Clinical Scenario # 1
Getachew, a 22 year old man, comes to your office
complaining of pain when he urinates for the past 3
days. This morning he noticed a “drip” from the tip of his
He has had unprotected sex with four new female partners
in the past 4 weeks, most recently 6 days ago.
a. What is your diagnosis?
b. What are the pathogens responsible for the disease?
c. How do you treat him?
Upon completion of this content you will be able to:
1. List the etiologic agents of urethritis.
2. Describe the clinical manifestations and sequelae of urethritis.
3. State the clinical and laboratory criteria for the diagnosis of
4. Summarize the clinical management of patients with urethritis to include:
recommended diagnostic tests ,
Patient counseling and
- Clinical syndrome:
- Inflammation of the urethra,
1. urethral discharge or without UD,
UD can be mucoid, mucopurulent or purulent
urethral pruritus or
- Microscopic definition:
Presence of >4 PMNs/oil immersion field ( x 1000)
on a smear
A. Gonococcal Urethritis:
~ 20% of urethritis are caused by Neisseria gonorrhoeae.
B. Nongonococcal Urethritis (NGU): ~80% of cases of urethritis
Etiologic Agents of NGU Based on Culture
Chlamydia trachomatis 15- 40%
Ureaplasma urealyticum 10---40%
Mycoplasma genitalium 15---25%
Trichomonas vaginalis Up to 13%
Candida albicans < 1%
Miscellaneous bacteria < 1%
Other (E. Coli, Haemophilus
species,Gm positives) ?
clinical features GU NGU
Incubation period 2-8 days 7-14 days
Onset Abrupt Gradual
Dysuria Severe Mild
Discharge quality Purulent Mucoid
Discharge quantity More Less
NB: a considerable overlap may exist between these presentations
General features of GU and NGU
III. Clinical Manifestations
Remember the following
- Distinguishing on clinical ground alone GU from NGU is not
reliable ( at best, 50% accurate)
- It does not also distinguish CT positive NGU from CT negative
- 15-40 % of GU also harbor CT.
Therefore Rx for GU should always include TX for CT
Gonnorhea and chlamydia Trachomatis
Sites of infection local complication general
Classi Sites Local general
In Men 1.Tysonitis 1. arthritis
2.paraurethral 2. anterior uveitis
3. Littritis 3 Myocarditis
Anterior 4. Periurethral 4. Endocarditis
5. Cowperitis 5. Pericarditis
6. Cowper ‘s gland 6. meningitis
7. Ureth. Stricture 7. DGI
Gonorrhea ( cont.)
2.Posterior acute/ chronic
urethra Prostatic Abscess
1.cervix Uteri Salpingo-oophoritis Pericarditis
Pelvic abscess Meningitis
Pelvic peritonitis DGI
In both sex
1. Anorectum Proctitis
2. Conjuctivae Conjuctivitis
3. Oropharynx Pharyngitis
1. Vulvovagina Vulvovaginitis
2. Anorectum Proctitis
Clinical Manifestations (cont”d)
B. complications of urethritis:
1. Epididymitis is an infrequent (<3%) complication.
2. Reiter’s syndrome complicates 1-2% of NGU (Chlamydia Infections).
3. DGI occurs very rarely as a result of GU.
~ 1/3 of men with NGU
10-15% of men with GU
uni- or bi-lateral ocular involvement as a result of self-inoculation
a) Chlamydial: follicular conjunctivitis with onset 1-2 wks
following an exposure.
b) Gonococcal: mucopurulent with copious discharge and
conjuctival swelling occurring 24-48 hrs after exposure.
Diagnosis is based onDiagnosis is based on (Documentaion Of Any ONE OF the followings)
1. History : Symptoms: UD, Dysuria, Meatal itching
2. Physical examination: confirmation of the presence of UD
a. Optimally, exam should occur two or more hrs post-
b. Examine urethra for discharge:
if no UD, stripping/milking of the urethra may
increase the yield of the examination.
3. Laboratory findings:
A. Gram stain: urethral swab specimen
1. look for 5 or more WBC/oil-immersion field (x1000) ,
qualifies as urethritis.
PMNs ≥ 5PMNs ≥ 5
2. Look for presence of Gram-negative intracellular diplococci (GNID),
the presence of which is suggestive of GU
B. First-catch Urine (FVU):
1. 10 or more WBC/high powered field (400)
qualifies as urethritis on sediment of first 10-15 ml of urine.
2. Leukocyte esterase test (LET) is less sensitive than FVU testing, but easier
to perform on fresh-spun urine.
Diagnosis ( cont’d )
C . Test for GC and Chlamydia (CT) with :
For GC-Non selective media-Chocolate-Agar media
Selective media-Thayer-martin, NY modified media
If possible do culture for CT using McCoy cells
Specimen collection: e
For GC : Okay to culture urethral exudates.
For CT insert swab 2-4 cm for optimal results.
