URETHRITIS

URETHRITIS - Chad M.Braun, MD
BASICS
DESCRIPTION
Syndrome of urethral inflammation marked by painful urination, urethral pruritis, and discharge
• Usually a sexually transmitted infection (STI); other causes not uncommon
• Untreated cases may gradually resolve, but complications, such as urethral stricture in males or pelvic inflammatory disease (PID) in women, may ensue.
• System(s) Affected: Renal/Urologic
GENERAL PREVENTION
• Safer sex protection techniques
• Sexual abstinence only sure way for complete prevention of STI-related causes
• Treatment of all sexual partners
EPIDEMIOLOGY
• Predominant age: 15-24 years, sexually active
• Predominant sex: Classic symptoms more commonly reported by males; incidence in females probably equal
Incidence
Very common: >830,000 cases of chlamydia and 350,000 cases of gonorrhea reported in 2002 in the US
RISK FACTORS
• Multiple sexual partners
• History of other STI
• Unprotected sexual activity
ETIOLOGY
• Predominantly Neisseria gonorrhoeae and Chlamydia trachomatis infection, often together
• Less common infectious agents, including
- Ureaplasma urealyticum
- Trichomonas vaginalis
- Herpesvirus
- Mycoplasma genitalium
• Noninfectious causes (generally rare)
- Foreign bodies, soaps, shampoos, douches, spermicides, urethral instrumentation
ASSOCIATED CONDITIONS
Other STIs: Patients should be strongly urged to undergo testing for syphilis, hepatitis B, and HIV.


DIAGNOSIS
SIGNS AND SYMPTOMS
• Both sexes may be asymptomatic carriers of the causative organisms.
• In males: Abrupt onset of symptoms 3-5 days after exposure to an infected sexual partner
• In females: Classic urethral syndrome often is not present. Infections that cause simple urethritis in males will often have symptoms other than dysuria, including vaginal discharge and cervicitis.
• Dysuria: Pain throughout urination
• Urethral discharge; may be profuse and purulent in acute gonorrhea, or scanty, evident only with milking of the urethra, with other causes
• Urethral itching or tenderness
• Tenderness, edema, and inflammation of the urethral meatus, especially in women
• Dyspareunia
• Vaginitis, cystitis, cervicitis in women
• Proctitis, pharyngitis, conjunctivitis may also be present (sexual history is important)
• Fever is not part of the syndrome and suggests another diagnosis.
• Bloody discharge: Rarely seen and suggests another diagnosis
• Suprapubic or abdominal pain suggests another diagnosis or presence of complications, e.g., PID, prostatitis, or cystitis.
ALERT
Pediatric Considerations
Proven cases of gonorrhea, chlamydia, and trichomoniasis should raise the question of sexual abuse.
TESTS
For patients who present without symptoms stating that a sexual partner was treated for this problem: Obtain specimens for lab tests, but immediate treatment is recommended.
Screening
• The US Preventative Services Task Force (USPSTF) recommends routine screening in all sexually active women 25 years old and younger and all other women at increased risk of infection. (4)[A]
• The optimal screening interval is uncertain.
• They make no recommendation for or against the screening of low-risk women. (4)[A]
• The USPSTF states that the evidence is insufficient to recommend for or against screening in asymptomatic men at increased risk. (4)[I]
Lab (1)[C]
• Gram stain of discharge: Intracellular gram-negative diplococci strongly indicate gonorrhea; 5 or more white blood cells (WBC) per high-power field (HPF) indicate urethritis.
• Cultures or reagin detection: DNA probe is probably the best screening test.
- Cultures may be difficult to obtain correctly but allow for antimicrobial sensitivity testing.
- Polymerase chain reaction (PCR) assay on urine is more sensitive and specific, but costly. Can get PCR on sample from ThinPrep test. Negatives may be false results or may indicate another infecting organism.
• Urinalysis: If indicated, sample discharge before patient voids; usually normal in cases of simple urethritis.
- 1st-void urine is often positive for leukocyte esterase and should have 10 or more WBC per HPF in urethritis.
- Ideally, men should not have urinated for at least 4 hours prior.
- Symptomatic patients in whom no urethritis is detected initially should be retested having held their urine overnight.
• Urine culture: Performed only if gram stain of discharge is unremarkable or unobtainable
• Wet prep of discharge: May reveal Trichomonas; usually reserved in males who fail adequate treatment for gonorrhea and chlamydia
• Syphilis, HIV, and hepatitis B serology as indicated to rule out concomitant STIs
• Recent treatment with antibiotics may lead to false-negative results.
Diagnostic Procedures/Surgery
Urethrocystoscopy for cases with suspected foreign body, intraurethral warts, urethral stricture
Pathological Findings
Urethral strictures (untreated gonorrhea), intraurethral lesions (venereal warts, congenital anomalies)
DIFFERENTIAL DIAGNOSIS
• Other urinary tract infections
- Cystitis
- Epididymitis
- Prostatitis
- PID
- Pyelonephritis
• Atrophy, especially in postmenopausal women
• Stevens-Johnson syndrome
• Reiter syndrome: Arthritis, uveitis, and urethritis
• Wegener granulomatosis may have urethritis as one of its manifestations.
TREATMENT
STABILIZATION
• Most cases can be treated in the outpatient setting.
• Single-dose regimens can be directly observed in the office for noncompliant or high-risk patients.
• Antibiotics should not be withheld from symptomatic patients until culture (test) results are known, rather they should be initiated as soon as cultures (samples) have been collected.
