Updated: 7/28/2017

Urethritis

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Snapshot
  • A 22-year-old man presents to his primary care physician due to pain with urination and a burning sensation. The patient was in his usual state of health until 3 days prior to presentation. He reports to having unprotected sex for the past few weeks. On physical examination, there is purulent discharge at the urethral meatus. The patient receives a single intramuscular injection of ceftriaxone with a 1 day course of oral azithromycin.
Introduction
  • Clinical definition
    • urethritis describes inflammation of the urethra
  • Epidemiology
    • incidence
      • gonococcal urethritis
        • second most commonly reported cause of sexually transmitted infections (STI) in men
          • the most commonly reported is chlamydia
      • nongonococcal urethritis
        • the most common cause is chlamydia
    • demographics
      • most commonly occurs in sexually active young men
        • N. gonorrhoeae and C. trachomatis are commonly identified
    • risk factors
      • sexual activity
  • Etiology
    • microbial infection such as
      • N. gonorrhoeae
      • C. trachomatis
      • M. genitalium
    • viruses such as
      • herpes simplex virus
  • Pathogenesis
    • bacterial invasion results in an inflammatory response
  • Prognosis
    • favorable for gonococcal or nongonococcal urethritis when treated appropriately
Presentation
  • Symptoms
    • dysuria
    • pruritis
    • burning sensation
  • Physical exam
    • discharge from the urethral meatus
    • urethral meatus may appear inflamed
Studies
  • Labs
    • first-void or first-catch urine
      • a positive leukocyte esterase on urine dipstick or having ≥ 10 WBC/hpf on microscopy is suggestive of urethritis
      • nucleic acid amplification tests allows for the specific identification of the offending organism such as
        • N. gonorrhoeae
        • C. trachomatis
        • M. genitalium
    • Gram stain
      • 2 WBC/hpf
      • organisms may or may not be present
        • lack of organisms suggests a nongonococcal urethritis
        • gram-negative diplococci suggests gonococcal urethritis
Differential
  • Cystitis
  • Epididymitis
  • Prostatitis
Treatment
  • Medical
    • intramuscular ceftriaxone and oral azithromycin
      • indications
        • this is initial therapy for men with urethritis
          • who have gonococcal urethritis supported by microscopic evidence
            • e.g., gram-negative intracellular diplococci
          • when there is high clinical suspicion of having a gonococcal infection
            • e.g., patient had sexual intercourse with someone with known N. gonorrhoeae infection
        • note this combination covers nongonococcal urethritis caused by C. trachomatis
    • oral azithromycin or doxycycline
      • indications
        • first-line treatment for nongonococcal urethritis in the absence of microscopic, laboratory, or clinical findings suggestive of N. gonorrhea infection
        • note that treatment is directed against C. trachomatis and azithromycin also covers M. genitalium
Complications
  • Gonococcal urethritis
    • gonococcal prostatitis and pharyngitis
    • acute epididymitis
    • disseminated gonococcal infection
    • infectious conjunctivitis
  • Nongonococcal urethritis
    • acute epididymitis
    • postinflammatory reactive arthritis (formerly known as Reiter's arthritis)
      • triad
        • urethritis
        • conjunctivitis
        • arthritis
 

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