AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Urethral discharge, dysuria, and exposure to a sexually transmitted disease (STD) are frequent presentations of urethritis in the male population presenting to the ED. Recent research has focused on cost-effective antibiotic therapy with minimal adverse effects and dosing; the goal is to optimize compliance and prevent recurrence of this disease, which is predominantly sexually transmitted.

Pathophysiology

Urethritis is an inflammatory condition that can be infectious or posttraumatic. Infectious causes of urethritis are typically sexually transmitted and categorized as gonococcal urethritis (GCU), due to infections of Neisseria gonorrhoeae, or nongonococcal urethritis (NGU), which follows infection with Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma genitalium, or Trichomonas vaginalis.

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

Posttraumatic urethritis can occur in 2-20% of patients practicing intermittent catheterization and following instrumentation or foreign body insertion. Urethritis is 10 times more likely to occur with latex catheters than with silicone catheters.

Urethritis may be associated with other infectious syndromes such as epididymitis, orchitis, prostatitis, proctitis, reactive arthritis, iritis, pneumonia, otitis media, or urinary tract infection.

Mortality/Morbidity

Urethritis usually resolves without complication, even if untreated, yet it can result in urethral stricture, stenosis, or abscess formation in rare cases.

Sex

This article discusses male urethritis.

Age

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

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Many patients, including approximately 25% of those with NGU, are asymptomatic and present following partner screening. However, patients may experience the following symptoms:
  
  
  • Urethral discharge, purulent or mucopurulent
  
  
  • Dysuria
  
  
  • Urethral pruritus


• 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 gonococcal, chlamydial, or mycoplasmal infections:
• • Arthritis
  
  
  • Conjunctivitis
  
  
  • Proctitis
  
  
  • Prostatitis
  
  
  • Epididymitis/orchitis
  
  
  • Pneumonia
  
  
  • Otitis media
  
  
  • Low back pain (reactive arthritis)
  
  
  • Iritis
  
  
  • Rash

Physical

Most patients with urethritis are not ill-appearing and do not manifest signs of sepsis, such as fever, tachycardia, tachypnea, or hypotension. The primary focus of the examination is on the genitalia.

• Examine the urethral meatus for skin lesion, stricture, or obvious urethral discharge. 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.


• Strip (milk) the urethra outwards to express discharge.


• Examine the testes and epididymis for swelling, tenderness, or warmth suggestive of orchitis or epididymitis.


• Palpate the prostate for tenderness or bogginess suggestive of prostatitis.


• Examine the penis, scrotum, and skin of the groin for rashes suggestive of other STDs, such as condyloma acuminatum, herpes simplex, or syphilis.


• In patients with symptoms suggestive of disseminated gonococcal, chlamydial, or mycoplasmal disease, the remainder of the physical examination should assess the joints, skin, conjunctivae, tympanic membranes, and lungs.

Causes

Promiscuous or unprotected sex is a significant risk factor for urethritis or other STDs.

• Gonococcal urethritis (GCU) (80% of cases)
• • N gonorrhoeae is a gram-negative intracellular diplococcus.
  
  
  • Patients with GCU have a shorter incubation period than with NGU and abrupt onset of both dysuria and purulent discharge.


• Nongonococcal urethritis (NGU) (50% of cases)
• • U urealyticum (40-60%)
  
  
  • C trachomatis (30-40%)
  
  
  • M genitalium (5-10%)
  
  
  • T vaginalis (fewer than 5%)
  
  
  • Patients with NGU present with a longer incubation period than with GCU and a subacute onset of either dysuria or, less commonly, a mucopurulent discharge.
  
  
  • Rare cases may be related to lymphogranuloma venereum, herpes genitalis, syphilis, mycobacterium, adenovirus, or gram-negative bacteria (urinary tract infection with urethral stricture or following insertive anal intercourse).
  
  
  • Urethritis following catheterization occurs in 2-20% of patients practicing intermittent catheterization and is 10 times more likely with latex than with silicone catheters.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Diagnostic testing is recommended in the United States since gonorrhea and chlamydia are reportable to the state health departments.


• Urethral swab specimen may be obtained for Gram stain, culture, direct immunofluorescence, enzyme immunoassay, and nucleic acid hybridization testing, whereas a urine specimen may be used for nucleic acid amplification testing (NAAT), which is the most sensitive test.


• Gram stain microscopy may identify gram-negative intracellular diplococci indicating gonococcal infection. A negative Gram stain, however, does not exclude gonococcal infection.


• The presence of more than 5 WBC per oil immersion field of urethral secretions secures the diagnosis of urethritis.


• Consider urethral culture for N gonorrhoeae and C trachomatis.
  
  
  • This culture may be useful screening for penicillinase-producing N gonorrhoeae or chromosomally mediated resistance to multiple antibiotics; however, the results will not influence the initial antibiotic therapy and may not be cost-effective.
  
