Updated: 7/28/2017

Urethritis

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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
  • Prognosis
    • favorable for gonococcal or nongonococcal urethritis when treated appropriately
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
 
 

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