Summary
Definition
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.[1] 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, Mycoplasma genitalium, and Ureaplasma urealyticum. The term postgonococcal urethritis refers to the occurrence of NGU after curative treatment for gonococcal urethritis.[2][3] Urethritis may also result from trauma but this topic focuses on infectious causes.
[Figure caption and citation for the preceding image starts]: Gonorrhea with penile meatal dischargeCDC Image Library; Susan Lindsley [Citation ends].
History and exam
Key diagnostic factors
- urethral discharge
- urethral irritation or itching
- dysuria
Other diagnostic factors
- orchalgia
- 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
Risk factors
- age 15 to 24 years
- female gender
- men who have sex with men
- low socioeconomic status
- new or multiple sex partners
- prior or current STD
- inconsistent condom use
- circumcision
Diagnostic investigations
1st investigations to order
- Gram stain of urethral discharge and/or urine sediment
- nucleic acid amplification tests (NAAT)
- culture of urethral discharge
- KOH prep of urethral discharge
- HIV test
- VDRL
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 nongonococcal, nonchlamydial organisms
Treatment algorithm
Contributors
Authors
Assistant Professor
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
San Diego
CA
Disclosures
SM has stocks in Bristol-Myers Squibb, Forty Seven Inc, and Geron Corp. He has received funding from Gilead Sciences. 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.
Peer reviewers
Associate Professor
Ob/Gyn and Urology
Director
Division of Urogynecology
Associate Residency Program Director
Temple University Hospital
Philadelphia
PA
Disclosures
VD declares that he has no competing interests.
Assistant Professor of Medicine
Associate Fellowship Program Director
Division of Infectious Diseases
Johns Hopkins University School of Medicine
Baltimore
MD
Disclosures
KG declares that he has no competing interests.
Professor of Sexual Health
University of Melbourne
Director
Melbourne Sexual Health Centre
Carlton
Victoria
Australia
Disclosures
CF is an author of a number of references cited in this topic. CF has received program grants of 6 figures US$.
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