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Emergency and Acute Medicine: Urethritis
Urethritis is inflammation of the urethra, most commonly caused by infection, and is a frequent presentation in emergency and acute care settings. It typically presents with urethral discharge and dysuria and often develops after exposure to a sexual partner with a sexually transmitted infection (STI), bacterial vaginosis, or urinary tract infection. It may also occur after orogenital contact.
The most common etiologies are sexually transmitted pathogens, particularly Neisseria gonorrhoeae, which accounts for about 35% of cases, and Chlamydia trachomatis, responsible for 25–50%. Other significant causes include Mycoplasma genitalium and Ureaplasma urealyticum. Less commonly, organisms such as Trichomonas vaginalis, Herpes simplex virus, adenovirus, Candida species, and enteric bacteria may be involved. Noninfectious causes such as chemical irritation, alcohol, systemic illness, or foreign bodies are rare.
Symptoms usually develop within 1 to 2 weeks after exposure but may take up to 4 to 6 weeks. Patients commonly report urethral discharge, dysuria, and cloudy first-void urine. Pyuria is often present, and some patients may have inguinal lymphadenopathy. Important historical features include the color and quantity of discharge, associated urinary symptoms, recent sexual history, and risk factors such as multiple partners or unprotected intercourse.
On physical examination, findings may include visible urethral discharge, staining on undergarments, meatal crusting, and sometimes genital lesions. Palpation of the testes, epididymis, and spermatic cord is important to evaluate for complications such as epididymitis. Inguinal lymphadenopathy may also be present.
Diagnosis is typically confirmed using nucleic acid amplification tests (NAATs), such as PCR, performed on first-void urine or urethral swabs, which are highly sensitive for detecting gonorrhea and chlamydia. Urinalysis is useful to rule out urinary tract infection. Because STIs often coexist, patients should also be screened for HIV and syphilis using appropriate serologic tests.
The differential diagnosis includes urinary tract infection, prostatitis, epididymitis, orchitis, pelvic inflammatory disease, reactive arthritis, and chemical irritation from soaps or spermicides. In children, urethritis should raise concern for possible abuse.
Management in the emergency setting is largely empirical, with treatment directed at both gonorrhea and chlamydia regardless of confirmed results. Standard therapy includes ceftriaxone for gonorrhea and either azithromycin or doxycycline for chlamydia. In pregnant patients, azithromycin is preferred, as doxycycline and fluoroquinolones are contraindicated.
Most patients can be discharged after treatment with appropriate follow-up arranged. Patients should be advised to abstain from sexual activity until symptoms resolve and for at least one week after completing treatment. All sexual partners should be evaluated and treated to prevent reinfection. Repeat testing may be recommended, particularly in pregnant patients, to ensure cure.
Complications of untreated urethritis include epididymitis, pelvic inflammatory disease, infertility, reactive arthritis, and ocular complications. Key clinical pearls include always treating for both gonorrhea and chlamydia, recognizing increasing antibiotic resistance, and considering atypical organisms in recurrent cases.
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