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.

Urinalysis and sometimes urine culture

  • Diagnosis by culture is not always necessary. If done, diagnosis by culture requires demonstration of significant bacteriuria in properly collected urine

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

  • A typical regimen is ceftriaxone 250 mg IM + azithromycin 1 g po once or doxycycline 100 mg po bid for 7 days.

Question 1
When the diagnosis of gonococcal urethritis is confirmed, which of the following is the treatment of choice?
A
Ceftriaxone (Rocephin)
B
Amoxicillin (Amoxil)
Hint:
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.
C
Penicillin G benzathine (Bicillin LA)
Hint:
Penicillin G benzathine is the treatment of choice for primary syphilis.
D
Doxycycline (Vibramycin)
Hint:
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?
A
doxycycline
B
penicillin G
Hint:
Penicillin G is not used in treating chlamydial infections.
C
ciprofloxacin (Cipro)
Hint:
Cephalexin and ciprofloxacin are not effective in treating Chlamydial infections.
D
cephalexin (Keflex)
Hint:
See C for explanation.
Question 2 Explanation: 
Tetracyclines, such as doxycycline, are drugs of first choice for Chlamydia.
Question 3
A 29 year-old male is involved in a motor vehicle crash. On the secondary survey it is noted that there is blood at the meatus and the patient is suspected of having a pelvic fracture. The patient is otherwise stable. Which of the following tests should be done to evaluate the urinary system?
A
Voiding cystourethrogram (VCUG)
Hint:
A VCUG is done to evaluate urinary reflux in children.
B
Intravenous pyelogram (IVP)
Hint:
An IVP can be done as part of an evaluation for hematuria however it is rarely used today.
C
Urethrogram
D
Renal Arteriography
Hint:
Renal arteriography does not have any place in this scenario as there is no evidence of a renal injury.
Question 3 Explanation: 
A urethrogram is the only procedure that should be done to evaluate this type of injury as urethral integrity may have been compromised secondary to the pelvic fracture. Blood at the meatus is the most important finding of suspected urethral injury.
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