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PATIENT STORY

A 24-year-old man presents to a primary care clinic with 3 days of dysuria and heavy purulent penile discharge (Figure 224-1). He was diagnosed with gonococcal urethritis by clinical appearance, and a urine specimen was sent for testing to confirm the gonorrhea and test for Chlamydia. He was treated with ceftriaxone 250 mg IM for gonorrhea and 1 g of oral azithromycin. He was tested for other sexually transmitted infections. He was advised to inform his partners of the diagnosis and was counseled about safer sex. On his 1-week follow-up visit, his symptoms were gone and he had no further discharge. Nucleic acid amplification tests were positive for gonorrhea and Chlamydia. Rapid plasma reagin (RPR) and HIV tests were negative. His case was reported to the Health Department for contact tracing.

FIGURE 224-1

A 24-year-old man with gonococcal urethritis and a heavy purulent urethral discharge. (Reproduced with permission from Richard P. Usatine, MD.)

INTRODUCTION

Urethritis is urethral inflammation caused by infectious or noninfectious causes (i.e., trauma). Gonococcal and chlamydial infections in men occur most commonly between the ages of 20 and 24 years, and the prevalence is highest in black men. Diagnosis is suspected clinically, reinforced by an office urine test positive for leukocyte esterase, and confirmed by a urine nucleic acid amplification test. Treat for both gonorrhea and Chlamydia until one or both are ruled out by laboratory testing.

EPIDEMIOLOGY

  • Worldwide, 151 million cases of gonococcal and nongonococcal urethritis are reported annually (Figures 224-1 and 224-2).1

  • Urethritis of all types occurs in 4 million Americans each year.1

  • The prevalence of gonorrhea in men was 140.9 per 100,000 population among men in the United States in 2015. The rate was highest among those men ages 20–24 years (539.1 per 100,000 population). Rates are 9.6 times higher among black men and women (424.9), compared to whites (44.2 per 100,000 population). The rate among Hispanics (80.5) was 1.8 times that of whites.2

  • The prevalence of Chlamydia in men in the United States in 2015 was 305.2 cases per 100,000 males. The rate was highest among those men ages 20–24 years (1307.8 cases per 100,000 males). The rate of Chlamydia among black men and women was 5.9 times the rate among whites (1097.6 and 187.6 cases per 100,000 population, respectively). The rate among Hispanics was 2.0 times the rate among whites.3

FIGURE 224-2

Nongonococcal urethritis caused by Chlamydia. Note that the discharge is clearer and less purulent than seen with gonorrhea. (Reproduced with permission from Seattle STD/HIV Prevention Training Center, University of Washington.)

ETIOLOGY AND PATHOPHYSIOLOGY

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