Chapter 215. Urethritis in Men

A 24-year-old man presents to a skid row shelter clinic with 3 days of dysuria and penile discharge. A heavy purulent urethral discharge is seen (Figure 215-1). He admits to using crack cocaine and having multiple female sexual partners. 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 for possible coexisting Chlamydia. He was offered and agreed to testing for other sexually transmitted diseases. He was told to inform his partners of the diagnosis. He was counseled about safe sex, and drug rehabilitation was recommended. On his 1-week follow-up visit, his symptoms were gone and he had no further discharge. His gonorrhea nucleic acid amplification test was positive and his Chlamydia, rapid plasma reagin (RPR), and HIV tests were ­negative. His case was reported to the Health Department for contact tracing.

Urethritis is urethral inflammation caused by infectious (gonococcal or chlamydial) or noninfectious causes (trauma or foreign bodies). 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.

• Worldwide, 151 million cases of gonococcal and nongonococcal urethritis are reported annually (Figures 215-1 and 215-2).1
• Urethritis of all types occurs in 4 million Americans each year.1
• The prevalence of gonorrhea in men was 94.1 per 100,000 population among men in the US in 2010. The rate was highest among those men aged 20-24 years (421.0 per 100,000 population). In 2010, gonorrhea rates remained highest among black men and women (432.5), which was 18.7 times the rate among whites (23.1 per 100,000 population). The rates among Hispanics (49.9) was 2.2 times those of whites.2
• The prevalence of Chlamydia in men in the US in 2010 was 233.7 cases per 100,000 males. Age-specific rates among men were highest in those aged 20-24 years (1,187.0 cases per 100,000 males). The rate of chlamydia among black men and women was more than eight times the rate among whites (1,167.5 and 138.7 cases per 100,000 population, respectively). The rate among Hispanics was 2.7 times the rate among whites.2

• Urethritis is urethral inflammation caused by infectious or noninfectious causes.
• Neisseria gonorrhoeae and Chlamydia trachomatis are the most important infectious causes. When transmitted, they can cause other illnesses and complications in men (epididymitis, prostatitis, and reactive arthritis) and women (pelvic inflammatory disease and infertility).
• Other infectious agents include Mycoplasma genitalium, Ureaplasma urealyticum, Trichomonas vaginalis, herpes simplex viruses 1 and 2, adenovirus, and enteric bacteria.
• Noninfectious causes include trauma, foreign bodies, granulomas or unusual tumors, allergic reactions, or voiding dysfunction (any abnormal holding or voiding pattern not caused by an anatomical or a neurologic process).

Clinical Features

Male patients with urethritis can be asymptomatic or present with urethral discharge, dysuria, or urethral pruritus.

Urethritis is diagnosed when one of the following is present:3

• Mucopurulent or purulent urethral discharge (Figures 215-1 and 215-2).
• First-void urine positive leukocyte esterase test ≥10 white blood cells (WBCs) per high-power field. (This can also be seen with a urinary tract infection [UTI]; however, the incidence of UTI in men younger than 50 years of age is approximately 50 per 100,000 per year, much lower than the incidence of gonococcal or chlamydial urethritis in this age group.)

Laboratory Testing

• Nucleic acid amplification test (NAAT) is the recommended test for screening asymptomatic at-risk men and testing symptomatic men.3 Urine is a better specimen than urethral swab and does not hurt.3,4
• Gram stain of urethral secretions with ≥5 WBC per oil immersion field. (If Gram-negative intracellular diplococci are seen, gonococcal urethritis is present.) Gram stain will identify most cases; ≥5 WBCs are seen in 82% of Chlamydia and 94% of gonococcal infections.5 Government regulations concerning in-office laboratory testing have severely curtailed the use of Gram stains in the office.
• Leukocyte esterase test on urine has a good negative predictive value (NPV) but poor positive predictive value (PPV) in a low-prevalence population (NPV 96.4% and PPV 35.4%).6 Urethral culture is less commonly necessary when NAAT is available.
• Consider culture when tests for gonorrhea and Chlamydia are negative, or symptoms persist despite adequate treatment in a patient who is unlikely to have been reinfected by an untreated partner.

