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.

  • Non-gonococcal urethritis is most commonly caused by C. trachomatis
• Risk factors:

  • Age <25 years
  • Men who have sex with men
  • Previous STI
  • Recent new sexual partner
  • More than one partner in the last year
• Clinical features:

  • Dysuria
  • Penile irritation
  • Discharge from the urethral meatus
  • Patients can also present with features from the complications or urethritis such as epididymitis or reactive arthritis
• The main differential is balanitis, which is inflammation of the glans penis. This 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.
• Investigations:

  • Urethral swabs - Urethral gram stain under microscopy (pus cells suggest urethritis, gram negative diplococci suggest 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
  • Mid-stream urine dipstick and MC+S
  • Consider further STI screening e.g. HIV and syphilis
• Initial management:

  • Antibiotics is the mainstay of initial management
  • Gonococcal = Ceftriaxone IM single dose + Azithromycin PO single dose
  • Non-gonococcal = doxycycline PO 7 days or Azithromycin PO single dose
• Long term management:

  • Abstain from sexual activity for 7 days after antibiotic course is finished, symptoms have resolved, and their sexual partners have been treated
  • In the case of gonorrhoea, a test of cure is required
  • Counsel patients on condom use and advise patient to notify their sexual partners to attend the sexual health clinic for testing and treatment
• Symptomatic patients contact tracing:

  • Gonorrhoea - all partners in previous 2 weeks
  • Chlamydia - partners in previous 4 weeks
  • Non-specific urethritis - partners in previous 4 weeks
• Non symptomatic patients contact tracing:

  • Gonorrhoea - all sexual partners in previous 3 months
  • Chlamydia - partners in previous 6 months
  • Non-specific urethritis - partners in previous 4 weeks