Urethritis

Original Author: Justin Koh
Last Updated: March 26, 2019
Revisions: 6

Introduction

Figure 1 – Histology demonstrating acute inflammation of the urethra, in keeping with urethritis

Urethritis is the inflammation of the urethra, most often due to infection. The infection can be classified by its aetiology, either as gonococcal urethritis and non-gonococcal urethritis.

Gonococcal urethritis is caused by N. gonorrhoeae, whereas non-gonococcal urethritis is caused most commonly by C. trachomatis, followed by M. genitalium, and T. vagninalis.


Risk Factors

The main risk factors for the condition are age <25yrs, men who have sex with men, previous STI, recent new sexual partner, or more than one partner in the last year.


Clinical Features

The typical presenting symptoms of urethritis are dysuria, penile irritation, and discharge from the urethral meatus.

Eliciting a thorough sexual history can help narrow down the likely pathogens and risk stratify the burden of disease, as well as inform necessary additional sexual health screens and partner notification.

Patients can also present with features from the complications of urethritis, such as epididymitis or reactive arthritis (see below).

Reactive Arthritis

Reactive Arthritis is a sterile inflammatory arthritis caused by a distant infection producing an autoimmune response to certain joints. Commonly caused by Chlamydia trachomatis, Chlamydia pneumoniae, Campylobacter spp., Shigella spp., or Salmonella spp..

It normally presents as an oligoarthritis, typically in the lower limb joints, alongside potential other extra-articular manifestations including conjunctivitis or uveitis, urethritis, cervicitis, or prostatitis, keratoderma blenorrhagicum or painless oral ulcers, or malaise or fatigue.

Around 80% of reactive arthritides resolve within 6 months. Treatment involves rest and treating the affected joint(s) with NSAIDs or local steroid injections; treatment of underlying condition often has limited impact on overall disease progression.


Differential Diagnosis

Balanitis, inflammation of the glans penis, presents with pruritis, erythema and discharge between the foreskin and the glans, contrasting with the urethral discharge and dysuria of urethritis. Balanitis is more common in older patients and can be secondary to bacterial or fungal infection.

Acute prostatitis may present with LUTS, ejaculatory pain, and pain in the penis, perineum, or rectum. Any urethral discharge present is often blood-tinged.

Cystitis presents with dysuria and frequency, however rarely is associated with urethral discharge.


Investigations

Figure 2 – Gram stain demonstrating gonococci bacteria amongst polymorphonuclear neutrophils

Urethral gram stain under microscopy should be performed on urethral swabs if available (available in the GUM setting); pus cells suggest urethritis, and any presence of Gram negative diplococci are highly sensitive for a gonococcal infection.

Gold standard diagnosis is from a first-void urine being sent for Nucleic Acid Amplification Test (NAAT), for N. gonorrhoeae, C. trachomatis, and M. genitalium.

All suspected cases should also have a mid-stream urine dipstick performed, with a low threshold for sending for culture (MC&S). Triple site testing for culture should also be done in the case of gonococcal infection.

Consider further STI screening, such as HIV and syphilis serology, as appropriate. Semen culture can also be appropriate where prostatitis is a suspected.


Management

Initial Management

Antibiotic management is the mainstay of initial management, with the specific regime dependent on the underlying or suspected causative organism.

Current BASHH guidelines recommend:

  • Gonococcal = Ceftriaxone 1g IM single dose + Azithromycin 1g PO single dose
  • Non-gonococcal = Doxycycline 100mg PO BD for 7 days OR Azithromycin 1g PO single dose*

*If trichomonas spp. are seen on microscopy, consider Metronidazole 2g PO single dose; in cases of recurrent NGU other regimens are also considered, such as azithromycin 500mg  PO stat and 250mg for 2 days or moxifloxacin 400mg PO OD for 10-14 days 

Mycoplasma genitalium is a growing concern as an under-treated cause of recurrent non-gonococcal urethritis and increasingly it will be relevant to run resistant tests in the cases of M. genitalium infections.

Long-term Management

Patients should abstain from sexual activity for 7 days after antibiotic course is finished, symptoms have resolved, and their sexual partners have been treated. In cases of gonorrhoea, a test of cure is required.

Counsel patients on condom use and advise the patient to notify their sexual partners to attend the GUM clinic for testing and treatment.

Contact Tracing

Guidelines from the Royal College of General Practitioners and RCGP and the British Association for Sexual Health and HIV (BASHH) advise the following

At time of diagnosis?

Gonorrhoea Chlamydia

Non-specific urethritis

Symptomatic All sexual partners in previous 2 weeks All sexual partners in previous 4 weeks All sexual partners in previous 4 weeks
Non-symptomatic All sexual partners in previous 3 months All sexual partners in previous 6 months All sexual partners in previous 4 weeks

Key Points

  • Urethritis is the inflammation of the urethra, most often due to infection
  • It can be classified by its aetiology into either gonococcal urethritis and non-gonococcal urethritis
  • Patients present with dysuria, penile irritation, and discharge
  • Antibiotic management is the mainstay of initial management, however need to ensure appropriate advice given and contact tracing performed

Quiz

Question 1 / 3
Which of the following is NOT a common causative organism of reactive arthritis?

Quiz

Question 2 / 3
What is the gold standard diagnosis for N. gonorrhoeae and C. trachomatis?

Quiz

Question 3 / 3
In an asymptomatic patient diagnosed with chlamydia urethritis, which sexual partners should be contacted?

Results

Medico Digital

Further Reading

Sterile pyuria
Wise GJ & Schlegel PN, NEJM

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