What is the appropriate workup and treatment for urethritis (inflammation of the urethra) in men?

From the Guidelines

The workup for urethritis in men should begin with a thorough history and physical examination, followed by specific testing, and empiric treatment with ceftriaxone 1g intramuscularly or intravenously as a single dose plus azithromycin 1g orally as a single dose, as recommended by the European Association of Urology guidelines 1. The initial evaluation should include collecting a urethral swab or first-void urine sample for nucleic acid amplification testing (NAAT) for Neisseria gonorrhoeae and Chlamydia trachomatis, the most common causative organisms. If discharge is present, perform a Gram stain to look for polymorphonuclear leukocytes and intracellular diplococci. For confirmed gonococcal urethritis, use ceftriaxone 1g IM or IV as a single dose, which has been shown to be safe and effective 1. For non-gonococcal urethritis (typically caused by Chlamydia), prescribe doxycycline 100mg orally twice daily for 7 days or azithromycin 1g orally as a single dose 1. Some key points to consider in the treatment of urethritis include:

• The use of ceftriaxone 1g IM or IV as a single dose for gonococcal urethritis, with alternative regimens including cefixime 400mg orally plus azithromycin 1g orally as single doses 1.
• The use of doxycycline 100mg orally twice daily for 7 days or azithromycin 1g orally as a single dose for non-gonococcal urethritis 1.
• The importance of testing for other sexually transmitted infections, such as Chlamydia and Mycoplasma genitalium, and treating accordingly 1. Patients should abstain from sexual activity for 7 days after treatment initiation and until all partners have been treated. Partners from the previous 60 days should be notified, tested, and treated. Follow-up testing is recommended if symptoms persist. This approach is effective because it targets the most common pathogens while providing coverage for potential resistant strains, with treatment success rates exceeding 95% when properly administered 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. Appropriate antimicrobial therapy and follow-up tests for these diseases should be initiated if infection is confirmed Appropriate culture and susceptibility tests should be performed before treatment to determine the causative organism and its susceptibility to azithromycin.

The workup for urethritis in men includes:

• Serologic test for syphilis
• Appropriate cultures for gonorrhea
• Culture and susceptibility tests to determine the causative organism and its susceptibility to azithromycin The treatment for urethritis in men is azithromycin for infections caused by Chlamydia trachomatis or Neisseria gonorrhoeae 2.

From the Research

Urethritis Workup

• Symptoms of urethritis in men typically include urethral discharge, penile itching or tingling, and dysuria 3
• A diagnosis 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, 4
• Diagnostic criteria include typical signs, 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

Urethritis Treatment

• The primary pathogens associated with urethritis are Chlamydia trachomatis and Neisseria gonorrhoeae 3
• First-line empiric treatment consists of ceftriaxone and doxycycline; however, the antibiotic regimen may be targeted to the isolated organism 4, 5
• A single-dose regimen of 1 g of ceftriaxone was microbiologically effective against gonococcal urethritis and was safe and tolerable 6
• The combination of azithromycin or doxycycline plus ceftriaxone or cefixime is considered first-line empiric therapy in patients with urethritis 3
• 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

Treatment Guidelines

• The Centers for Disease Control and Prevention (CDC) recommends a single 500 mg IM dose of ceftriaxone for treatment of uncomplicated urogenital, anorectal, and pharyngeal gonorrhea 5
• If chlamydial infection has not been excluded, concurrent treatment with doxycycline (100 mg orally twice a day for 7 days) is recommended 5
• Repeat testing is not recommended less than three weeks after treatment because false-positive results are possible during this time 4
• Patients treated for a sexually transmitted infection should have repeat screening in three months, with shared decision-making about future screening intervals 4