Diagnosis and Treatment of Sexually Transmitted Urethritis

Etiology and Diagnosis

Chlamydia trachomatis is the most common cause of non-gonococcal urethritis, accounting for 30-40% of cases, in young males with new sexual contact 2
Neisseria gonorrhoeae must be considered given the sexual exposure, even without classic purulent discharge, in the diagnosis of urethritis 1
The absence of visible urethral discharge does not exclude urethritis, as many chlamydial infections present with minimal or absent discharge, emphasizing the need for nucleic acid amplification testing (NAAT) 2

Urinalysis on first-void urine to document pyuria is essential in the diagnostic approach for urethritis 5
Nucleic acid amplification testing (NAAT) for both N. gonorrhoeae and C. trachomatis on first-void urine or urethral swab is recommended for the diagnosis of sexually transmitted urethritis 1

The Centers for Disease Control and Prevention (CDC) recommends treating empirically with azithromycin 1 g orally as a single dose or doxycycline 100 mg orally twice daily for 7 days, combined with ceftriaxone 250 mg IM as a single dose, for the treatment of urethritis 1
The American College of Physicians suggests that medication should ideally be provided and administered in the clinic to ensure compliance, for the treatment of sexually transmitted infections 1

The CDC recommends that all sexual partners within the preceding 60 days must be evaluated and treated with the same empiric treatment regimen as the index patient, to prevent the spread of sexually transmitted infections 7
Partners should receive the same empiric treatment regimen as the index patient, and both patient and partners must abstain from sexual intercourse for 7 days after treatment initiation, according to the CDC guidelines 1

The CDC recommends confirming objective signs of urethritis before re-treating, and not re-treating based on symptoms alone without documenting objective signs of urethritis (discharge or pyuria) 1
The European Urology association suggests that metronidazole 2 g orally as a single dose or tinidazole 2 g orally as a single dose, plus azithromycin 1 g orally as a single dose, can be used for the treatment of persistent urethritis 6

The CDC recommends that patients should return if symptoms persist or recur after completing therapy, and repeat screening at 3 months is recommended for all patients treated for sexually transmitted infections 4
The CDC also recommends that persistence of symptoms beyond 3 months should prompt evaluation for chronic prostatitis/chronic pelvic pain syndrome 1

The CDC recommends that HIV-infected patients should receive the same treatment regimen as HIV-negative patients, and urethritis may facilitate HIV transmission, making partner treatment particularly important 7
The CDC also recommends that all patients must have syphilis serology performed at diagnosis, with appropriate follow-up if positive, to prevent the spread of syphilis 5