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Updated: Jul 28 2017


  • 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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