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Infectious Diseases and Microbiology: Urethritis and Urethral Discharge
Basics
Description
Urethritis is inflammation of the urethra, often presenting with purulent or mucopurulent urethral discharge. In women, urethral syndrome or dysuria with sterile pyuria describes dysuria and urinary frequency with few or no bacteria detected in urine.
Approach to the Patient
Symptoms range from mild intermittent discomfort to persistent pain. History should include onset and duration of dysuria, associated symptoms, characteristics of discharge, and prior sexually transmitted infections. A complete genital examination is required. In men, palpate testes and spermatic cord to exclude epididymitis and evaluate for prostatitis; assess for cystitis in both sexes. To obtain discharge for examination, the urethra should be gently milked after the patient has avoided urination for several hours, ideally overnight.
Epidemiology
Urethritis is more common in men and represents one of the most frequently recognized sexually transmitted infections. Nongonococcal urethritis remains prevalent. Gonorrhea continues to affect adolescents and young adults disproportionately, particularly women aged 15–24 years. A substantial proportion of nongonococcal urethritis is caused by Chlamydia trachomatis. Antimicrobial resistance patterns, including quinolone-resistant Neisseria gonorrhoeae, have influenced treatment recommendations. Endourethral syphilitic chancre should also be considered in appropriate settings.
Risk Factors
Transmission risk depends on sexual exposure type. A high proportion of women exposed to men with urethral gonorrhea develop cervicitis, whereas fewer exposed men acquire infection from infected women. Incidence is highest among young, single individuals of lower socioeconomic and educational status.
General Prevention
Condom use reduces transmission of most sexually transmitted infections. Sexual partners of individuals with gonococcal or nongonococcal urethritis require evaluation and treatment to prevent reinfection and complications. Women with urinary symptoms without bacteriuria should be tested for N. gonorrhoeae. Patients diagnosed with urethritis should undergo screening for other sexually transmitted infections.
Etiology
Infectious causes include N. gonorrhoeae, C. trachomatis, Ureaplasma urealyticum, Mycoplasma genitalium, Trichomonas vaginalis, herpes simplex virus, and adenovirus. Noninfectious causes include Stevens–Johnson syndrome, granulomatosis with polyangiitis, chemical or mechanical irritation, and reactive arthritis (Reiter syndrome).
Diagnosis
Most men with urethral gonorrhea develop symptoms within days to two weeks after exposure, whereas nongonococcal urethritis typically has a 7–14 day incubation period. Dysuria is common in both conditions. Gonococcal discharge is usually purulent; nongonococcal discharge is less often purulent. Acute urethral syndrome presents with dysuria, urgency, and frequency.
Diagnostic Tests and Interpretation
Laboratory Studies
Gram-stained urethral smear showing five or more neutrophils per high-power field supports urethritis. Intracellular gram-negative diplococci confirm gonorrhea. Absence of diplococci suggests nongonococcal urethritis. Gram stain has high sensitivity for gonococcal infection in symptomatic men. First-void urine sediment may also demonstrate inflammatory cells. Nucleic acid amplification testing for N. gonorrhoeae and C. trachomatis is highly sensitive and specific and is recommended to guide patient and partner management. Candida has occasionally been implicated in urethritis when no other pathogen is identified.
Differential Diagnosis
Exclude systemic complications such as disseminated gonococcal infection or reactive arthritis. Consider bacterial prostatitis, cystitis, and in women, pyelonephritis if fever or flank pain is present. In sterile pyuria, evaluate for sexually transmitted pathogens such as C. trachomatis and N. gonorrhoeae, as well as other causes including tuberculosis or prostatitis.
Treatment
Medications
Gonococcal urethritis requires ceftriaxone in a single intramuscular dose, and most patients should also receive therapy targeting chlamydia. Nongonococcal urethritis is treated with doxycycline for seven days or a single dose of azithromycin. Alternative regimens include oral cephalosporins or spectinomycin where available. Fluoroquinolones are no longer recommended for gonorrhea due to resistance. Persistent or recurrent symptoms warrant reassessment for reinfection, treatment nonadherence, resistant strains, or coinfection such as T. vaginalis, which may require metronidazole. Recurrent nongonococcal urethritis may need prolonged therapy and evaluation for prostatic or structural abnormalities.
Ongoing Care and Follow-Up
Persistent hematuria after treatment requires urologic evaluation. Recurrence may reflect reinfection, coinfection, or treatment failure.
Complications
Chlamydia can cause salpingitis or bartholinitis and may result in neonatal conjunctivitis or pneumonia. Ureaplasma carriage has been associated with infertility. Both N. gonorrhoeae and C. trachomatis can cause acute epididymitis.
