Treatment of Male Urethritis

Diagnosis

The Centers for Disease Control and Prevention recommends confirming urethritis with at least one of the following: mucopurulent or purulent urethral discharge, positive leukocyte esterase test on first-void urine, or ≥10 WBC per high-power field on microscopic examination of first-void urine sediment 1, 3
All patients with confirmed or suspected urethritis should be tested for Neisseria gonorrhoeae and Chlamydia trachomatis 1, 3

The Centers for Disease Control and Prevention recommends first-line treatment with azithromycin 1g orally in a single dose or doxycycline 100mg orally twice daily for 7 days 1, 2, 3
Azithromycin 1g orally in a single dose is particularly effective against Mycoplasma genitalium 3, 4
Doxycycline 100mg orally twice daily for 7 days is highly effective for chlamydial urethritis 3

Empiric treatment without documentation of urethritis is recommended only for patients at high risk for infection who are unlikely to return for follow-up, and should include treatment for both gonorrhea and chlamydia 1, 3
All sex partners within the preceding 60 days should be referred for evaluation and treatment, and should receive treatment effective against chlamydia regardless of whether a specific etiology is identified in the index patient 2, 5

If symptoms persist or recur after treatment, confirm objective signs of urethritis before initiating further antimicrobial therapy, and rule out non-compliance with initial treatment or re-exposure to untreated partner 5
Recommended treatment for persistent or recurrent urethritis is metronidazole 2g orally in a single dose or tinidazole 2g orally in a single dose, plus azithromycin 1g orally in a single dose (if not used for initial episode) 2, 5

Patients should return for evaluation if symptoms persist or recur after treatment, and test-of-cure is not recommended for asymptomatic patients who received recommended treatment 2, 5
Consider repeat testing 3-6 months after treatment due to high rate of reinfection 2, 5