4 times daily, ofloxacin 300 mg twice daily, levofloxacin 500 mg once daily,[36, 37, 6] or sitafloxacin 100 mg twice daily.[17] Minocycline or tetracycline is a reasonable alternative to doxycycline. Ciprofloxacin is ineffective against chlamydial infection. Combinations of probenecid with penicillin, amoxicillin, or ampicillin are no longer used because of resistance.

Therapy for T vaginalis

Consider empiric treatment for T vaginalis (although this organism may be present in as few as 2.5% of urethritis cases),[20] or base treatment on presence of this organism on urine microscopy, with single treatment of metronidazole or tinidazole 2 g orally.

Antibiotic therapy with 2 g metronidazole or tinidazole is also recommended for sexual partners of individuals with documented Trichomonas, even if asymptomatic.

Therapy for recurrent or persistent urethritis

Recurrent symptoms may be related to reexposure (especially if sexual partner not also treated), noncompliance, chronic nonbacterial prostatitis, or infection with T vaginalis, M genitalium, or U urealyticum. Noncompliance with medications may not be as important of factor in recurrent or persistent symptoms as previously thought[57] and should prompt consideration of atypical organisms.

A single dose of metronidazole 2 g orally, or tinidazole 2 g orally, should be used (especially if not given initially) for suspected Trichomonas.

M genitalium can be a common cause of persistent urethritis. Failure rates after doxycycline therapy are high,[58] and azithromycin resistance and failure are increasing. Therefore, a single-dose azithromycin 1 g is recommended[47, 5] if the patient did not previously receive azithromycin (or cannot afford quinolones). Moxifloxacin 400 mg daily for 10 days is recommended if the patient previously received azithromycin.[54, 55, 56, 5, 59]

Prolonged (14-28 d) therapy with erythromycin has not been demonstrated to be of value.

Antibiotics

Class Summary

Single-dose therapy to cover GCU and chlamydia includes azithromycin 2 g PO (limited by gastrointestinal intolerance) or azithromycin 1 g PO plus a cephalosporin.

Cefixime (Suprax)

Arrests bacterial cell wall synthesis and inhibits bacterial growth by binding to one or more penicillin-binding proteins.

Ceftriaxone (Rocephin)

Used because of increasing prevalence of penicillinase-producing N gonorrhoeae. Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms; arrests bacterial growth by binding to one or more penicillin-binding proteins.

Spectinomycin (Trobicin)

Structurally different from related aminoglycosides, inhibits protein synthesis in bacterial cells. Site of action is 30S ribosomal subunit. Used as alternative antimicrobial in treatment of urethral, endocervical, or rectal gonococcal infections in patients who cannot take cephalosporins or fluoroquinolones. Same regimen of this medication administered to pregnant women who are allergic to cephalosporins.

Azithromycin (Zithromax)

Used to treat mild to moderately severe infections caused by susceptible strains of microorganisms. Indicated for chlamydia and gonorrheal infections of genital tract.

Doxycycline (Dory, Bio-Tab)

Used in treatment of rectal syphilis. Inhibits protein synthesis and bacterial growth by binding with 30S and possibly 50S ribosomal subunits of susceptible bacteria.

Tetracycline (Sumycin)

Treats susceptible bacterial infections of both gram-positive and gram-negative organisms as well as mycoplasmal, chlamydial, and rickettsial infections. Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunits of susceptible bacteria.

Minocycline (Dynacin, Minocin)

Treats infections caused by susceptible gram-negative and gram-positive organisms, in addition to susceptible chlamydial, rickettsial, and mycoplasmal infections.

Erythromycin (E-Mycin, Eryc, Ery-Tab)

Indicated for treatment of infections caused by susceptible strains of microorganisms, including Staphylococcus aureus. Inhibits RNA-dependent protein synthesis, possibly by stimulating dissociation of peptidyl tRNA from ribosomes, thus inhibiting bacterial growth. Twice-a-day dosing not recommended when doses greater than 1 g/d are administered.