2. Non culture method:
DNA amplification testing
NAAT : PCR, LCR,
specimens: urethral exudates, Urine
For urine based test, collect the first 10-15 ml of
D. If diagnosis is equivocal (e.g., symptoms but no signs),
the decision to empirically treat vs. treat based on test results is made
on an individual basis (i.e., high-risk pts unlikely to return for follow up,
A. Gonococcal urethritis( treat for co-existent chlamydial
Recommended regimens to cover GC;
1. cefixime 400 mg po x1
2. ceftriaxone 125 mg IM x1
3. Ciprofloxacin 500 mg pox1
4. Ofloxacin 400 mg po x1
5. Levofloxacin 250 mg po x1
6. Spectinomycin 2 gm IM x 1
Quinolones should be avoided whose infection may have originated from
an area where quinolone resistance is common (e.g., Asia , the Pacific
B. Chlamydial Urethritis and NGU :
1. Recommended regimens:
a) Azithromycin 1 gm orally x 1
b) Doxycycline 100 mg b.i.d. x7 days
efficacy of rx for CT urethritis 95-100%, and non-CT NGU 60-
2. Alternative regimens:
a) Erythromycin Base 500 mg qid x 7 days
b) Erythromycin ethylsuccinate 800 mg qid x7 days
c) Ofloxacin 300 mg bid x 7 days
d) levofloxacin 500 mg q.d. po x 7 days
Rx of Gonococcal infections at selected Sites
Pharyngitis : Preferred regimens are:
Ceftriaxone, 125 mg IM or
Ciprofloxacin,500 mg po
both with doxycycline 100 mg po bid x 7 days Or
Azithromycin,1 gm po )
Conjuctivitis: Ceftriaxone, 1 gm IM x 1 PLUS lavage of
infected eyes x 1
a. Hospitalization may be needed
b.Recommended Rx: Cefttiaxone 1 gm IV or IM daily
Treatment of DGI
cefotaxime, 1 gm IV q8h or
Ceftizoxime, 1 gm IV q8h or
Spectinomycin, 2 gm IM q12h ( allergy to betalactam drugs)
Duration of Parenteral rx: 24-48 hr after symptoms resolve,
cefixime, 400 mg po bid or
Ciprofloxacin, 500 mg, po bid
Duration of oral Rx : to complete a full week of antibiotic Rx
Meningitis : Ceftriaxone, 1-2 gm IV q12h X 10-14 days
Endocarditis: Ceftriaxone, 1-2 gm IV q12h x4 wk
C. Other management considerations
1. Follow-up: pts should be instructed to return for
evaluation if symptoms persist or recur after completion of
2. Referral Partner:
● Chlamydia can be isolated from 30-60%.
● Pts should refer all sexual partners of
the past 60 days for evaluation and Rx.
● Testing for gonorrhea and chlamydia is
3. Recurrent or persistent urethritis
Recurrent or persistent urethritis after standard 1st
Pts should be evaluated for
a) Possible causes of persistent urethritis:
1) Re-infection : a. Re-exposure to untreated partner
b. Infection acquired from new partner
2) Medication not taken correctly / not completed
3) Persistent infection due to:
a) Inadequate drug tissue levels( prostatic involvement ?)
b) Resistant pathogen( quinolone-resistant gonorrhea;
tetracycline resistant ureaplasma / mycoplasma.
e) Non-infectious etiologies.
f) Intraurethral growth( e.g., condyloma)
Treatment ( cont’d )
b) Approach to the patient:
1) Question pt closely regarding:
re exposure during or after Rx,
compliance with oral regimen, and
concurrent Rx of partner (s) .
2) Re-examine and establish objective evidence of urethritis by
urethral Gram stain,
urine sediment or LET.
3) Examine for trichomonas with saline wet mount,
4) Culture if wet mount negative on spun urine or urethral swab.
Presumptive therapy may be warranted even in the face of normal wet
C) Treatment of persistent/ recurrent urethritis:
1) Pts should be treated with the initial regimen if:
- they failed to comply with the Rx regimen or
- they were re-exposed to an treated sex partner.
2) If pt has been compliant and not re-exposed, consider:
a) Metronidazole 2 gm po single dose PLUS
b) Erythromycin base 500 mg po 4 times a day for 7
c) Erythromycin ethyl succinate 800 mg po qid for 7
3) Pts with s/s of persistent urethritis following re-treatment, where re-
infection is unlikely, should be referred to a urologist for further evaluation
A. Partner management:
1. all sex partners within the preceding 60 days should be evaluated and
2. Testing for gonorrhea and chlamydia is encouraged.
B. Patient counseling/ education:
Nature of the infection:
1. Explain urethritis as a syndrome vs. an infection, specific disease
etiology if known, routes of transmission and acquisition.
2) Explain to pt why they are being treated, including possible sequelae to
self and partners (e.g., increased HIV susceptibility, PID/infertility/ectopic
pregnancy in female partners).
3) Explain need for referral/ treatment of sex partners to establish etiology
an possible treatment. A specific diagnosis of STD should prompt
treatment of partners