STI-associated syndromes guide: Urethritis

This guide provides an overview of the management and empiric treatment of sexually transmitted infection (STI) - associated urethritis, which is an inflammation of the urethra.

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Public health importance

There are limited data on the incidence and prevalence of urethritisFootnote 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 GCFootnote 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 peopleFootnote 3Footnote 4Footnote 5. Other possible infectious causes include Trichomonas vaginalisFootnote 6, Herpes simplex virus (HSV), adenovirusFootnote 7Footnote 8 and Candida albicansFootnote 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:

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

Empiric treatment and management

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

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 Empiric treatment for suspected CT-urethritis

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.

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,

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.

References

Footnote 1

George Mueller. Overview: What every practitioner needs to know. Are you sure your patinet has urethritis? What should you expect to find? Infectious Disease Advisor 2013.

Return to footnote 1 referrer

Footnote 2

Ito S, Hanaoka N, Shimuta K, et al. Male non-gonococcal urethritis: From microbiological etiologies to demographic and clinical features. Int J Urol. 2016;23(4):325-331.

Return to footnote 2 referrer

Footnote 3

Bachmann LH. Urethritis in adult men. UpToDate 2019.

Return to footnote 3 referrer

Footnote 4

Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015 Jun 5;64(RR-03):1-137.

Return to footnote 4 referrer

Footnote 5

Alberta Health. Non-Gonococcal Urethritis. Public Health Notifiable Disease Management Guidelines 2013.

Return to footnote 5 referrer

Footnote 6

Wendel KA, Erbelding EJ, Gaydos CA, Rompalo AM. Use of urine polymerase chain reaction to define the prevalence and clinical presentation of Trichomonas vaginalis in men attending an STD clinic. Sex Transm Infect 2003; 79(2):151-153.

Return to footnote 6 referrer

Footnote 7

Bradshaw CS, Denham IM, Fairley CK. Characteristics of adenovirus associated urethritis. Sex Transm Infect 2002; 78(6):445-447.

Return to footnote 7 referrer

Footnote 8

Azariah S, Reid M. Adenovirus and non-gonococcal urethritis. Int J STD AIDS 2000;11(8):548-550.

Return to footnote 8 referrer

Footnote 9

Varela JA, Otero L, GarcÍa MJ, et al. Trends in the prevalence of pathogens causing urethritis in Asturias, Spain, 1989-2000. Sex Transm Dis 2003;30(4):280-283.

Return to footnote 9 referrer

Footnote 10

Johnson RE, Newhall WJ, Papp JR, et al. Screening tests to detect Chlamydia trachomatis and Neisseria gonorrhoeae infections-2002. MMWR Recomm Rep 2002;51(RR-15):1-38.

Return to footnote 10 referrer

Footnote 11

Burstein GR, Zenilman JM. Nongonococcal urethritis--a new paradigm. Clin Infect Dis. 1999;28 Suppl 1:S66-S73.

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Footnote 12

Simmons PD. Evaluation of the early morning smear investigation. Br J Vener Dis 1978; 54(2):128-129.

Return to footnote 12 referrer

Footnote 13

Swartz SL, Kraus SJ, Herrmann KL, Stargel MD, Brown WJ, Allen SD. Diagnosis and etiology of nongonococcal urethritis. J Infect Dis 1978;138(4):445-454.

Return to footnote 13 referrer

Footnote 14

Handsfield HH, McCormack WM, Hook EW 3rd, et al. A comparison of single-dose cefixime with ceftriaxone as treatment for uncomplicated gonorrhea. The Gonorrhea Treatment Study Group. N Engl J Med. 1991;325(19):1337-1341.

Return to footnote 14 referrer

Footnote 15

Lyss SB, Kamb ML, Peterman TA, et al. Chlamydia trachomatis among patients infected with and treated for Neisseria gonorrhoeae in sexually transmitted disease clinics in the United States. Ann Intern Med. 2003;139(3):178-185. 

Return to footnote 15 referrer

Footnote 16

Tapsall JW. What management is there for gonorrhea in the postquinolone era? Sex Transm Dis 2006; 33(1):8-10.

Return to footnote 16 referrer

Footnote 17

Workowski KA, Berman S, Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep 2010; 59(RR-12):1-110.

Return to footnote 17 referrer

Footnote 18

World Health Organization. Guidelines for the Management of Sexually Transmitted Infections. 2003.

Return to footnote 18 referrer

Footnote 19

Lau C, Qureshi AK. Azithromycin versus doxycycline for genital chlamydial infections: a meta-analysis of randomized clinical trials. Sex Transm Dis 2002;29(9):497-502.

Return to footnote 19 referrer

Footnote 20

Stamm WE, Stamm WE, Hicks CB, Martin DH, et al. Azithromycin for empirical treatment of the nongonococcal urethritis syndrome in men. A randomized double-blind study. JAMA. 1995;274(7):545-549.

Return to footnote 20 referrer

Footnote 21

Steingrímsson O, Olafsson JH, Thórarinsson H, Ryan RW, Johnson RB, Tilton RC. Single dose azithromycin treatment of gonorrhea and infections caused by C. trachomatis and U. urealyticum in men. Sex Transm Dis. 1994;21(1):43-46./p>

Return to footnote 21 referrer

Footnote 22

McKee Jr KT, McKee KT Jr, Jenkins PR, Garner R, et al. Features of urethritis in a cohort of male soldiers. Clin Infect Dis. 2000;30(4):736-741.

Return to footnote 22 referrer

Footnote 23

Borchardt KA, Borchardt KA, al-Haraci S, Maida N. Prevalence of Trichomonas vaginalis in a male sexually transmitted disease clinic population by interview, wet mount microscopy, and the InPouch TV test. Genitourin Med. 1995;71(6):405-406.

Return to footnote 23 referrer

Footnote 24

Lautenschlager S, Eichmann A. Urethritis: an underestimated clinical variant of genital herpes in men?. J Am Acad Dermatol. 2002;46(2):307-308.

Return to footnote 24 referrer

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