  
  • Endourethral culture (obtained by gently inserting a malleable cotton-tipped swab 1-2 cm into the urethra) rather than culture of the expressible discharge is necessary for C trachomatis.


• Polymerase chain reaction assays are available for both organisms. However, as with culture, the results will not influence the initial antibiotic therapy and may not be cost-effective.


• Traditionally, treatment had been based on Gram stain results. Those patients with gram-negative intracellular diplococci received therapy for GCU, and those patients without gram-negative intracellular diplococci received therapy for NGU. Because current recommendations suggest patients receive concomitant treatment for both, a Gram stain may not be necessary.


• Urinalysis
  
  
  • Urine specimen can be obtained for nucleic acid amplification testing (NAAT).
  
  
  • Urinalysis is not useful in urethritis, except for excluding cystitis or pyelonephritis, which may be necessary in cases of dysuria without discharge.
  
  
  • Urinalysis may identify T vaginalis infection.
  
  
  • Patients with GCU may have leukocytes in a first-void urine specimen and fewer or none in a midstream specimen. More than 30% of patients with NGU do not have leukocytes in urine specimens.


• Patients should be screened for HIV and syphilis serology (Venereal Disease Research Laboratory [VDRL] test or rapid plasma reagin test) should be obtained.

Imaging Studies

• Imaging studies, specifically a retrograde urethrogram, are not necessary in urethritis except in cases of trauma or suspected foreign body.

Procedures

• Gram stain of the urethral discharge is no longer considered essential, since the results usually do not alter therapy.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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.

Consultations

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

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Antibiotic therapy should cover both GCU and NGU, unless culture or NAAT testing is negative for gonorrhea or chlamydia. If concomitant treatment for NGU is not given, the rate of postgonococcal urethritis is approximately 50%. The choice of antibiotics should be based on cost, adverse effects, effectiveness, and compliance. In most situations, single-dose therapy administered in the ED is optimal.

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, but it may cause gastrointestinal distress and has theoretical concern for emerging resistance. Quinolone resistance is increasing worldwide and is common in Asia, the Pacific, Europe, and the Middle East as well as in some parts of the United States. 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 CDC for routine or alternative regimens. 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. 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.

In the treatment of NGU, a single dose of azithromycin 1 g orally or doxycycline 100 mg by mouth twice daily for 7 days is recommended; they have similar efficacy rates (>97%). Single-dose azithromycin ensures compliance, but it is also more effective for Mycoplasma genitalium and Ureaplasma urealyticum infections. Alternative regimens include 7 days of erythromycin base 500 mg 4 times daily, erythromycin ethylsuccinate 800 mg 4 times daily, ofloxacin 300 mg twice daily, or levofloxacin 500 mg twice daily. Ciprofloxacin is ineffective against chlamydial infection. No longer used are combinations of probenecid with penicillin, amoxicillin, or ampicillin because of resistance.

Antibiotic therapy is recommended both for affected individuals as well as sexual partners of individuals with documented Trichomonas, even if asymptomatic.

Drug Category: Antibiotics

Single-dose therapy to cover GCU and chlamydia includes azithromycin 2 g PO or a cephalosporin or quinolone plus azithromycin 1 g PO.

Drug Name	Ceftriaxone (Rocephin)
Description	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.
Adult Dose	Uncomplicated gonococcal infections: 125 mg IM single dose Depending on type and severity of infection, 1-2 g IV qd or divided bid; not to exceed 4 g/d
Pediatric Dose	>7 days: 25-50 mg/kg IV single dose; not to exceed 125 mg/dose Infants and children: 125 mg IV single dose plus doxycycline For serious infection: 50-75 mg/kg/d IV divided q12h; not to exceed 2 g/d
Contraindications	Documented hypersensitivity
Interactions	Probenecid may decrease clearance, causing increase in levels; ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in renal impairment; use with caution in breastfeeding women and patients allergic to penicillin

Drug Name	Spectinomycin (Trobicin)
Description	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.
Adult Dose	2 g IM single dose
Pediatric Dose	<45 kg or <12 years: 40 mg/kg/d IM single dose; not to exceed 2 g/dose >45 kg or >12 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Benzyl alcohol used as diluent associated with fatal gasping syndrome in infants; antibiotics may mask or delay symptoms of incubating syphilis; perform serologic test for syphilis in all patients with gonorrhea at time of diagnosis followed by additional test after 3 mo; monitor clinical effectiveness to detect resistance by N gonorrhoeae

