Treatment of Urethritis
The recommended first-line treatment for urethritis is either azithromycin 1g orally in a single dose or doxycycline 100mg orally twice daily for 7 days. 1
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 WBCs per oil immersion field
- Positive leukocyte esterase test on first-void urine
- Microscopic examination of first-void urine showing ≥10 WBCs per high-power field 1
Treatment Regimens
First-Line Treatment Options
Azithromycin: 1g orally in a single dose 1, 2
- Advantages: Single-dose therapy improves compliance and allows for directly observed therapy
- Particularly effective against Chlamydia trachomatis
Doxycycline: 100mg orally twice daily for 7 days 1, 3
- Highly effective against Chlamydia trachomatis and other common pathogens
Alternative Treatment Options
- Erythromycin base: 500mg orally four times daily for 7 days 1
- Erythromycin ethylsuccinate: 800mg 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
Pathogen-Specific Considerations
- Gonococcal urethritis: Requires treatment for both gonorrhea and possible chlamydial co-infection
- Non-gonococcal urethritis (NGU): Most commonly caused by Chlamydia trachomatis, Mycoplasma genitalium, or Ureaplasma urealyticum 4
- Persistent/recurrent urethritis: Consider testing for Trichomonas vaginalis and treating with metronidazole 2g orally in a single dose plus azithromycin 1g orally (if not used initially) 5
Patient Management
- Patients should abstain from sexual intercourse until 7 days after therapy is initiated and symptoms have resolved 1, 5
- All sexual partners within the preceding 60 days should be referred for evaluation and treatment 1
- Patients should return for evaluation if symptoms persist or recur after completing therapy 1
Treatment Efficacy
Clinical studies have demonstrated that single-dose azithromycin is as effective as a 7-day course of doxycycline for the treatment of urethritis, with clinical cure rates of 81% and 77% respectively 6. Both regimens show comparable efficacy regardless of whether the infection is caused by Chlamydia trachomatis or Ureaplasma urealyticum.
Important Caveats
- Empiric treatment without documentation of urethritis is only recommended for high-risk patients unlikely to return for follow-up 1
- Symptoms alone, without objective signs of urethritis, are not sufficient basis for re-treatment 1
- Testing for gonorrhea and chlamydia is strongly recommended to facilitate partner notification and improve treatment compliance 1
- Patients treated for sexually transmitted infections should have repeat screening in three months 4
By following these evidence-based guidelines for the treatment of urethritis, clinicians can effectively manage this common condition while minimizing complications and preventing transmission.