• Treatment should cover both gonorrhea and chlamydia because they cause the majority of cases and often coexist.
• Patients with persistent symptoms and signs after adequate treatment should be
- Evaluated and/or treated for trichomoniasis
- Retreated with the original regimen if not compliant or re-exposed
- Retreated with an alternative regimen for 14 days if U. urealyticum is suspected (tetracycline resistance in 10% of isolates)
- Evaluated for HSV
GENERAL MEASURES
Identification and treatment of sexual partners
All sexual partners within the previous 60 days should be investigated and treated.
Diet
Avoid alcohol with metronidazole.
Activity
• Full activity
• No sexual intercourse until 7 days after single dose therapy or completion of 7-day therapy
MEDICATION (DRUGS)
First Line
• Gonorrhea: (1)[C]
- Cefixime: 400 mg PO single dose
- Ceftriaxone: 125 mg IM single dose (superior for gonococcal pharynigitis)
• Chlamydia: (5)[A]
- Azithromycin: 1 g PO single dose
- Doxycycline: 100 mg PO b.i.d. for 7 days
• Trichomoniasis: Metronidazole 2 g PO single dose or 250 mg t.i.d. for 7 days
• Recurrent and resistant urethritis: (5)[C] Metronidazole 2 mg PO single dose PLUS erythromycin base 500 mg PO q.i.d. for 7 days or erythromycin ethylsuccinate 800 mg PO q.i.d. for 7 days
• Contraindications: Sensitivity to any of the indicated medications. Pregnant patients should not receive tetracyclines, and metronidazole should be avoided in the 1st trimester.
• Precautions: Patients taking tetracyclines need to be told of the possibility of increased sensitivity to sunlight.
• Significant possible interactions
- Tetracyclines should not be taken with milk products or antacids.
- Oral contraceptives may be rendered ineffective by oral antibiotics. Patients and partners should use a backup method of birth control for remainder of the cycle.
ALERT
Pregnancy Considerations
• Tetracyclines and quinolones are contraindicated.
• Avoid erythromycin estolate because of an increased risk of cholestatic jaundice; otherwise use the standard treatment recommendations.
• 7-day therapy for chlamydia is favored in pregnancy, but single dose is still recommended.
Second Line
• Gonorrhea
- Because of the spread of quinolone-resistant N. gonorrhoeae from the Pacific and Asia, quinolones are no longer recommended treatment in individuals who have acquired gonorrhea from that area. (2)[C]
- Fluoroquinolones are also not recommended as 1st-line therapy for people in Hawaii and California and men who have sex with men, because of endemic spread of quinolone-resistant gonorrhea. (2)[C]
- Resistance to penicillin and tetracycline has been reported in up to 1/3 of isolates of N. gonorrhoeae.
- Ciprofloxacin: 500 mg PO single dose (1)[C]
- Ofloxacin: 400 mg PO single dose (1)[C]
- Levofloxacin: 250 mg PO single dose (1)[C]
- Others drugs are available, but offer no particular advantage over the drugs of choice.
• Chlamydia
- Erythromycin base: 500 mg PO q.i.d. for 7 days (5)[A]
- Erythromycin ethylsuccinate: 800 mg PO q.i.d. for 7 days. If intolerant of high-dose erythromycin: Erythromycin base 250 mg PO q.i.d. for 14 days or erythromycin ethylsuccinate 400 mg PO q.i.d. for 14 days
- Ofloxacin: 300 mg PO b.i.d. for 7 days (5)[A]
- Levofloxacin: 500 mg PO daily for 7 days
FOLLOW-UP
DISPOSITION
Outpatient management
PROGNOSIS
If the diagnosis is firmly established, appropriate medications are prescribed, and the patient is compliant with treatment, there will be relief of symptoms within days and the problem will resolve without sequelae.
COMPLICATIONS
• Stricture formation
• Epididymitis
• PID in women
• Disseminated gonococcal infection
• Gonococcal meningitis
• Gonococcal endocarditis
• Perinatal transmission (chlamydial conjunctivitis, chlamydial pneumonia, ophthalmia neonatorum)
• Reiter syndrome
PATIENT MONITORING
Instruct patients to return if symptoms persist or recur after completing treatment. Test of cure cultures is not usually required unless patient is pregnant.
REFERENCES
1. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines for 2002. MMWR Recomm Rep. 2002;51(RR-06):1-80.
2. Centers for Disease Control and Prevention. Increases in fluoroquinolone-resistant Neisseria gonorrhoeae among men who have sex with menUnited States, 2003, and revised recommendations for gonorrhea treatment, 2004. MMWR Morb Mortal Wkly Rep. 2004;53:335-338.
3. Groseclose SL et al. Centers for Disease Control and Prevention. Summary of notifiable diseasesUnited States, 2002. MMWR Morb Mortal Wkly Rep. 2004;51:1-84.
4. Berg AO. Screening for chlamydia infections: Recommendations and rationale. Am J Prev Med. 2001;20:90-4.
5. 2002 National Guideline on the Management of Non-gonoccal urethritis, Association for Genitourinary Medicine.
MISCELLANEOUS
See also: Chlamydial sexually transmitted diseases; Epididymitis; Gonococcal infections; Pelvic inflammatory disease (PID); Prostatitis; Urinary tract infection in females; Urinary tract infection in males; Vulvovaginitis, bacterial; Vulvovaginitis, candidal