Metronidazole (Flagyl)

Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Usually used in combination with other antimicrobial agents except when used for Clostridium difficile enterocolitis in which monotherapy is appropriate. Active against various anaerobic bacteria and protozoa. Appears to be absorbed into cells, and intermediate-metabolized compounds that are formed bind DNA and inhibit protein synthesis, causing cell death.

Antibiotic, Quinolone

Class Summary

The quinolone class antibiotics are no longer considered effective against GCU due to increasing resistance. However, these antibiotics are useful for NGU as initial alternative to or when refractory to initial treatment with azithromycin.

Moxifloxacin (Avelox)

Inhibits the A subunits of DNA gyrase, resulting in inhibition of bacterial DNA replication and transcription. Useful for refractory NGU secondary to Mycoplasma genitalium infection.

Ofloxacin (Floxin)

Treats GU only. Penetrates prostate well and is effective against N gonorrhea and C trachomatis. A derivative of pyridine carboxylic acid with broad-spectrum bactericidal effect. Useful for the treatment of NGU.

Levofloxacin (Levaquin)

For pseudomonal infections and infections due to multidrug resistant gram-negative organisms as well as atypical infections such as Chlamydia, Mycoplasma and Ureaplasma species.

 

Follow-up

Further Outpatient Care

Refer patients to their primary physician, urologist, or local health department for follow-up care.

Recurrent or persistent symptoms should prompt culture for N gonorrhoeae to determine resistance, as well as evaluation or treatment for T vaginalis and Mycoplasma and Ureaplasma species.

Retesting in 3 months is recommended for men with gonococcal urethritis (GCU).

Deterrence/Prevention

Instruct patients regarding abstinence for 1 week (or until therapy is complete and symptoms have resolved) and safe sex practices (condom use) thereafter.

Sexual partners should be referred for evaluation and treatment. This includes all sexual partners of the patient with GCU during the last 60 days or the most recent sexual partner if last intercourse was more than 60 days prior to symptoms.

Complications

Urethritis can rarely result in urethral stricture, urethral stenosis, or periurethral abscess formation.

Chronic prostatitis, diagnosed when symptoms of urinary discomfort persist beyond 3 months, and epididymitis can follow untreated urethritis.

Urethritis may recur. Recurrence may be less likely due to noncompliance with treatment than previously thought[57] and should prompt consideration for atypical infections, including M genitalium and trichomonal infections.

Venereophobia, inflammation of the urethra resulting from persistent milking of the urethra for fear of recurrence, may develop.

Organisms involved in urethritis may also result in epididymitis, balanoposthitis, cystitis, and rarely sepsis, osteomyelitis, abscess formation, and septic arthritis.

Pharyngeal infection with Neisseria gonorrhoeae or Chlamydia trachomatis can occur. The prevalence of these organisms in the pharynx of men with urethritis may be as high as 20% and 6%, respectively.[60]

Reactive arthritis following chlamydial infection is uncommon.

Infertility in men following untreated urethritis is rare.

The greatest risk, especially in asymptomatic men with NGU, is sexual transmission during unprotected sex.

Sexual transmission of GCU or NGU to women may lead to cervical neoplasia, postoperative infections (cuff cellulitis or abscess), Bartholin gland abscess, endometritis, cervicitis, pelvic inflammatory disease, tubo-ovarian abscess, scarring of the fallopian tube, and infertility. Pregnant women may experience preterm labor resulting in low birth weight newborns who may also be at risk for chorioamnionitis, meningitis, pneumonia, and conjunctivitis.

Patient Education

Instruct patients on abstinence for 1 week (or until therapy is complete and symptoms have resolved) and safe sex practices (condom use) thereafter.

For patient education resources, see the Pregnancy and Reproduction Center, as well as Birth Control Overview and Birth Control FAQs.