PANCE Blueprint Genitourinary (5%)

Urethritis (Lecture)

Patient will present as → a 22-year-old heterosexual male who recently started having unprotected intercourse with his new girlfriend. He now reports a painful itching and burning sensation with urination and discomfort in the urethra. He says that sometimes in the morning, it appears that the walls of the meatus are stuck together with evidence of dried secretions. On exam, there is no purulent discharge. The meatus does appear red. His girlfriend does not have any symptoms.

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Urethritis is an infection of the urethra with bacteria (or with protozoa, viruses, or fungi) and occurs when organisms that gain access to it acutely or chronically colonize the numerous periurethral glands in the bulbous and pendulous portions of the male urethra and in the entire female urethra

  • The sexually transmitted pathogens Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and herpes simplex virus are common causes in both sexes

In urethritis, the main symptoms are dysuria and, primarily in men, urethral discharge

  • Discharge can be purulent, whitish, or mucoid
  • Characteristics of the discharge, such as the amount of purulence, do not reliably differentiate gonococcal from non-gonococcal urethritis

First-void or first-catch urine and sometimes urine culture

    • Positive leukocyte esterase on urine dipstick or having ≥ 10 WBC/HPF on microscopy is suggestive of urethritis
    • Gram stain is sensitive and specific for gonorrhea in men with urethral discharge; gram-negative intracellular diplococci typically are seen
    • Diagnosis by culture is not always necessary. If done, diagnosis by culture requires demonstration of significant bacteriuria in properly collected urine
    • Nucleic acid amplification test allows for the specific identification of N. gonorrhoeae, C. trachomatis, M genitalium
"The optimal urine sample is the first-void urine, which refers to the initial portion of the first urinary stream after awakening, collected without pre-cleaning the urethral meatus. However, collection of the first-void urine at the point-of-care is impractical, so most practitioners request a first-catch urine, which refers to the initial portion of the urinary stream (generally the first 10 to 20 mL), collected without pre-cleaning the urethral meatus and ideally at least one hour after the previous micturition. "

Sexually active patients with symptoms are usually treated presumptively for STDs pending test results

  • The preferred regimen for gonococcal infections is a single IM dose of ceftriaxone (500 mg for individuals <150 kg or 1 g for individuals ≥150 kg)
  • If testing results for C. trachomatis are not available at the time of treatment, presumptive therapy for chlamydia coinfection is also indicated. In such cases, doxycycline 100 mg twice daily for seven days
  • Consider replacing doxycycline with azithromycin 1 g PO if compliance is in question or pregnancy
  • In the event that results of microbial diagnostic testing are available prior to the patient's receipt of therapy, antimicrobial treatment can be directed toward the identified pathogen(s)

Urethritis (causes)

IM_NUR_Chlamydia_V1.7_Urethritis is inflammation of the urethra, usually resulting from bacterial infection, and most commonly presenting with painful or difficult urination. It is usually caused by infection with bacteria. The infection is often a sexually transmitted infection (STI). Gonococcal: Neisseria gonorrhea, Non-gonococcal: Chlamydia trachomatis (most common), and Mycoplasma genitalium.

Chlamydia trachomatis
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Question 1
When the diagnosis of gonococcal urethritis is confirmed, which of the following is the treatment of choice?
Ceftriaxone (Rocephin)
Amoxicillin (Amoxil)
Effective single-dose regimens for uncomplicated gonococcal urethritis include cefixime or one of the fluoroquinolones, but NOT amoxicillin due to penicillin-resistant strains of gonorrhea.
Penicillin G benzathine (Bicillin LA)
Penicillin G benzathine is the treatment of choice for primary syphilis.
Doxycycline (Vibramycin)
Doxycycline is the treatment of choice for Chlamydia urethritis, not gonococcal urethritis.
Question 1 Explanation: 
Ceftriaxone is recommended therapy for gonococcal urethritis.
Question 2
A 34 year-old male presents with symptoms of painful urethral discharge. History reveals recent (7 days ago) intercourse with a new partner. A Gram stain is negative for intracellular diplococci. Assuming no allergies, which of the following is the antibiotic of choice?
penicillin G
Penicillin G is not used in treating chlamydial infections.
ciprofloxacin (Cipro)
Cephalexin and ciprofloxacin are not effective in treating Chlamydial infections.
cephalexin (Keflex)
See C for explanation.
Question 2 Explanation: 
Tetracyclines, such as doxycycline, are drugs of first choice for Chlamydia.
There are 2 questions to complete.
Shaded items are complete.

References: Merck Manual · UpToDate

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