What is the treatment for urethritis?

Treatment of Urethritis

For urethritis treatment, azithromycin 1g orally in a single dose or doxycycline 100mg orally twice daily for 7 days are the recommended first-line therapies. 1

Diagnosis Before Treatment

Before initiating treatment, confirm urethritis diagnosis by one of the following:

• Mucopurulent or purulent urethral discharge 1
• Gram stain of urethral secretions showing >5 WBC per oil immersion field 1
• Positive leukocyte esterase test on first-void urine or microscopic examination showing >10 WBC per high power field 1
• Perform a validated nucleic acid amplification test (NAAT) on first-void urine or urethral smear to diagnose chlamydial and gonococcal infections 1

First-Line Treatment Options

Recommended Regimens:

• Azithromycin 1g orally in a single dose 1
  • Advantages: Single-dose regimen improves compliance and allows for directly observed therapy
  • Particularly effective for Mycoplasma genitalium infections 1

OR

• Doxycycline 100mg orally twice daily for 7 days 1
  • Highly effective for chlamydial urethritis

Alternative Treatment Options

If first-line treatments cannot be used, consider:

• 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 Treatment

For Gonococcal Urethritis:

• Ceftriaxone 1g IM or IV as a single dose plus azithromycin 1g orally in a single dose 1
• For cephalosporin allergy: Gentamicin 240mg IM single dose plus azithromycin 2g orally single dose 1

For Trichomonas vaginalis:

• Metronidazole or Tinidazole 2g orally in a single dose 1

Management of Recurrent or Persistent Urethritis

If symptoms persist or recur after initial treatment:

1. Confirm objective signs of urethritis are present 1
2. Rule out reinfection or non-compliance with initial treatment 1
3. If compliant with initial regimen and reexposure excluded, recommended treatment is:
   • Metronidazole 2g orally in a single dose OR Tinidazole 2g orally in a single dose 1
   • PLUS Azithromycin 1g orally in a single dose (if not used for initial episode) 1

Important Patient Instructions

• Abstain from sexual intercourse until 7 days after therapy is initiated 1
• Return for evaluation if symptoms persist or recur after treatment completion 1
• Symptoms alone, without objective signs or laboratory evidence of urethral inflammation, are not sufficient basis for re-treatment 1

Partner Management

• Refer all sexual partners within the preceding 60 days for evaluation and treatment 1
• Perform urethral swab culture before treatment initiation in patients with positive NAAT for gonorrhea to assess antimicrobial resistance 1

Special Considerations

• HIV infection: Patients with urethritis who are HIV-positive should receive the same treatment regimens as HIV-negative patients 1
• Persistent symptoms beyond 3 months should raise suspicion for chronic prostatitis/chronic pelvic pain syndrome 1
• Testing for other STIs including syphilis and HIV is recommended for patients diagnosed with urethritis 1

Common Pitfalls to Avoid

• Treating without confirming diagnosis - always document objective evidence of urethritis 1
• Failing to test for both gonorrhea and chlamydia 1
• Re-treating based on symptoms alone without objective evidence of persistent infection 1
• Neglecting partner notification and treatment, which can lead to reinfection 1
• Not considering tetracycline-resistant U. urealyticum in cases of recurrent urethritis following doxycycline treatment 1