Snapshot A 26-year-old man presents to his primary care physician with 3 days of dysuria. He reports to also noticing discharge arising from the penis and denies any scrotal or rectal pain. Medical history is significant for a prior sexually transmitted infection that was treated with oral azithromycin for one day. He says that he is sexually active with both men and women and infrequently uses condoms. On physical examination, there is purulent discharge at the urethral meatus. The patient receives a single intramuscular injection of ceftriaxone with a 1 day course of oral azithromycin. introduction Clinical definition urethritis describes inflammation of the urethra Epidemiology Incidence gonococcal urethritis second most commonly reported cause of sexually transmitted infections (STI) in men the most commonly reported is chlamydia nongonococcal urethritis the most common cause is chlamydia Demographics most commonly occurs in sexually active young men N. gonorrhoeae and C. trachomatis are commonly identified Risk factors sexual activity Etiology Microbial infection such as N. gonorrhoeae C. trachomatis M. genitalium Viruses such as herpes simplex virus adenovirus Pathogenesis bacterial invasion results in an inflammatory response Presentation Symptoms dysuria pruritis burning sensation Physical exam discharge from the urethral meatus urethral meatus may appear inflamed Studies Labs first-void or first-catch urine a positive leukocyte esterase on urine dipstick or having ≥ 10 WBC/hpf on microscopy is suggestive of urethritis nucleic acid amplification tests allows for the specific identification of the offending organism such as N. gonorrhoeae C. trachomatis M. genitalium Gram stain ≥ 2 WBC/hpf organisms may or may not be present lack of organisms suggests a nongonococcal urethritis gram-negative diplococci suggests gonococcal urethritis Differential Cystitis Epididymitis Prostatitis Treatment Medical intramuscular ceftriaxone and oral azithromycin indications this is initial therapy for men with urethritis who have gonococcal urethritis supported by microscopic evidence e.g., gram-negative intracellular diplococci when there is high clinical suspicion of having a gonococcal infection e.g., patient had sexual intercourse with someone with known N. gonorrhoeae infection note this combination covers nongonococcal urethritis caused by C. trachomatis oral azithromycin or doxycycline indications first-line treatment for nongonococcal urethritis in the absence of microscopic, laboratory, or clinical findings suggestive of N. gonorrhea infection note that treatment is directed against C. trachomatis and azithromycin also covers M. genitalium oral azithromycin is preferred over doxycycline since patients only need on dose if patients are treated with doxycycline, they need a 7 day course 2-times a day Complications Gonococcal urethritis gonococcal prostatitis and pharyngitis acute epididymitis disseminated gonococcal infection infectious conjunctivitis Nongonococcal urethritis acute epididymitis postinflammatory reactive arthritis (formerly known as Reiter's arthritis) triad urethritis conjunctivitis arthritis Prognosis Favorable for gonococcal or nongonococcal urethritis when treated appropriately