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.
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
- 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
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.
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 is the treatment of choice for Chlamydia urethritis, not gonococcal urethritis.
Penicillin G is not used in treating chlamydial infections.
Cephalexin and ciprofloxacin are not effective in treating Chlamydial infections.
See C for explanation.
Voiding cystourethrogram (VCUG)
A VCUG is done to evaluate urinary reflux in children.
Intravenous pyelogram (IVP)
An IVP can be done as part of an evaluation for hematuria however it is rarely used today.
Renal arteriography does not have any place in this scenario as there is no evidence of a renal injury.