What is the initial workup and treatment for a patient presenting with penile discharge?

Initial Workup and Treatment for Penile Discharge

The initial workup for penile discharge should include urethral Gram stain, nucleic acid amplification testing (NAAT) for Neisseria gonorrhoeae and Chlamydia trachomatis, and empiric antibiotic treatment with azithromycin 1g orally in a single dose plus ceftriaxone 125mg IM in a single dose. 1

Diagnostic Evaluation

History and Physical Examination

• Determine onset, duration, and characteristics of discharge
• Assess for associated symptoms:
  • Dysuria, urinary frequency, or urgency
  • Penile itching or tingling
  • Testicular pain or swelling
  • Sexual history (recent partners, unprotected intercourse)

Laboratory Testing

1. Urethral Gram stain - Essential for distinguishing gonococcal from non-gonococcal urethritis

   • Presence of ≥5 WBCs per oil immersion field confirms urethritis 1
   • Presence of intracellular Gram-negative diplococci indicates gonococcal infection

2. NAAT testing for:

   • Neisseria gonorrhoeae
   • Chlamydia trachomatis

3. Urinalysis

   • First-void urine sample (first 10-20 mL of urine)
   • Positive leukocyte esterase or ≥10 WBCs per high-power field supports diagnosis of urethritis 1

4. Additional testing based on clinical suspicion:

   • Trichomonas vaginalis testing (if suspected)
   • HSV PCR (if vesicular lesions present)
   • Syphilis serology

Treatment Algorithm

1. Empiric Treatment (Initiate immediately)

• First-line regimen:

  • Azithromycin 1g orally in a single dose 2, 1
  • PLUS
  • Ceftriaxone 125mg IM in a single dose 1

• This combination provides coverage for both gonococcal and non-gonococcal urethritis while awaiting test results

2. Alternative Regimens for Non-Gonococcal Urethritis

• Doxycycline 100mg orally twice daily for 7 days 1
• Erythromycin base 500mg orally four times daily for 7 days 1
• Ofloxacin 300mg orally twice daily for 7 days 1
• Levofloxacin 500mg orally once daily for 7 days 1

3. Management Based on Specific Etiology

• Gonococcal urethritis:

  • Continue dual therapy as above
  • Test of cure not needed if symptoms resolve 1

• Chlamydial urethritis:

  • Complete azithromycin or doxycycline course
  • Test of cure not routinely recommended 1

• Trichomoniasis:

  • Add metronidazole 2g orally in a single dose 1

Partner Management

• Notify and treat all sexual partners from the past 60 days 1
• Partners should be evaluated and treated for both gonorrhea and chlamydia
• Consider expedited partner therapy where legally permitted 3
• Advise abstinence from sexual activity until:
  • 7 days after single-dose therapy OR
  • Completion of multi-day regimen AND
  • Resolution of symptoms in both patient and partner(s) 1

Follow-up Recommendations

• Patients should return for evaluation if symptoms persist or recur after completing therapy 1

• Persistent symptoms require:

  • Culture for N. gonorrhoeae with antimicrobial susceptibility testing
  • Evaluation for other causes (Trichomonas, HSV, etc.)
  • Assessment for reinfection vs. treatment failure

• Consider retesting in 3 months due to high risk of reinfection 1

Special Considerations

• Differential diagnosis for penile discharge beyond STIs:

  • Penile abscess 4
  • Congenital prepubic sinus 5
  • Median raphe cyst infection 6

• Common pitfalls:

  1. Failing to test for both gonorrhea and chlamydia
  2. Not treating partners, leading to reinfection
  3. Treating with antibiotics without obtaining appropriate specimens
  4. Misdiagnosing non-infectious causes of penile discharge
  5. Not considering drug resistance, particularly for N. gonorrhoeae

Recent evidence suggests that empirical treatments are becoming less recommended due to increasing antibiotic resistance, with a trend toward pathogen-specific therapy guided by NAAT results 7. However, in the acute setting, the current guidelines still support empiric treatment while awaiting test results to prevent complications and reduce transmission.