Urethritis

• Urethritis is an inflammation of the urethra, which may be due to many different aetiological agents
• Usually sexually transmitted, but may have other causes
• Consider urethritis in men presenting with dysuria and urethral discharge, irritation or discomfort
• Urinary frequency, urgency, haematuria or nocturia are more suggestive of urinary tract infection (UTI)
• UTIs are uncommon in men aged under 35 years, so a sexually transmitted infection (STI) should be suspected unless proven otherwise
• Persistent or recurrent urethritis is defined as symptoms persisting for longer than 2 weeks after initiation of treatment, or recurrence of symptoms within 90 days following treatment of acute urethritis

• Gonococcal urethritis: Neisseria gonorrhoeae
• Non-gonococcal urethritis
  • Often due to Chlamydia trachomatis
  • Sometimes due to genital mycoplasmas (e.g. Mycoplasma genitalium)
  • Other rarer causes include Trichomonas vaginalis, herpes simplex virus (HSV), adenovirus, enteric bacteria (insertive anal sex) and pharyngeal organisms (oral sex)

Persistent or recurrent urethritis is due to Mycoplasma genitalium in over 40% of those who fail initial treatment with doxycycline

Ureaplasma urealyticum is considered part of the normal urethral flora, and generally does not require treatment

• Urethral discharge, dysuria, discomfort or irritation

Examination is important, so that correct syndromic management can be initiated

Urethritis

• Screening for STIs as per sexual health check guideline
• Mid-stream urine for microscopy, culture and sensitivities if UTI suspected
• Consider swab of urethral meatus for HSV if inguinal lymphadenopathy, severe dysuria or meatitis

Persistent or recurrent urethritis

If adherent to treatment, and re-infection excluded:

• Repeat first-void urine for chlamydia and gonorrhoea nucleic acid amplification test (NAAT), add trichomonas NAAT (in men who have sex with women)
• First-void urine for Mycoplasma genitalium

Treatment options

• Advise to abstain from sex or use condoms for 1 week from the start of treatment, and until partner(s) tested and treated.

• Contact tracing is important to prevent re-infection and reduce transmission
• All sexual contacts in the last 3 months should be notified
• Most patients choose to tell contacts themselves; giving written information can be helpful
• Notifying all contacts may not be possible e.g. if there is insufficient information or a threat of violence

Management of sexual contacts

• Contacts should have a full sexual health check, and empirical treatment with doxycycline 100 mg orally twice daily for 7 days, assuming no allergies or contraindications. If gonorrhoea is suspected in the index case, use ceftriaxone 500 mg intramuscularly as a single dose, plus azithromycin 1 g orally
• Advise contacts to abstain from sex or use condoms until results are available, and 1 week from start of treatment
• If index case or contacts test positive for an STI, see appropriate STI guideline for management
• Patient-delivered partner therapy is not legal in Aotearoa New Zealand

Referral to or discussion with a specialist is recommended for:

• Screening and treatment of sexual contacts if clinician wishes
• Allergy or contraindication to standard treatment options
• Males with recurrent or persisting urethritis that have not responded to empirical treatment
• All people testing positive for Mycoplasma genitalium

• 100% of patients diagnosed with urethritis are treated with an appropriate antibiotic regimen
• 100% of patients are advised to avoid sexual contact for 7 days after treatment is commenced

Just the facts