urethritis

Introduction

Inflammation of the urethra.

Etiology

• common causes
  • Neisseria gonorrhoeae
  • Chlamydia trachomatis
  • Ureaplasma urealyticum
• less common causes
  • viral
    • Herpes simplex (may be particulary painful)
    • condylomata accuminata
  • bacterial
    • coliforms (colonic bacteria)
    • Mycoplasma genitalium
    • Neisseria meningitidis among heterosexual men
      • receptive oral sex suggested as mechanism
  • fungal
    • Candida
    • Rhinosporidium
  • parasitic
    • Trichomonas vaginalis
    • schistosomes
• no infectious etiology found in 20-65% of cases

Clinical manifestations

• general
  • urethral discharge
    • mucoid or mucopurulent
    • clear, brown, yellow, white, green
    • profuse, yellow mucopurulent discharge suggests gonococcus
    • scantly, mucoid clear or white discharge suggests Chlamydia
  • urethra meatal crusting & erythema
  • dysuria
  • urethral itch
  • urethral tenderness
• associated manifestations of specific etiologies
  • Herpes simplex: regional lymphadenopathy
  • Chlamydia trachomatis
    • conjunctivitis
    • Reiter's syndrome
    • epididymitis
    • incubation period is 1-5 weeks, generally 2-3 weeks
• Neisseria gonorrhoeae
  • incubation period 2-8 days

Laboratory

• gram stain of urethral discharge
  • > 5 WBC/hpf (oil)
  • presence of bacteria
• urinalysis
  • first 10-15 mL of urine
  • > 20 WBC/hpf in spun specimen
• culture of urethral discharge
• test for Chlamydia
  • antigen detection tests
  • nucleic acid hybridization

Differential diagnosis

• urethral foreign body or calculi
  • pain is usually intermittent
  • may be bloody discharge
  • may be palpable
• clinical manifestation of systemic disorder
  • Stevens-Johnson syndrome
  • Wegener's granulomatosis
  • tumor
• chemical irritation of the urethra
  • soaps
• congenital anomalies

Management

• Neisseria gonorrhea:
  • primary therapy
    • ceftriaxone 125 mg IM
    • cefixime 400 mg PO
    • ciprofloxacin 500 mg PO
    • ofloxacin 400 mg PO
    • penicillin-sensitive strains
      • amoxicllin 3 g PO
      • ampicillin 3.5 g PO
      • penicillin G 4.8 million units IM distributed in 2 sites
      • probencid 1 g PO along with agent
  • also treat for Chlamydia trachomatis
    • azithromycin 1 g PO once
    • doxycycline 100 mg PO for 7 days
    • erythromycin 500 mg PO QID for 7 days (pregnancy)
• non-gonococcal urethritis
  • doxycycline 100 mg PO BID for 7 days
  • tetracycline 500 mg PO QID for 7 days
  • azithromycin (Zithromax) 1 g PO once
  • ofloxacin (Floxin) 300 mg PO BID for 7 days (other quinolones may not be effective)
  • erythromycin 500 mg PO QID for 7 days
  • amoxicillin 500 mg PO TID for 120 days
  • clindamycin 450 mg PO QID for 10 days
  • sulfisoxazole 500 mg PO QID for 10 days
• patient education
  • urethritis is sexually transmitted
  • affected individuals may be asymptomatic (carriers)
  • partners should be referred for treatment
  • Chlamydia & Ureaplasma rarely cause serious sequelae in men
  • Chlamydia infection in women
    • infertility secondary to tubal occlusion
    • ectopic pregnancy
    • chronic pelvic pain
    • infection may be transmitted to fetus
• follow-up
  • asymptomatic patients after course of antibiotics
    • test of cure for Chlamydia after 3 weeks
      • false negative may result if tested sooner
  • persistence of symptoms after course of antibiotics
    • consider Mycoplasma genitalium infection
      • consider course of azithromycin or fluoroquinolone if doxycyline (tetracycine) was used
    • consider metronidazole 2 g PO once if Trichomonas vaginalis is suspected
    • referral to urology

More general terms

• urologic disease

Additional terms

• urinary tract infection (UTI)