Chapter 16-6: Urethritis from Sexually Transmitted Infection [STIs] (Cervicitis in Women)

TEXTBOOK PRESENTATION

Urethritis in men typically presents with dysuria, urethral pruritus, and penile discharge. Patients may also have dyspareunia, abdominal pain, or testicular pain. Women with cervicitis typically have cervical discharge, dysuria, and dyspareunia. They may also have spontaneous or postcoital vaginal bleeding.

DISEASE HIGHLIGHTS

1. Urethritis and cervicitis are usually due to an STI.

2. The most common sexually transmitted pathogens causing cervicitis and urethritis are N gonorrhoeae and C trachomatis.

3. Other less common causes include

   1. Mycoplasma genitalium

   2. Trichomonas

   3. Herpes simplex virus (may also cause cervicitis)

   4. Adenovirus

EVIDENCE-BASED DIAGNOSIS

1. Urethritis can be difficult to distinguish from cystitis in men. In a man with dysuria, STI testing is often warranted. Urethritis can be diagnosed based on:

   1. History or presence of discharge, with or without:

      1. Microscopy of discharge showing > 5 WBCs per oil immersion field (sensitivity, 26%; specificity, 95%; LR+, 2.7)

      2. Positive leukocyte esterase on first-void urine

      3. Microscopy of first-void urine showing > 10 WBCs per high power field

      4. Gram stain of discharge or urine culture that identifies organisms

   2. Absence of discharge and any of the following:

      1. positive STI testing (see PCR below)

      2. Inability to identify organisms on urine culture and lack of response to appropriate empiric treatment for cystitis

2. Cervicitis can be diagnosed by identifying mucopurulent endocervical discharge on pelvic exam. Sustained cervical bleeding caused by gentle passage of a swab in the cervical os may also be seen.

3. PCR

   1. To confirm the diagnosis of urethritis or cervicitis, an endocervical, vaginal, urine or urethral sample should be sent for PCR testing for gonorrhea and chlamydia.

   2. Urine PCR is the preferred test for males (sensitivity and specificity 90–100% and 97–100%, respectively).

   3. Vaginal, cervical, and urine testing are considered equivalent for women, and the Centers for Disease Control and Prevention (CDC) advocates using any type of sample.

TREATMENT

1. Patients should be treated empirically prior to confirmation of a pathogen.

2. The first-line treatment for chlamydia is a 1-time dose of 1 g of oral azithromycin or a 1-week course of 100 mg of doxycycline given twice daily.

3. Concurrent treatment for gonorrhea should be given if there is clinical suspicion or gonorrhea prevalence in the patient population is high.

4. The first-line treatment for gonorrhea is a 1-time injection of ceftriaxone 250 mg intramuscularly and a 1-time dose of 1 g of oral azithromycin.

5. Given increased antimicrobial resistance of gonorrhea, the CDC recommends dual therapy with ceftriaxone and azithromycin.

6. Patients should abstain from intercourse until 1 week after a single-dose treatment or until completion of a 1-week regimen (assuming symptoms have also resolved).

7. Partners

   1. Sexual partners of all patients infected with an STI should be evaluated and treated.

   2. If partners are unable to be seen at a health practice, the CDC recommends expedited partner treatment (the physician gives the patient a prescription for their partner). The laws regarding this practice vary by state.

8. Repeat testing to ...