Urethritis in Men

Urethritis describes urethral inflammation and can be the result of infectious or non-infectious causes but is primarily a sexually acquired disease.

1. Gonococcal urethritis - caused by Neisseria gonorrhoea.³
2. Non-gonococcal urethritis - caused by a number of organisms other than N. gonorrhoeae.
3. Persistent or recurrent urethritis - 20 - 60% cases treated for NGU.¹ Probable multifactorial causes but may also be due to tetracycline-resistant Ureaplasma urealyticum.

NGU is more common than gonococcal urethritis. Chlamydia has been estimated to currently infect 5-10% of sexually active women under 24 and men aged between 20-24.⁶ The diagnoses of chlamydia infections have increased in both heterosexual and homosexual men.² Gonorrhoea is most common in men aged 20-24 years and rates of diagnosis in GUM clinics increased between 1994 - 2002 but recently the numbers have reduced.²

• May be asymptomatic (10% of patients with gonorrhoea and 50% of chlamydial infections)²
• Urethral discharge - mucopurulent or purulent; with or without blood; more noticeable after holding urine overnight and more common in gonococcus infection⁴
• Dysuria - burning discomfort during urination
• Urethral pruritus
• Other symptoms associated with the cause e.g. skin lesions in HSV
• Systemic symptoms if involvement of other organs e.g. conjunctivitis or arthritis

Examination may be normal or may reveal haematuria and/or lymphadenopathy.

There is currently a national screening programme for chlamydia.⁶

Identify high risk patients^2,7

• Sexually active
• Male
• Unprotected vaginal sex
• Homosexual or bisexual
• More common in cities
• Age < 35-40 years
• Recent partner change

Ideally this should be performed in a GUM clinic with available microscopy and medications (for DOT - direct observation of treatment).² In a GUM clinic the following will be done:

• Urethral smear - urethritis confirmed if on microscopy there are > 5 polymorphonuclear lymphocytes per high power field. Microscopy will also reveal Gram negative intracellular diplococci (GNID) of gonorrhoea.
• FPU - best if patients hold urine for at least 4 hours prior to the test and send for nucleic acid amplification (NAAT) test to look for chlamydia and gonorrhoea.
• Pharynx and rectal swabs may also be needed.

• Physiological discharge
• Candidiasis
• Cystitis
• Urethral malignancy

Patients with urethritis should be counselled and offered testing for HIV, hepatitis and syphilis.⁹

• Full history including full sexual history.
• Examination: local looking for discharge, skin lesions and systemic examination.
• Refer to GUM if possible.
• Urethral smear for microscopy and/or FPU (both ideally performed if urine held for at least 4 hours).
• If smear positive - manage as below.
• If smear negative and no definitive evidence of urethritis then defer treatment and re examine in one week. Also check MSU for urinary tract infection.
• Screen for other sexually transmitted infections.
• There is some debate as to whether there should be blind treatment of those with symptoms and at high risk of infection or those unlikely to return for follow-up.

Treatment is the same in HIV negative and positive patients. Always use local guidelines where possible.

• Non-gonococcal urethritis - azithromycin 1gm as single oral dose is first line or doxycycline 100 mg b.d. for 7 days.¹
• Gonococcal urethritis³ - cefixime 400 mg single oral dose or ceftriaxone 250 mg as single IM dose. Quinolones are an alternative provided no resistance.
• Empirical treatment - cover C. trachomatis e.g. doxycycline 100 mg b.d. for 7 days or azithromycin 1gm as single oral dose.

• Need to explain the diagnosis, treatment, adverse effects and importance of completing the course of antibiotics.
• Discuss methods of prevention including advice on safe sex e.g. condom use.
• Must avoid sexual intercourse until infection cleared up and partner checked out.
• Contact tracing - important to maintain patient confidentiality. Need to trace sexual contacts in the last 4 weeks and up to 6 months if asymptomatic (for NGU).

• Patients should be followed up for review at approximately 2 weeks.
• Take this opportunity to reinforce health education.
• Assess compliance and efficacy.
• Test of cure can also be performed for gonorrhoea e.g. NAAT or repeat culture 72 hours after treatment finished. It is not routine for chlamydia unless the patient is pregnant, non-compliance suspected or re-exposure may have occurred.⁶
• If persistent symptoms or persistent urethritis despite being asymptomatic consider treatment failure, reinfection or infection with uncommon pathogen e.g. TV. Treat with original course of antibiotics if the course was not completed.
• If doxycycline used initially then need to be aware that there is tetracycline resistant forms of U. urealyticum and an alternative may need to be tried e.g. metronidazole or erythromycin.
• If no laboratory evidence of infection then advise no sexual intercourse for 7 days and until partner completes treatment.
• If symptoms continue for >3 months consider the possibility of complications e.g. prostatitis, epididymitis
• If persistent or recurrent NGU treat with erythromycin or metronidazole.

• Epididymitis and/or orchitis
• Prostatitis
• Systemic dissemination of gonorrhoea e.g. conjunctivitis, skin lesions
• Reactive arthritis
• Pelvic inflammatory disease - infection of female partners with the organisms that cause urethritis can cause PID and subsequent complications
• Reiter's syndrome
• HIV transmission increased

If NGU, chlamydia and gonorrhoea remain untreated they may rarely remit spontaneously. However, this may take several months and carries the risk of transmission to others if the patient continues to have unprotected sexual intercourse.