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Urethritis in Men

Description

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

Urethritis can be diagnosed if any of the following are present

  • Mucopurulent or purulent discharge from urethral meatus.
  • Gram stain of urethral smear showing >5 polymorphonuclear (PMN) cells per high power field. This is the preferred test as rapid, highly sensitive and specific for both urethritis and gonorrhoea.
  • First pass urine (FPU) positive for >10 PMN per high power field. Some advocate the use of positive leucocytes in FPU - but the sensitivity is low.

Classification of male urethritis1
  1. Gonococcal urethritis - caused by N. gonorrhoea
  2. Non-gonococcal urethritis - caused by a number of organism other than N. gonorrhoeae.
  3. Persistent or recurrent urethritis - 20 - 60% cases treated for NGU. Probable multifactorial causes but may also be due to tetracycline-resistant U. urealyticum

Causes of Non-gonococcal urethritis 1,2,3,4

  • Chlamydia trachomatis 40%
  • Ureaplasma urealyticum 10 - 20%
  • Mycoplasma genitalium 10 - 20%
  • Trichomonas vaginalis 1 - 17%
  • Rarer causes - N. meningitidis, HSV, E.coli infection, trauma, foreign body, UTI, pyelonephritis, bacteroides infection, reactive arthritis, Reiters syndrome
  • No obvious cause 20 -30%

Epidemiology

NGU is more common than gonococcal urethritis. Chlamydia has a prevalence of 2-6% in 16-24 year old men and diagnoses of chlamydia infections have increased in both heterosexual and homosexual men.1 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.1

Presentation
  • May be asymptomatic (10% of patients with gonorrhoea and 50% of chlamydial infections)1
  • Urethral discharge - mucopurulent or purulent; with or without blood; more noticeable after holding urine overnight and more common in gonococcus infection3
  • 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 lymphadenopathy.

Identify high risk patients1,5

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

Ideally this should be performed in a GUM clinic with available microscopy and medications (for DOT).1 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

An increasing number of sexually transmitted diseases are treated in primary care. However, in a primary care setting microscopy may not be available and the following approach can be taken:1,6

  • Diagnose urethritis if urethral discharge present or if symptoms in a high risk patient
  • Urine dipstick positive for leukocytes supports the diagnosis of urethritis and if normal can also help exclude UTI
  • Threads in urine passed after holding for at least four hours supports diagnosis
  • FPU - send for NAAT to look for Chlamydia and gonorrhoea7
  • Need to check with local laboratory as to which test they perform - some may require urethral swabs to be sent

Differential diagnosis1
  • Physiological discharge
  • Candidiasis
  • Cystitis
  • Urethral malignancy
Associated Diseases

Patients with urethritis should be counselled and offered testing for HIV, hepatitis and syphilis.8

Approach to a patient with symptoms suggestive of urethritis
  • 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.
Management1,9

Treatment is the same in HIV negative and positive patients
Use local guidelines where possible

  • Non-gonococcal urethritis - doxycycline 100 mg BD for 7 days or azithromycin 1gm as single oral dose or ofloxacin 200 mg BD for 7 days
  • Gonococcal urethritis10 - 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 BD for 7 days or azithromycin 1gm as single oral dose

Patient education1
  • 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)

Further management1
  • 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
  • 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

Complications1
  • 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

Prognosis

If NGU, chlamydia and gonorrhoea not treated than may spontaneously remit. However, this may take several months and then there is a risk of transmission to others if continue to have sexual intercourse.

Document references
  1. Urethritis - male, Clinical Knowledge Summaries (2006)
  2. Management of non-gonococcal urethritis, British Association for Sexual Health & HIV (2002)
  3. Richens J; Main presentations of sexually transmitted infections in men. BMJ. 2004 May 22;328(7450):1251-3.
  4. Miller KE; Diagnosis and treatment of Chlamydia trachomatis infection. Am Fam Physician. 2006 Apr 15;73(8):1411-6. [abstract]
  5. Iser P, Read TH, Tabrizi S, et al; Symptoms of non-gonococcal urethritis in heterosexual men: a case control study. Sex Transm Infect. 2005 Apr;81(2):163-5. [abstract]
  6. Cassell JA, Mercer CH, Sutcliffe L, et al; Trends in sexually transmitted infections in general practice 1990-2000: population based study using data from the UK general practice research database. BMJ. 2006 Feb 11;332(7537):332-4. Epub 2006 Jan 26. [abstract]
  7. UK National Guideline for the Management of Genital Tract Infection with Chlamydia trachomatis, British Association for Sexual Health & HIV (2006).
  8. Nusbaum MR, Wallace RR, Slatt LM, et al; Sexually transmitted infections and increased risk of co-infection with human immunodeficiency virus. J Am Osteopath Assoc. 2004 Dec;104(12):527-35. [abstract]
  9. Guidelines on the Management of Urinary and Male Genital Tract Infections, European Association of Urology (2006)
  10. Management of gonorrhoea in adults, British Association for Sexual Health & HIV (2005)
Acknowledgements EMIS is grateful to Dr Gurvinder Rull for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2008.
DocID: 2902
Document Version: 21
DocRef: bgp406
Last Updated: 18 Jan 2007
Review Date: 17 Jan 2009












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