STI-associated syndromes guide: Urethritis

On this page:

• Public health importance
• Common STI-related etiology
• Clinical Manifestations
• Diagnostic testing
• Empiric treatment and management
• Follow-up
• Reporting and partner notification
• References

Public health importance

There are limited data on the incidence and prevalence of urethritis^{Footnote 1}. However, it is well established that STIs are important infectious causes of urethritis.

Common STI-related etiology

Neisseria gonorrhoeae (GC) is the most common cause of urethritis. In one study, 30% of males with acute urethritis had GC^{Footnote 2}.

In cases of non-gonococcal urethritis, Chlamydia trachomatis (CT) was identified in 15-40% of people and M. genitalium was identified in 15-25% of people^{Footnote 3Footnote 4Footnote 5}. Other possible infectious causes include Trichomonas vaginalis^{Footnote 6}, Herpes simplex virus (HSV), adenovirus^{Footnote 7Footnote 8} and Candida albicans^{Footnote 9}. In almost half of the cases of non-gonococcal urethritis, the specific microbial etiology is unknown and no specific organism is identified.

Clinical Manifestations

Symptoms and signs of urethritis include:

• Mucoid, mucopurulent or purulent urethral discharge
• Dysuria
• Urethral/meatal itching or irritation
• Meatal erythema and edema

Symptoms of gonococcal urethritis typically develop 2-6 days after acquisition.

Symptoms of non-gonococcal urethritis typically develop 1-5 weeks after acquisition (usually at 2-3weeks).

In women, CT and GC may present as urethritis with or without cervicitis. Dysuria and urinary frequency are symptoms of urethritis that may mimic cystitis; but discharge is not common in cystitis.

Consider an alternate diagnosis when any of the following symptoms are present: hematuria, nocturia, frequency, urgency, difficulty initiating and maintaining stream, fever, chills, perineal pain, flank pain, scrotal masses or lymphadenopathy.

Diagnostic testing

• Obtain first-void urine (FVU) or urethral swab for nucleic acid amplification tests (NAAT) for CT and GC, plus culture for GC (where available)^{Footnote 10Footnote 11Footnote 12}.
• Gram stain, when available at point of care, can help distinguish GC-urethritis from non-gonococcal urethritis and guide empiric treatment:
  • The presence of ≥ 5 polymorphonuclear leukocytes (PMNs) per oil immersion field (x1000) in five non-adjacent, randomly selected fields is suggestive of non-gonococcal urethritis^{Footnote 13}
  • The presence of Gram-negative intracellular diplococci is generally diagnostic of GC
  • The presence of extracellular Gram-negative diplococci is an equivocal finding and requires confirmatory testing for GC
• Consider testing for M. genitalium in persons with persistent or recurrent urethritis following treatment for CT and GC when pre- or post-treatment NAAT tests are negative for CT and GC.

Empiric treatment and management

The decision to treat empirically or to wait for test results should reflect the:

• Severity of the clinical condition
• Probability of infection
• Person's risk factors for a sexually transmitted and blood-borne infection (STBBI)
• Person's willingness to abstain from sex and to return for test results or follow-up

A "test and wait" approach (versus empiric treatment) may be best in certain circumstances. This is because many cases of urethritis are of unknown etiology and rates of antimicrobial resistance (AMR) are increasing.

Empiric treatment for suspected GC-urethritisFootnote 14

Ceftriaxone 250 mg IM in a single dose [A-l] or Cefixime 800 mg PO in a single dose [A-l] plus Azithromycin 1 g PO in a single dose [B-ll] Note: Cefixime is considered an alternate treatment in gay, bisexual and other men who have sex with men (gbMSM). CT and GC are the most common bacterial STIs in Canada and coinfection is common. The recommended dual therapy for GC is also effective for CTFootnote 15Footnote 16Footnote 17Footnote 18.

Empiric treatment for suspected CT-urethritis
Doxycycline 100 mg PO BID for 7 days [A-l] or Azithromycin 1 g PO in a single dose, if poor compliance is expected [A-l] Footnote 19Footnote 20Footnote 21

Follow-up

Test of cure (TOC) will depend on which pathogen is confirmed by laboratory testing. Refer to the etiology-specific guide for follow-up and TOC.

In the case of recurrent or persistent urethritis,

• Assess the possibility of:
• Poor adherence to treatment
• Use of alternate rather than preferred (first-line) treatment
• Reinfection
• AMR
• Presence of other pathogens that were not part of initial testing (e.g. M. genitalium)
• Presence of other etiologies (e.g. urinary tract infection, prostatitis, phimosis, chemical irritation, urethral strictures, tumours)
• Consider:
  • Repeating specimen collection (urine or urethral swabs) for Gram stain, culture for GC and NAAT for GC and CT
  • Urethral swabs or FVU urine for NAAT for T. vaginalis^{Footnote 22Footnote 23}
  • Urethral swab for NAAT or culture for HSV; note that HSV usually presents with lesions^{Footnote 6Footnote 24}
  • If not done previously, consider NAAT testing for M. genitalium including antibiotic susceptibility (where available). If testing is not available, consider empiric treatment for M. genitalium. Refer to Mycoplasma genitalium guide.
  • Consider consulting an experienced colleague or urologist.

Reporting and partner notification

When treatment is indicated for an STI: notify, evaluate, test and treat (as appropriate) sexual partners. Refer to the etiology-specific guide(s) for guidance on reporting and partner notification.