Basics
Description
Urethritis is inflammation of the urethra, often presenting with purulent or mucopurulent urethral discharge. In women, urethral syndrome or dysuria with sterile pyuria describes dysuria and urinary frequency with few or no bacteria detected in urine.
Approach to the Patient
Symptoms range from mild intermittent discomfort to persistent pain. History should include onset and duration of dysuria, associated symptoms, characteristics of discharge, and prior sexually transmitted infections. A complete genital examination is required. In men, palpate testes and spermatic cord to exclude epididymitis and evaluate for prostatitis; assess for cystitis in both sexes. To obtain discharge for examination, the urethra should be gently milked after the patient has avoided urination for several hours, ideally overnight.
Epidemiology
Urethritis is more common in men and represents one of the most frequently recognized sexually transmitted infections. Nongonococcal urethritis remains prevalent. Gonorrhea continues to affect adolescents and young adults disproportionately, particularly women aged 15–24 years. A substantial proportion of nongonococcal urethritis is caused by Chlamydia trachomatis. Antimicrobial resistance patterns, including quinolone-resistant Neisseria gonorrhoeae, have influenced treatment recommendations. Endourethral syphilitic chancre should also be considered in appropriate settings.
Risk Factors
Transmission risk depends on sexual exposure type. A high proportion of women exposed to men with urethral gonorrhea develop cervicitis, whereas fewer exposed men acquire infection from infected women. Incidence is highest among young, single individuals of lower socioeconomic and educational status.
General Prevention
Condom use reduces transmission of most sexually transmitted infections. Sexual partners of individuals with gonococcal or nongonococcal urethritis require evaluation and treatment to prevent reinfection and complications. Women with urinary symptoms without bacteriuria should be tested for N. gonorrhoeae. Patients diagnosed with urethritis should undergo screening for other sexually transmitted infections.
Etiology
Infectious causes include N. gonorrhoeae, C. trachomatis, Ureaplasma urealyticum, Mycoplasma genitalium, Trichomonas vaginalis, herpes simplex virus, and adenovirus. Noninfectious causes include Stevens–Johnson syndrome, granulomatosis with polyangiitis, chemical or mechanical irritation, and reactive arthritis (Reiter syndrome).
Diagnosis
Most men with urethral gonorrhea develop symptoms within days to two weeks after exposure, whereas nongonococcal urethritis typically has a 7–14 day incubation period. Dysuria is common in both conditions. Gonococcal discharge is usually purulent; nongonococcal discharge is less often purulent. Acute urethral syndrome presents with dysuria, urgency, and frequency.
Diagnostic Tests and Interpretation
Laboratory Studies
Gram-stained urethral smear showing five or more neutrophils per high-power field supports urethritis. Intracellular gram-negative diplococci confirm gonorrhea. Absence of diplococci suggests nongonococcal urethritis. Gram stain has high sensitivity for gonococcal infection in symptomatic men. First-void urine sediment may also demonstrate inflammatory cells. Nucleic acid amplification testing for N. gonorrhoeae and C. trachomatis is highly sensitive and specific and is recommended to guide patient and partner management. Candida has occasionally been implicated in urethritis when no other pathogen is identified.
Differential Diagnosis
Exclude systemic complications such as disseminated gonococcal infection or reactive arthritis. Consider bacterial prostatitis, cystitis, and in women, pyelonephritis if fever or flank pain is present. In sterile pyuria, evaluate for sexually transmitted pathogens such as C. trachomatis and N. gonorrhoeae, as well as other causes including tuberculosis or prostatitis.
Treatment
Medications
Gonococcal urethritis requires ceftriaxone in a single intramuscular dose, and most patients should also receive therapy targeting chlamydia. Nongonococcal urethritis is treated with doxycycline for seven days or a single dose of azithromycin. Alternative regimens include oral cephalosporins or spectinomycin where available. Fluoroquinolones are no longer recommended for gonorrhea due to resistance. Persistent or recurrent symptoms warrant reassessment for reinfection, treatment nonadherence, resistant strains, or coinfection such as T. vaginalis, which may require metronidazole. Recurrent nongonococcal urethritis may need prolonged therapy and evaluation for prostatic or structural abnormalities.
Ongoing Care and Follow-Up
Persistent hematuria after treatment requires urologic evaluation. Recurrence may reflect reinfection, coinfection, or treatment failure.
Complications
Chlamydia can cause salpingitis or bartholinitis and may result in neonatal conjunctivitis or pneumonia. Ureaplasma carriage has been associated with infertility. Both N. gonorrhoeae and C. trachomatis can cause acute epididymitis.
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