Urethritis classically presents as acute urethral discharge following unprotected sex.
The two most important aetiological agents are Neisseria gonorrhoeae and Chlamydia trachomatis.
Increased risk is associated with new sex partner, multiple sex partners, or age under 25 years. Disease may be transmitted to infants from infected mothers, resulting in conjunctivitis, iritis, otitis media, or pneumonia.
Higher morbidity in untreated women (10% to 40%) than in men (1% to 2%).
Untreated gonococcal urethritis may disseminate, causing arthritis, meningitis, and endocarditis. Untreated non-gonococcal urethritis may present with complications such as reactive arthritis or infertility.
Urethritis is usually a sexually transmitted disease that typically presents with dysuria, urethral discharge, and/or pruritus at the end of the urethra. Urethral discharge is the classic physical finding. If the urinalysis is positive for leukocyte esterase, the Gram stain of the discharge (≥2 white blood cells per oil immersion field) or sediment of the first-voided urine (≥10 white blood cells per high power field) reveals abnormal numbers of polymorphonuclear leukocytes, the diagnosis of urethritis is confirmed. Urethritis is divided into 2 main categories: gonococcal, if Neisseria gonorrhoeae is isolated; non-gonococcal (NGU), if N gonorrhoeae is not isolated. The most common causes of NGU include Chlamydia trachomatis and Mycoplasma genitalium. Urethritis may also result from trauma but this topic focuses on infectious causes.
History and exam
Key diagnostic factors
- presence of risk factors
- urethral discharge
- urethral irritation or itching
Other diagnostic factors
- absence of epididymal tenderness and/or swelling
- absence of pelvic pain (women)
- absence of pustular or petechial rash
- absence of arthritis
- absence of eye inflammation
- age 15 to 24 years
- female sex
- men who have sex with men
- low socio-economic status
- new or multiple sex partners
- prior or current STD
- inconsistent condom use
1st investigations to order
- Gram stain of urethral discharge and/or urine sediment
- nucleic acid amplification tests (NAAT)
- culture of urethral discharge
- potassium hydroxide prep of urethral discharge
- HIV test
- Venereal Disease Research Laboratory
Investigations to consider
- urinalysis and culture
- wet mount of urethral discharge (women)
- NAAT and culture of urine or urethral/vaginal swab for Trichomonas vaginalis
- NAAT for other organisms
initial Gram stain suggestive of gonorrhoea: non-pregnant
initial Gram stain suggestive of gonorrhoea: pregnant
initial Gram stain not suggestive of gonorrhoea: non-pregnant
initial Gram stain not suggestive of gonorrhoea: pregnant
recurrent or resistant urethritis
Sheldon Morris, MD, MPH
Division of Infectious Diseases
Department of Medicine
UCSD Antiviral Research Center
Division of Family Medicine
Department of Family and Preventive Medicine
UCSD La Jolla Family and Sports Medicine
SM has completed a National Institutes of Health contract for research study on the Visby Medical Sexual Health Test. SM is an author of a number of references cited in this topic.
Dr Sheldon Morris would like to gratefully acknowledge Dr Christina Bailey, a previous contributor to this topic.
CB declares that she has no competing interests.
Vani Dandolu, MD, MPH
Ob/Gyn and Urology
Division of Urogynecology
Associate Residency Program Director
Temple University Hospital
VD declares that he has no competing interests.
Khalil Ghanem, MD, PhD
Assistant Professor of Medicine
Associate Fellowship Program Director
Division of Infectious Diseases
Johns Hopkins University School of Medicine
KG declares that he has no competing interests.
Christopher Fairley, PhD
Professor of Sexual Health
University of Melbourne
Melbourne Sexual Health Centre
CF is an author of a number of references cited in this topic. CF has received programme grants of 6 figures US$.
- Urinary tract infection
- Candida balanitis or vaginitis
- Non-infectious urethritis
- Guidelines for the management of symptomatic sexually transmitted infections
- Sexually transmitted diseases: expedited partner therapy
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