Canadian Guidelines on Sexually Transmitted Infections

Supplementary statement for recommendations related to the diagnosis, management, and follow-up of Urethritis: March 2014

Key Issue

The Gonococcal Infections chapter has been revised in response to emerging antimicrobial resistance. As a result, the 2010 print and online versions of the Urethritis chapter of the Canadian Guidelines on Sexually Transmitted Infections also require updates.

This statement is intended to inform clinicians of key changes in the management of urethritis until such time as the full chapter revision is available.

The current full chapter should be consulted for management of children presenting with urethritis.

Diagnosis

How to collect an endourethral swab for men presenting with urethral discharge:

  • Moisten the swab with sterile water before insertion to help reduce discomfort.
  • Introduce the swab slowly (3–4 cm), rotate slowly and withdraw gently.
  • Prepare a smear for Gram stain by gently rolling the swab across a slide; then, directly inoculate a culture medium or place the swab in a transport medium for laboratory detection of N. gonorrhoeae.
  • Test for both gonorrhea and chlamydia.
    • In symptomatic patients, depending on the clinical situation, consideration should be given to collection of samples for N. gonorrhoeae using both culture and NAAT.
  • Obtain 10–20 ml of first-catch urine, any time of day, but preferably after the patient has not voided for at least 2 hours.
  • Refer to the Gonococcal Infections chapter for recommended management based on whether results are available or pending. These tables should be used when gonococcal infection is suspected or confirmed.
  • Figure 1 at the end of the current Urethritis chapter is out of date and should not be used to guide treatment decisions.

Treatment

In patients with urethritis who have a suspected or confirmed gonococcal infection, treatment should include combination therapy in response to increasing antimicrobial resistance.

  • Combination therapy using medications with two different mechanisms of action is thought to improve treatment efficacy as well as to potentially delay the emergence of cephalosporin-resistant gonorrhea.
  • This combination therapy also includes effective treatment for concomitant chlamydia infection, which occurs frequently.
  • Refer to Table 7 of the Gonococcal Infections chapter for treatment recommendations for women and non-MSM and to Table 8 for MSM. Refer to the Follow-up section for test of cure recommendations.

If the risk of gonococcal infection is low AND follow-up can be assured, treat for non-gonococcal urethritis (NGU) with doxycycline 100 mg orally twice a day for 7 days OR (if poor compliance is expected) azithromycin 1 g orally in a single dose.

Follow-up

  • Patients treated for urethritis do not generally require follow-up post-treatment except if there are recurrent or persistent symptoms. Refer to the recurrent urethritis section of the current Urethritis chapter.
  • Those who have confirmed gonococcal infection should be reported to local public health and followed up as per the recommendations in the Partner notification and Follow-up sections of the Gonococcal Infections chapter.
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