Urethritis classically presents as acute urethral discharge following unprotected sex.
The two most important etiologic 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%).
Antibiotic therapy is the mainstay of treatment.
Untreated gonococcal urethritis may disseminate, causing arthritis, meningitis, and endocarditis. Untreated nongonococcal 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; nongonococcal (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
- 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 socioeconomic 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
- syphilis test
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 gonorrhea: nonpregnant
initial Gram stain suggestive of gonorrhea: pregnant
initial Gram stain not suggestive of gonorrhea: nonpregnant
initial Gram stain not suggestive of gonorrhea: pregnant
recurrent or resistant urethritis
- Urinary tract infection
- Candida balanitis or vaginitis
- Noninfectious urethritis
- Guidelines on urological infections
- 2021 European guideline on Mycoplasma genitalium infections
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