Dysuria in men can be caused by the following:7

• Infections in other sites or the urogenital tract—Cystitis, prostatitis with perineal pain or prostate tenderness, or epididymitis with scrotal pain.
• Penile lesions—Vesicles of herpes simplex, ulcers of syphilis, chancroid, or lymphogranuloma venereum, and glans irritation from balanitis.
• Mechanical causes—Obstruction from benign prostatic hyperplasia (BPH) causing inflammation without infection, trauma including catheterization, urethral strictures, or genitourinary cancers.
• Inflammatory conditions—Spondyloarthropathies, drug reactions, or autoimmune diseases.

Treat patients who meet criteria for urethritis. Test patients with dysuria who do not meet criteria for urethritis, for N. gonorrhoeae and C. trachomatis, and treat if positive. Advise sex partners to be evaluated and treated.2

Nonpharmacologic

• Encourage safe-sex practices.

Medications

• The 2010 CDC STD treatment guidelines recommend treating uncomplicated gonococcal urethritis with ceftriaxone 250 mg IM in a single dose plus treatment for Chlamydia with azithromcyin or doxycycline. Most gonococci in the United States are susceptible to doxycycline and azithromycin, so that routine cotreatment might also hinder the development of antimicrobial-resistant N. gonorrhoeae.8 Avoid fluoroquinolones and oral cefixime as drug resistance is too high.8,9 SOR A
• The 2010 CDC STD treatment guidelines recommend treating Chlamydia urethritis with azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice a day for 7 days.10 SOR A Acceptable alternate regimens include:
  • Erythromycin base 500 mg 4 times a day for 7 days or erythromycin ethylsuccinate 800 mg 4 times a day for 7 days or ofloxacin 300 mg orally twice a day for 7 days or levofloxacin 500 mg orally once daily for 7 days.10
• For persistent urethritis, consider Trichomonas vaginalis as a possible cause—Culture and treat with a single dose of metronidazole 2 g.
• Consider expedited partner therapy (EPT). EPT is the delivery of medications or prescriptions by persons infected with a sexually transmitted disease (STD) to their sex partners without clinical assessment of the partners. Legal status by state is available at http://www.cdc.gov/std/ept/legal/default.htm.

Consider screening the following groups of men for Chlamydia, using urine NAAT for testing and screening.2 Twelve percent of male patients with chlamydial and 5% with gonococcal infections had no Gram stain evidence of urethral inflammation.5

• Men attending an STD clinic.
• Men attending a national job training program.
• Men younger than 30 years of age who are military recruits.
• Men younger than 30 years of age entering jail.

Gonococcal and chlamydial urethritis respond well to appropriate antibiotic therapy. Partners must be treated to avoid reinfection.

• Reevaluate patients with persistent or recurrent symptoms after treatment. Reexamine for evidence of urethral inflammation and retest for gonorrhea and Chlamydia.
• Routine test-of-cure laboratory examination is not recommended by the CDC for gonorrhea or chlamydia infections unless therapeutic compliance is in question, symptoms persist, or reinfection is suspected.8,10
• However, patients who have symptoms that persist after treatment of gonorrhea should be evaluated by culture for N. gonorrhoeae, and any gonococci isolated should be tested for antimicrobial susceptibility.8
• Consider chronic prostatitis if symptoms persist for more than 3 months.

The Centers for Disease Control and Prevention (CDC) recommends the following for patients diagnosed with gonorrhea or Chlamydia:2

• Return for evaluation if the symptoms persist or return after therapy is completed.
• Abstain from sexual intercourse until 7 days after starting therapy, symptoms have resolved, and sexual partners have been adequately treated.
• Undergo testing for other STDs, including HIV and syphilis.
• Advise sexual partners of the need for treatment and/or take medications directly to them using EPT.

Patient Resources

• Centers for Disease Control and Prevention—http://www.cdc.gov/std/Gonorrhea/STDFact-gonorrhea.htm.
• Centers for Disease Control and Prevention—http://www.cdc.gov/std/chlamydia/default.htm.

Provider Resources

• The Centers for Disease Control and Prevention (CDC) website has the latest epidemiologic data and management recommendations—http://www.cdc.gov/std/default.htm.
• The newest CDC Treatment Guidelines are at http://www.cdc.gov/std/treatment.