Drug Name	Azithromycin (Zithromax)
Description	Used to treat mild to moderately severe infections caused by susceptible strains of microorganisms. Indicated for chlamydia and gonorrheal infections of genital tract.
Adult Dose	1 g PO once for chlamydia or 2 g PO once for both GCU and chlamydia
Pediatric Dose	10 mg/kg PO once on day 1, not to exceed 500 mg/d; followed by 5 mg/kg on days 2-5, not to exceed 250 mg/d
Contraindications	Documented hypersensitivity; hepatic impairment; concurrent pimozide may cause sudden death
Interactions	May increase theophylline and digoxin levels, increasing their toxicity; may potentiate anticoagulant effects of warfarin; aluminum-containing and magnesium-containing antacids reduce peak serum levels but not amount of azithromycin absorption; may elevate cyclosporine concentrations with increased risk of toxicity (nephrotoxicity, neurotoxicity)
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Local IV site reactions can occur with IV administration; use of antibiotics, especially prolonged or repeated therapy, may result in bacterial or fungal overgrowth of nonsusceptible organisms that may lead to secondary infection; take appropriate measures if superinfection occurs; can cause increases in hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function; not recommended for pneumonia in hospitalized patients or in elderly or debilitated patients; use with caution in patients with prolonged QT intervals

Drug Name	Doxycycline (Dory, Bio-Tab)
Description	Used in treatment of rectal syphilis. Inhibits protein synthesis and bacterial growth by binding with 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult Dose	Acute infection: 100 mg PO bid for 7 d
Pediatric Dose	<8 years: Not recommended >8 years: 2-5 mg/kg/d PO in 1-2 divided doses; not to exceed 200 mg/d
Contraindications	Documented hypersensitivity; severe hepatic dysfunction
Interactions	Antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate can decrease bioavailability; can increase hypoprothrombinemic effects of anticoagulants, monitor prothrombin activity in patients taking both medications; can decrease pharmacologic effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Pregnancy	D - Unsafe in pregnancy
Precautions	Avoid prolonged exposure to sunlight or tanning equipment because photosensitivity reaction may occur; use lower-than-usual doses in patients with renal impairment (drug serum level determinations may be advisable if therapy is prolonged); administration during tooth development (last half of pregnancy through 8 y) may cause permanent discoloration of teeth; never administer outdated tetracyclines because degradation products are highly nephrotoxic and can cause Fanconilike syndrome

Drug Name	Tetracycline (Sumycin)
Description	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.
Adult Dose	Mild to moderately severe infections: 500 mg PO bid or 250 mg PO qid for 7-14 d Severe infections: 500 mg PO qid for 7-14 d
Pediatric Dose	<8 years: Not recommended >8 years: 10-20 mg/lb (25-50 mg/kg) PO qid
Contraindications	Documented hypersensitivity; severe hepatic dysfunction
Interactions	Antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate can decrease bioavailability; can increase hypoprothrombinemic effects of anticoagulants, monitor prothrombin activity in patients taking both medications; can decrease pharmacologic effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Pregnancy	D - Unsafe in pregnancy
Precautions	Avoid prolonged exposure to sunlight or tanning equipment because photosensitivity reaction may occur; use lower-than-usual doses in patients with renal impairment (drug serum level determinations may be advisable if therapy is prolonged); administration during tooth development (last half of pregnancy through 8 y) may cause permanent discoloration of teeth; never administer outdated tetracyclines because degradation products are highly nephrotoxic and can cause Fanconilike syndrome

Drug Name	Minocycline (Dynacin, Minocin)
Description	Treats infections caused by susceptible gram-negative and gram-positive organisms, in addition to susceptible chlamydial, rickettsial, and mycoplasmal infections.
Adult Dose	100 mg PO bid for 5-7 d
Pediatric Dose	<8 years: Not recommended >8 years: Initially 4 mg/kg PO, followed with 2 mg/kg PO q12h
Contraindications	Documented hypersensitivity; severe hepatic dysfunction
Interactions	Antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate may decrease bioavailability; may increase hypoprothrombinemic effects of anticoagulants, monitor prothrombin activity in patients taking both medications; may decrease pharmacologic effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Pregnancy	D - Unsafe in pregnancy
Precautions	Avoid prolonged exposure to sunlight or tanning equipment because photosensitivity reaction may occur; use lower-than-usual doses in patients with renal impairment (drug serum level determinations may be advisable if therapy is prolonged); administration during tooth development (last half of pregnancy through 8 y) may cause permanent discoloration of teeth; never administer outdated tetracyclines because degradation products are highly nephrotoxic and can cause Fanconilike syndrome

