What are the diagnostic criteria for a male with suspected urethritis (inflammation of the urethra)?

From the Guidelines

Testing for urethritis in males should include a urethral swab or first-void urine sample for nucleic acid amplification tests (NAATs) to detect common causative organisms like Neisseria gonorrhoeae and Chlamydia trachomatis. The patient should avoid urinating for at least one hour before providing a first-void urine sample to ensure adequate specimen collection. A physical examination should be performed, looking for urethral discharge which can be expressed by milking the penis from base to tip. If discharge is present, a Gram stain should be obtained to look for white blood cells (>5 WBCs per high-power field indicates urethritis) and to potentially identify gonococci 1.

Key Considerations

• Testing should also include screening for other sexually transmitted infections including HIV, syphilis, and hepatitis B and C.
• While awaiting results, empiric treatment may be initiated with a single dose of ceftriaxone 500mg intramuscularly for gonorrhea plus doxycycline 100mg twice daily for 7 days for chlamydia, as recommended by the CDC guidelines 1.
• Patients should abstain from sexual activity until treatment is completed and partners from the past 60 days should be notified and treated.
• Urethritis testing is important because untreated infections can lead to complications such as epididymitis, prostatitis, and reactive arthritis.

Diagnostic Approaches

• Nucleic acid amplification tests (NAATs) are the preferred method for detecting Chlamydia trachomatis and Neisseria gonorrhoeae, due to their high sensitivity and specificity 1.
• Culture and hybridization tests can also be used, but require urethral swab specimens, whereas NAATs can be performed on urine specimens 1.

Treatment and Prevention

• Empiric treatment with ceftriaxone and doxycycline can be initiated while awaiting test results, to prevent complications and reduce the risk of transmission to partners 1.
• Patients should be counseled on the importance of completing treatment, abstaining from sexual activity until treatment is completed, and notifying partners from the past 60 days 1.

From the FDA Drug Label

Urethritis and cervicitis due to Chlamydia trachomatis or Neisseria gonorrhoeae. All patients with sexually-transmitted urethritis or cervicitis should have a serologic test for syphilis and appropriate cultures for gonorrhea performed at the time of diagnosis.

For male testing for urethritis, azithromycin is indicated for the treatment of urethritis due to Chlamydia trachomatis or Neisseria gonorrhoeae. Key points to consider include:

• Serologic testing for syphilis and cultures for gonorrhea should be performed at the time of diagnosis.
• Appropriate antimicrobial therapy and follow-up tests for these diseases should be initiated if infection is confirmed 2.

From the Research

Male Testing for Urethritis

• The diagnosis of urethritis in men can be made if at least one of the following is present: discharge, a positive result on a leukocyte esterase test in first-void urine, or at least 10 white blood cells per high-power field in urine sediment 3.
• The primary pathogens associated with urethritis are Chlamydia trachomatis and Neisseria gonorrhoeae, with other less common pathogens including Trichomonas species, adenovirus, and herpes simplex virus 3.
• Diagnostic criteria for urethritis include typical signs and symptoms, or history of exposure, in addition to mucopurulent discharge, Gram stain of urethral secretions showing at least two white blood cells per oil immersion field, first-void urinalysis showing at least 10 white blood cells per high-power field, or a positive leukocyte esterase result with first-void urine 4.
• Nucleic acid amplification tests (NAATs) are highly sensitive and specific, and can be used to diagnose gonorrhea and chlamydia infections using alternative sample types, such as urine or self-collected genital specimens 5.
• The criteria for diagnosis of male urethritis based on a Gram-stained smear of urethral discharge may be too stringent, and lowering the diagnostic criteria to ≥2 polymorphonuclear cells per high power field may be supported 6.
• Confirmation of diagnosis of gonorrhoea, which can present as urethritis in men, requires microscopy of Gram-stained samples, bacterial culture or nucleic acid amplification tests 7.

Testing Methods

• Gram stain of urethral secretions can be used to diagnose urethritis, with a diagnosis made if at least two white blood cells per oil immersion field are present 4.
• First-void urinalysis can be used to diagnose urethritis, with a diagnosis made if at least 10 white blood cells per high-power field are present 3, 4.
• Leukocyte esterase test in first-void urine can be used to diagnose urethritis, with a positive result indicating the presence of urethritis 3, 4.
• Nucleic acid amplification tests (NAATs) can be used to diagnose gonorrhea and chlamydia infections, and can be performed on alternative sample types such as urine or self-collected genital specimens 5, 7.

Treatment and Prevention

• The combination of azithromycin or doxycycline plus ceftriaxone or cefixime is considered first-line empiric therapy in patients with urethritis 3.
• First-line empiric treatment for urethritis consists of ceftriaxone and doxycycline, although the antibiotic regimen may be targeted to the isolated organism 4.
• Patients treated for urethritis should abstain from sex for seven days after the start of treatment, until their partners have been adequately treated, and until their symptoms have fully resolved 4.
• Prevention of urethritis and other sexually transmitted infections relies on promoting safe sexual behaviours and reducing STI-associated stigma 7.