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GENERAL PRINCIPLES

  • Worldwide, most adults acquire at least one sexually transmitted infection (STI).

  • Three factors determine the initial rate of spread of any STI within a population: rate of sexual exposure of susceptible to infectious people, efficiency of transmission per exposure, and duration of infectivity of those infected.

  • STI care and management begin with risk assessment and proceed to clinical assessment, diagnostic testing or screening, syndrome-based treatment to cover the most likely causes, and prevention and control. The "4 C's" of control are contact tracing, ensuring compliance with treatment, and counseling on risk reduction, including condom promotion and provision.

SPECIFIC SYNDROMES

URETHRITIS IN MEN

Microbiology and Epidemiology

Most cases are caused by either Neisseria gonorrhoeae or Chlamydia trachomatis. Other causative organisms include Mycoplasma genitalium, Ureaplasma urealyticum, Trichomonas vaginalis, and herpes simplex virus (HSV). Chlamydia causes 30–40% of nongonococcal urethritis (NGU) cases. M. genitalium is the probable cause in many Chlamydia-negative cases of NGU.

Clinical Manifestations

Urethritis in men produces urethral discharge, dysuria, or both, usually without frequency of urination.

Diagnosis

Pts present with a mucopurulent urethral discharge that can usually be expressed by milking of the urethra; alternatively, a Gram's-stained smear of urethral exudates containing ≥5 PMNs/1000× field confirms the diagnosis.

  • Centrifuged sediment of the day's first 20–30 mL of voided urine can be examined instead.

  • N. gonorrhoeae can be presumptively identified if intracellular gram-negative diplococci are present in Gram's-stained samples.

  • Early-morning, first-voided urine should be used in "multiplex" nucleic acid amplification tests (NAATs) for N. gonorrhoeae and C. trachomatis.

TREATMENT Urethritis in Men

  • Treat urethritis promptly, while test results are pending.

    • – Unless these diseases have been excluded, treat gonorrhea with a single dose of ceftriaxone (250 mg IM), cefpodoxime (400 mg PO), or cefixime (400 mg PO) and treat Chlamydia with azithromycin (1 g PO once) or doxycycline (100 mg bid for 7 days); azithromycin may be more effective for M. genitalium.

    • – Sexual partners of the index case should receive the same treatment.

  • For recurrent symptoms: With re-exposure, re-treat pt and partner. Without re-exposure, consider infection with T. vaginalis (with culture or NAATs of urethral swab and early-morning, first-voided urine) or doxycycline-resistant M. genitalium or Ureaplasma. Consider treatment with metronidazole, azithromycin (1 g PO once), or both.

EPIDIDYMITIS

Microbiology

In sexually active men <35 years old, epididymitis is caused by C. trachomatis and, less commonly, by N. gonorrhoeae.

  • In older men or after urinary tract instrumentation, urinary pathogens are most common.

  • In men who practice insertive rectal intercourse, Enterobacteriaceae may be responsible.

Clinical Manifestations

Acute epididymitis—almost always unilateral—produces pain, swelling, and tenderness of the epididymis, with or without ...

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