Drug Name	Erythromycin (E-Mycin, Eryc, Ery-Tab)
Description	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.
Adult Dose	250 mg erythromycin stearate/base (or 400 mg ethylsuccinate) PO q6h taken 1 h ac or 500 mg PO q12h for 7-14 d (28 d for recurrence) Alternatively, 333 mg PO q8h; not to exceed 4 g/d If twice-a-day dosage desired, recommended dose is 500 mg q12h
Pediatric Dose	20 mg/kg PO 2 h prior to procedure, followed by 10 mg/kg/6h after initial dose Alternatively, 30-50 mg/kg/d (15-25 mg/lb/d) PO in divided doses In children, age, weight, and severity of infection determine proper dosage; when bid dosing desired, one-half total daily dose may be taken q12h; for more severe infections, dose may be doubled
Contraindications	Documented hypersensitivity; hepatic impairment
Interactions	May increase theophylline, digoxin, carbamazepine, and cyclosporine toxicity; may potentiate anticoagulant effects of warfarin; lovastatin and simvastatin significantly increase risk of rhabdomyolysis
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Caution in patients with liver disease; estolate preparation may cause cholestatic jaundice; adverse GI effects are common, and doses should be given after meals; discontinue use if nausea, vomiting, malaise, abdominal colic, and/or fever occur

Drug Name	Metronidazole (Flagyl)
Description	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.
Adult Dose	250-500 mg PO q8h for 7 d or 2 g once
Pediatric Dose	15-30 mg/kg/d PO divided bid for 7 d or 40 mg/kg PO once; not to exceed 500 mg
Contraindications	Documented hypersensitivity
Interactions	Cimetidine may increase toxicity; may increase effects of anticoagulants; may increase toxicity of lithium and phenytoin; disulfiramlike reaction may occur with orally ingested ethanol
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in patients with severe hepatic disease because they may metabolize metronidazole slowly; monitor patients for seizures and development of peripheral neuropathy

Drug Name	Levofloxacin (Levaquin)
Description	A fluoroquinolone with better gram-positive activity but less activity against Pseudomonas aeruginosa. Active L-isomer of ofloxacin.
Adult Dose	500 mg PO bid
Pediatric Dose	Not recommended
Contraindications	Documented hypersensitivity
Interactions	Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; levofloxacin reduces therapeutic effects of phenytoin; probenecid may increase levofloxacin serum concentrations May increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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 for T vaginalis.


• Retesting in 3 months is recommended for men with 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

• Complications, such as stricture, stenosis, or abscess formation, are rare.


• Concomitant epididymitis or prostatitis is not uncommon. Chronic prostatitis is diagnosed when symptoms of urinary discomfort persist beyond 3 months.


• Recurrent urethritis


• Reactive arthritis following chlamydial infection is uncommon.


• 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 cervicitis, pelvic inflammatory disease, tubo-ovarian abscess, scarring of the fallopian tube, and infertility.

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 excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center. Also, see eMedicine's patient education articles Birth Control Overview and Birth Control FAQs.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Special Concerns

• Recurrent symptoms may be related to reexposure, noncompliance, chronic nonbacterial prostatitis, or infection with T vaginalis or U urealyticum. Recommended therapy includes either a single dose of metronidazole 2 g orally or tinidazole 2 g orally, for the former, and azithromycin 1 g orally for the latter. Prolonged (14-28 d) therapy with erythromycin has not been demonstrated to be of value.


• Treatment regimens are the same whether the patient is HIV positive or HIV negative.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• CDC, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. Aug 4 2006;55(RR-11):1-94. [Medline].
• Beltrami JF, Cohen DA, Hamrick JT. Rapid screening and treatment for sexually transmitted diseases in arrestees: a feasible control measure. Am J Public Health. Sep 1997;87(9):1423-6. [Medline].
• CDC. 2006 guidelines for treatment of sexually transmitted diseases. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 55(RR-11):1-94. [Full Text].
• CDC. Update to CDC's Sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR [serial online]. Apr 13 2007;56(14):332-334. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5614a3.htm?s_cid=mm5614a3_e.
• Cote AM, Sobela F, Dzokoto A, et al. Transactional sex is the driving force in the dynamics of HIV in Accra, Ghana. AIDS. Apr 2 2004;18(6):917-925. [Medline].
• Kirsch TD, Shesser R, Barron M. Disease surveillance in the ED: factors leading to the underreporting of gonorrhea. Am J Emerg Med. Mar 1998;16(2):137-40. [Medline].
• Lau CY, Qureshi AK. Azithromycin versus doxycycline for genital chlamydial infections: a meta-analysis of randomized clinical trials. Sex Transm Dis. Sep 2002;29(9):497-502. [Medline].
• Sizemore JM, Sanders WM, Lackey PC, et al. Risk-taking and health-seeking behavior in men with a history of urethritis: is there a learning curve?. Sex Transm Dis. Apr 2004;31(4):225-8. [Medline].
• Workowski KA, Berman SM. Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines. Clin Infect Dis. Apr 1 2007;44 Suppl 3:S73-6. [Medline].

Article Last Updated: May 3, 2007