What is the initial workup for a patient with constant urethral burning?

Initial Workup for Constant Urethral Burning

The initial workup for a patient with constant urethral burning should include testing for both Neisseria gonorrhoeae and Chlamydia trachomatis, along with evaluation for objective signs of urethritis. 1

Diagnostic Approach

Step 1: Confirm Urethritis

Look for objective evidence of urethral inflammation:

• 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

Step 2: Specific Testing

• Nucleic Acid Amplification Tests (NAATs) for:
  • Neisseria gonorrhoeae
  • Chlamydia trachomatis 1

Step 3: Additional Testing Based on Risk Factors

• Consider testing for:
  • Trichomonas vaginalis (wet mount and culture of intraurethral swab)
  • Mycoplasma genitalium (if available)
  • Ureaplasma urealyticum (if available)
  • HIV and syphilis 2

Treatment Approach

If objective signs of urethritis are present, treatment should be initiated promptly:

First-line Treatment Options:

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

Alternative Treatment Options:

• 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

Symptomatic Relief

While identifying and treating the underlying cause, phenazopyridine can be used for symptomatic relief of urethral burning:

• Phenazopyridine HCl for pain relief
• Should not be used for more than 2 days
• Does not replace the need for appropriate antimicrobial therapy 3

Important Considerations

Partner Management

• All sexual partners within the preceding 60 days should be referred for evaluation and treatment
• Partners should receive the same treatment as the index patient
• Patients should abstain from sexual intercourse until 7 days after therapy is initiated and symptoms have resolved 1, 2

Follow-up

• Patients should return for evaluation if symptoms persist or recur after completing therapy
• For persistent or recurrent urethritis after initial treatment, consider:
  • Metronidazole 2g orally in a single dose PLUS
  • Erythromycin base 500mg orally four times daily for 7 days 1

Common Pitfalls to Avoid

1. Treating without confirming diagnosis - Always obtain objective evidence of urethritis before starting antimicrobial therapy
2. Neglecting partner treatment - Failure to treat partners leads to high reinfection rates
3. Premature re-treatment - Symptoms alone, without objective signs of inflammation, are not sufficient basis for re-treatment
4. Empiric treatment without testing - Should only be done for high-risk patients unlikely to return for follow-up 1, 2

For patients with persistent symptoms despite appropriate treatment, consider urologic evaluation to rule out other causes of urethral burning such as interstitial cystitis, chronic prostatitis/chronic pelvic pain syndrome, or other urologic conditions 4.