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urethritis

Inflammation of the urethra. Etiology: 1) common causes - Neisseria gonorrhoeae - Chlamydia trachomatis - Ureaplasma urealyticum 2) less common causes a) viral - Herpes simplex (may be particulary painful) [3] - condylomata accuminata b) bacterial - coliforms (colonic bacteria) - Mycoplasma genitalium [6] - Neisseria meningitidis among heterosexual men [7] - receptive oral sex suggested as mechanism c) fungal - Candida - Rhinosporidium d) parasitic - Trichomonas vaginalis - schistosomes 3) no infectious etiology found in 20-65% of cases [3] Clinical manifestations: 1) general a) urethral discharge - mucoid or mucopurulent - clear, brown, yellow, white, green - profuse, yellow mucopurulent discharge suggests gonococcus - scantly, mucoid clear or white discharge suggests Chlamydia b) urethra meatal crusting & erythema c) dysuria d) urethral itch e) urethral tenderness 2) associated manifestations of specific etiologies a) Herpes simplex: regional lymphadenopathy b) Chlamydia trachomatis - conjunctivitis - Reiter's syndrome - epididymitis - incubation period is 1-5 weeks, generally 2-3 weeks 3) Neisseria gonorrhoeae - incubation period 2-8 days Laboratory: 1) gram stain of urethral discharge a) > 5 WBC/hpf (oil) b) presence of bacteria 2) urinalysis a) first 10-15 mL of urine b) > 20 WBC/hpf in spun specimen 3) culture of urethral discharge 4) test for Chlamydia a) antigen detection tests b) nucleic acid hybridization Differential diagnosis: 1) urethral foreign body or calculi a) pain is usually intermittent b) may be bloody discharge c) may be palpable 2) clinical manifestation of systemic disorder a) Stevens-Johnson syndrome b) Wegener's granulomatosis c) tumor 3) chemical irritation of the urethra - soaps 4) congenital anomalies Management: 1) Neisseria gonorrhea: a) 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 b) 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) 2) 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 3) patient education a) urethritis is sexually transmitted b) affected individuals may be asymptomatic (carriers) c) partners should be referred for treatment d) Chlamydia & Ureaplasma rarely cause serious sequelae in men e) Chlamydia infection in women - infertility secondary to tubal occlusion - ectopic pregnancy - chronic pelvic pain - infection may be transmitted to fetus 4) follow-up a) asymptomatic patients after course of antibiotics - test of cure for Chlamydia after 3 weeks - false negative may result if tested sooner b) persistence of symptoms after course of antibiotics - consider Mycoplasma genitalium infection - consider course of azithromycin or fluoroquinolone if doxycyline (tetracycine) was used [4] - consider metronidazole 2 g PO once if Trichomonas vaginalis is suspected - referral to urology

Related

urinary tract infection (UTI)

General

urologic disease

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 552-553
  2. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 318
  3. Bradshaw CS et al, Etiologies of nongonococcal urethritis: Bacteria, viruses, and the association with orogenital exposure. J Infect Dis 2006, 193:336 PMID: 16388480
  4. Sena AC et al. Chlamydia trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis infections in men with nongonococcal urethritis: Predictors and persistence after therapy. J Infect Dis 2012 Aug; 206:357 PMID: 22615318
  5. Medical Knowledge Self Assessment Program (MKSAP) 16, 18. American College of Physicians, Philadelphia 2012, 2018.
  6. Workowski KA, Bolan GA (CDC) Sexually Transmitted Diseases Treatment Guidelines, 2015 Recommendations and Reports. MMWR June 5, 2015 / 64(RR3);1-137 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm
  7. Bazan JA, Peterson AS, Kirkcaldy RD, et al Notes from the Field: Increase in Neisseria meningitidis- Associated Urethritis Among Men at Two Sentinel Clinics- Columbus, Ohio, and Oakland County, Michigan, 2015. MMWR Morb Mortal Wkly Rep 2016;65:550-552 http://www.cdc.gov/mmwr/volumes/65/wr/mm6521a5.htm