What is the initial treatment approach for a male with urethritis (inflammation of the urethra) following sexual intercourse?

Initial Treatment Approach for Male Urethritis Following Sexual Intercourse

For males with urethritis following sexual intercourse, the recommended first-line treatment is azithromycin 1g orally in a single dose OR doxycycline 100mg orally twice daily for 7 days, after confirming the diagnosis with appropriate testing. 1, 2

Diagnosis Confirmation

Before initiating treatment, urethritis should be confirmed by at least one of the following:

• Mucopurulent or purulent urethral discharge
• Gram stain of urethral secretions showing ≥5 WBC per oil immersion field
• Positive leukocyte esterase test on first-void urine
• Microscopic examination of first-void urine showing ≥10 WBC per high-power field 1, 2

If none of these criteria are present, treatment should be deferred, and the patient should be tested for N. gonorrhoeae and C. trachomatis and followed closely if test results are negative 1.

Treatment Algorithm

1. Confirm diagnosis with objective signs of urethritis

2. Test for specific pathogens:

   • N. gonorrhoeae and C. trachomatis testing is strongly recommended 1
   • Consider testing for other STIs including syphilis and HIV 2

3. Initiate empiric treatment immediately after diagnosis:

   First-line options:

   • Azithromycin 1g orally in a single dose, OR
   • Doxycycline 100mg orally twice daily for 7 days 1, 2

   Alternative options (if first-line medications cannot be used):

   • Erythromycin base 500mg orally four times daily for 7 days
   • Erythromycin ethylsuccinate 800mg orally four times daily for 7 days
   • Levofloxacin 500mg orally once daily for 7 days
   • Ofloxacin 300mg orally twice daily for 7 days 1

4. Special considerations:

   • If gonorrhea is suspected or confirmed, add ceftriaxone to the regimen 3
   • For M. genitalium infections, azithromycin is preferred over doxycycline 1, 2

Patient Education and Follow-up

• Instruct patients to abstain from sexual intercourse until:

  • 7 days after therapy is initiated
  • Symptoms have resolved
  • All sexual partners have been adequately treated 1

• Advise patients to return for evaluation if symptoms persist or recur after completing therapy 1

• Symptoms alone, without documentation of signs or laboratory evidence of urethral inflammation, are not sufficient basis for re-treatment 1

Partner Management

• All sexual partners within the preceding 60 days should be referred for evaluation and treatment 1, 2
• Partner treatment is crucial to prevent reinfection 2
• Expedited partner treatment is an alternative approach when partners are unlikely to seek medical care 1

Common Pitfalls and Caveats

1. Treating without confirming diagnosis: Objective signs of urethritis should be present before initiating antimicrobial therapy to avoid unnecessary antibiotic use 2

2. Inadequate pathogen coverage: The most common causes of urethritis are C. trachomatis, N. gonorrhoeae, M. genitalium, and T. vaginalis 3. Empiric treatment should cover these pathogens when specific testing results are pending.

3. Neglecting partner treatment: Failure to treat partners leads to high reinfection rates 2

4. Premature re-treatment: Symptoms alone are not sufficient basis for re-treatment without objective signs of inflammation 1

5. Missing chronic conditions: Persistent symptoms beyond 3 months should prompt evaluation for chronic prostatitis/chronic pelvic pain syndrome 2

6. Inadequate follow-up: Patients treated for sexually transmitted infections should have repeat screening in 3 months 3

Single-dose azithromycin has the advantage of improved compliance and directly observed treatment, making it an excellent choice for patients who may have difficulty adhering to a 7-day regimen 1, 4.