Urethritis (non-specific) and urethral irritation diagnosis and management

Last updated: December 2017

Diagnosis

Symptoms of urethritis in men include: urethral discomfort or itch, urethral discharge and dysuria. Some men report only dysuria or discomfort without discharge.

Urethritis can be classified as gonococcal or non-gonococcal urethritis (NGU), or non-specific urethritis (NSU), when no specific pathogen is identified. Non-specific urethritis is a diagnosis of exclusion.

Gonococcal urethritis often presents with copious purulent urethral discharge.

The discharge in NSU usually tends to be mucoid or clear.

NGU is most commonly caused by Chlamydia trachomatis or Mycoplasma genitalium. Less common causes are herpes simplex virus, adenovirus, trichomonas vaginalis, coliforms and bacteria found in the respiratory tract, such as Haemophilus influenzae and Neisseria meningitides. In a proportion of cases, no specific pathogen is identified. This is NSU. Some organisms like Mycoplasma hominis and Ureaplasma urealyticum may be present in the normal urethra and detected BUT not necessarily indicate infection or need for treatment. Routine testing for Ureaplasma urealyticum and Mycoplasma hominis are not recommended.

All men presenting with urethral symptoms should be tested with a urethral swab for gonococcal culture and sensitivities - for diagnosis and surveillance of antibiotic sensitivities. In addition, first void urine test for chlamydia, gonorrhoea and mycoplasma genitalium Nucleic Acid Amplification Test (NAAT) should be performed. UTIs are uncommon in men, but where risk factors are present, such as urinary tract abnormalities, older age and prostatic symptoms, especially in the absence of urethral discharge, consider testing mid-stream urine for M/C/S.

 Non Gonococcal Urethritis (NGU) is diagnosed in males only, by the following criteria:

• symptoms of urethritis  AND
• gram stain evidence of urethritis (5 or more polymorphs per high power field in 5 consecutive high power fields) in the absence of Gram negative intracellular diplococci

       OR

•  urethral discharge and/or significant meatitis on examination.

If gonococci (gram negative intracellular diplococci) are visible on gram stain microscopy, diagnosis of presumptive gonorrhoea is made and the patient is managed accordingly.

Urine NAAT test results may identify a specific cause for urethritis. In the absence of organisms like gonococci, chlamydia trachomatis, mycoplasma genitalium, herpes simplex virus (HSV), trichomonas and adenovirus on testing, the diagnosis of Non-Specific Urethritis (NSU) is made.

Treatment

Antibiotic treatment should not be commenced until urethral swabs have been taken.

First line treatment - Doxycycline 100 mg orally twice a day for 7 days (D).

OR

Azithromycin 1 g orally as one dose (B1)

In settings where microscopic examination of a urethral smear is unavailable on site, treatment of presumptive urethritis is justified in symptomatic men with signs of urethritis as described above. However, if the risk factors and symptoms suggest gonorrhoea (such as copious purulent discharge),the patient should be treated with ceftriaxone 500mg imi and 1g of azithromycin.

Neisseria meningitidis is occasionally identified on urethral culture in symptomatic and asymptomatic men. Neisseria meningitidis isolated in the genital tract has very rarely been associated with invasive meningococcal disease. Therefore, all symptomatic and asymptomatic ano-genital N. meningitidis infections should be treated with Ceftriaxone 500 mg IMI as a single dose (B1).  Seek further specialist advice regarding partner notification and follow up for genital meningococcal isolates.

Patient education

The following points should be covered:

• chlamydia, mycoplasma and gonorrhoea test results will be pending at the first visit
• advise abstinence from sex for one week and until results are given
• the nature of the infection
• there is no equivalent in females
• symptoms may be slow to resolve despite treatment
• consider screening of sexual partners for sexually transmitted infection (STIs)/human immunodeficiency virus (HIV).

Partner notification

Partner notification and empiric treatment of partners are only required if chlamydia , M genitalium, gonorrhoea or trichomonas are isolated. However, sexual partners of men with NSU should be advised to have screening for STIs/HIV.

Follow up

The patient should be clinically reviewed at one week after the completion of medication for:

• results of tests
  
• medication compliance
• evaluation of symptoms and signs
• enquiry about sexual activity since treatment.

If symptoms persist, repeat urethral smear for gram stain to determine if urethritis is persisting, at least 2 hours after voiding.

Persistent Non-specific urethritis

Seek specialist Sexual Health Physician advice for persistent NSU.

In some men, the symptoms of urethritis do not resolve despite compliance with antibiotic therapy and abstinence from sexual activity. A repeat urethral smear for gram stain should be taken to determine if urethritis is still present and retested for urethral pathogens. If this is not available, consider testing first-void urine for trichomonas, adenovirus and herpes simplex virus NAAT.

Where the urethral smear still shows 5 or more polymorphs per high power field, treat with the alternative regimen to that used initially.

Azithromycin 1 g orally as one dose (B1) if the patient was initially treated with Doxycycline

OR

Doxycycline 100 mg twice daily orally for 7 days (D) if the patient was initially treated with Azithromycin 

PLUS

Metronidazole 400 mg orally 12 hourly for 5 days

Urethral irritation

The diagnosis is made in men with dysuria and/or urethral discomfort but no microscopic evidence of urethritis, and negative tests for urethral pathogens. Where microscopy of a urethral smear is not available, this diagnosis cannot be reliably made. The urethral smear must be collected at the optimal time of more than 2 hours after micturition to confidently make this diagnosis.

Management

The patient should be reassured that the symptoms are due to a mild irritation and not infection. Possible causes may include trauma, for example vigorous sexual activity or masturbation, dehydration or urethral irritants such as alcohol, certain medications (including antibiotics themselves), skin products, soap and shampoos. The symptoms subside in one to two weeks.

The patient should be advised to avoid manipulation of the penis (no squeezing or milking the urethra) and should abstain from sexual activity and masturbation until symptoms resolve, as well as increase fluid (water) intake and decrease alcohol and caffeine intake.

Ensure that tests for urethral pathogens (and urinary tract infection if clinically indicated) have been done to exclude these infections. The patient should not have sex until negative tests are confirmed.

Further information

For further information on the diagnosis and management of urethritis (non-specific) or urethral irritation contact Adelaide Sexual Health Centre.

Acknowledgement: with thanks to Melbourne Sexual Health Centre 

Disclaimer

These guidelines are based on review of current literature, current recommendations of the United States Centres for Disease Control and Prevention, World Health Organization, the British Association for Sexual Health and HIV, Australian national and state guidelines, and expert opinion. Local antimicrobial sensitivities are reflected in these recommendations.

They are written primarily for use by Adelaide Sexual Health Centre in the setting of a specialist Sexual Health Clinic, with on-site laboratory facilities. Some flexibility is required in applying them to other clinical settings.