Urethritis

Urethritis, as characterized by urethral inflammation, can result from infectious and noninfectious conditions. Symptoms include discharge of mucopurulent or purulent material, dysuria, or urethral pruritus. Asymptomatic infections are common. N. gonorrhoeae and C. trachomatis are the most common causes of urethritis; Mycoplasma genitalium has also been associated with urethritis. Gram stain can provide an immediate diagnosis of gonorrhea. Nucleic acid amplification tests enable detection of N. gonorrhoeae and C. trachomatis on all specimens. These tests are more sensitive than culture for C. trachomatis and are the preferred method for the detection of these organisms. Because of their higher sensitivity, NAATs are preferred for the detection of C. trachomatis.

 

Signs of Urethritis

1.   Mucopurulent or purulent discharge

2.   Gram stain of urethral secretions demonstrating >5 WBCs per oil-immersion field; Gram stain is the preferred rapid diagnostic test for evaluating urethritis

3.   Positive leukocyte esterase test on first-void urine or microscopic examination of first-void urine demonstrating >10 WBCs per high-power field

If none of these criteria are present, testing for N. gonorrhoeae and C. trachomatis using NAATs might identify additional infections. If the results demonstrate infection with either of these pathogens, the appropriate treatment should be given and sex partners referred for evaluation and treatment. If none of these criteria are present, empiric treatment of symptomatic males is recommended with drug regimens effective against gonorrhea and chlamydia. Partners of patients treated empirically should be evaluated and treated, if indicated.

 

The presence of nongonococcal urethritis is demonstrated by the absence of gram-negative intracellular diplococci, by a negative gonococcal culture result, and by the detection of inflammatory cells (at least five polymorphonuclear leukocytes) in the urethral smear or in the urine sediment for each patient with clinical symptoms of urethral inflammation.

If clinic-based diagnostic tools (e.g., Gram-stain microscopy, first-void urine with microscopy, and leukocyte esterase) are not available, patients should be treated with drug regimens effective against both gonorrhea and chlamydia.

Comparison of Nongonococcal and Gonococcal Urethritis

	Nongonococcal urethritis	Gonococcal urethritis
Incubation period	7-28 days	3-5 days
Onset	Gradual	Abrupt
Dysuria	Smarting feeling	Burning
Discharge	Mucoid or purulent	Purulent
Gram stain of discharge	Polymorphonuclear leukocytes	Gram-negative intracellular diplococci

 

Etiology

Several organisms can cause infectious urethritis. The presence of Gram-negative intracellular diplococci (GNID) on urethral smear is indicative of gonorrhea infection, which is frequently accompanied by chlamydial infection. Nongonococcal urethritis (NGU), which is diagnosed when examination findings or microscopy indicate inflammation without GNID, is caused by C. trachomatis in 15% to 40% of cases. In most cases of nonchlamydial NGU, no pathogen can be detected. Mycoplasma genitalium, which appears to be sexually transmitted, is associated with symptoms of both urethritis and accounts for 15% to 25% of NGU cases. Trichomonas vaginalis, HSV, and adenovirus also can cause NGU.

 

Nongonococcal urethritis

 

Diagnosis

All patients who have confirmed or suspected urethritis should be tested for gonorrhea and chlamydia. All sex partners within the preceding 60 days should be referred for evaluation, testing, and empiric treatment with a drug regimen effective against chlamydia.

Treatment

Azithromycin and doxycycline are effective for chlamydial urethritis; however, infections with M. genitalium respond better to azithromycin. Men treated for NGU should abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a 7-day regimen. Men should abstain from sexual intercourse until all of their sex partners are treated. Test for syphilis and HIV.

 

Follow-up

Return if symptoms persist or recur. Symptoms alone, without documentation of signs or laboratory evidence of urethral inflammation, are not a sufficient basis for retreatment. Providers should be alert to the possibility of chronic prostatitis/chronic pelvic pain syndrome in male patients experiencing persistent pain (perineal, penile, or pelvic), discomfort, irritative voiding symptoms, pain during or after ejaculation, or new-onset premature ejaculation lasting for >3 months.

Men with documented chlamydial or gonococcal infections have a high rate of reinfection within 6 months after treatment; repeat testing of all men diagnosed with chlamydia or gonorrhea is recommended 3 to 6 months after treatment, regardless of whether patients believe that their sex partners were treated.

 

Recurrent and persistent urethritis

Persons who have persistent or recurrent urethritis can be retreated with the initial regimen if they did not comply with the treatment regimen or if they were re exposed to an untreated sex partner. Persistent urethritis after doxycycline treatment might be caused by doxycycline-resistant Ureaplasma urealyticum or M. genitalium. T. vaginalis is also known to cause urethritis in men; a urethral swab, first-void urine specimen, or semen for culture or an NAAT (PCR or transcription-mediated amplification [TMA]) on a urethral swab or urine can be performed. Referral to an urologist should be considered for men who experience pain for more than 3 months within a 6-month period.

 

Cervicitis

Cervicitis is characterized by (1) a purulent or mucopurulent endocervical exudate visible in the endocervical canal or on an endocervical swab specimen, or by (2) sustained endocervical bleeding easily induced by gentle passage of a cotton swab through the cervical os. Either or both signs might be present. Cervicitis frequently is asymptomatic, but some women complain of an abnormal vaginal discharge and inter menstrual vaginal bleeding (e.g., after sexual intercourse). A finding of leukorrhea (>10 WBCs per high-power field on microscopic examination of vaginal fluid) has been associated with chlamydial and gonococcal infection of the cervix.

 

Etiology

When an etiologic organism is isolated in the presence of cervicitis, it is typically C. trachomatis or N. gonorrhoeae. Cervicitis also can accompany trichomoniasis and genital herpes (especially primary HSV-2 infection). In most cases of cervicitis, no organism is isolated. Cervicitis can persist despite repeated courses of antimicrobial therapy. Because most persistent cases of cervicitis are not caused by relapse or reinfection with C. trachomatis or N. gonorrhoeae, other factors (e.g., persistent abnormality of vaginal flora, douching [or exposure to other types of chemical irritants], or idiopathic inflammation in the zone of ectopy) might be involved.

 

Diagnosis

Because cervicitis might be a sign of upper-genital–tract infection (endometritis), women who seek medical treatment for a new episode of cervicitis should be assessed for signs of pelvic inflammatory disease (PID) and should be tested for C. trachomatis and for N. gonorrhoeae with the most sensitive and specific test available. Women with cervicitis also should be evaluated for the presence of bacterial vaginosis (BV) and trichomoniasis. NAAT should be used for diagnosing C. trachomatis and N. gonorrhoeae in women with cervicitis; this testing can be performed on vaginal, cervical, or urine samples. A finding of >10 WBCs in vaginal fluid, in the absence of trichomoniasis, might indicate endocervical inflammation caused by C. trachomatis or N. gonorrhoeae.

 

Treatment

Treatment with antibiotics for C. trachomatis should be provided for those women at increased risk for this common STD (e.g., those aged ≤25 years, those with new or multiple sex partners, and those who engage in unprotected sex), especially if follow-up cannot be ensured and if a relatively insensitive diagnostic test is used in place of NAAT. Concurrent therapy for N. gonorrhoeae is indicated if the prevalence of this infection is >5% (those in younger age groups and those living in certain facilities).

Trichomoniasis and BV should also be treated if detected. For women in whom any component of (or all) presumptive therapy is deferred, the results of sensitive tests for C. trachomatis and N. gonorrhoeae (e.g., NAATs) should determine the need for treatment subsequent to the initial evaluation.