Management of Urethral Discharge in Men
For men presenting with urethral discharge, the initial management should include empiric treatment with azithromycin 1g orally in a single dose OR doxycycline 100mg orally twice daily for 7 days, as these medications effectively treat the most common causative pathogens. 1
Etiology and Diagnosis
- Urethral discharge in men is primarily caused by two bacterial agents: Neisseria gonorrhoeae and Chlamydia trachomatis 1
- Other less common causes include Ureaplasma urealyticum (20-40% of cases) and Trichomonas vaginalis (2-5% of cases) 1
- Diagnosis can be confirmed by the presence of ≥5 polymorphonuclear leukocytes per oil immersion field on a smear of an intraurethral swab specimen 1
- Leukocyte esterase test (LET) can be used to screen urine from asymptomatic males, but positive results should be confirmed with a Gram-stained smear of a urethral swab specimen 1
Initial Assessment
- A complete medical history focusing on symptom duration, severity, associated symptoms, sexual activity, and previous episodes is essential 2
- Physical examination should include evaluation of the external genitalia and assessment for discharge 2
- Urinalysis and urine culture should be performed to guide appropriate antibiotic therapy 2
- Testing for both gonorrhea and chlamydia is recommended as both infections are reportable to state health departments and specific diagnosis improves treatment compliance and partner notification 1
Treatment Recommendations
First-Line Treatment Options:
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
Follow-Up and Partner Management
- Patients should return for evaluation if symptoms persist or recur after completion of therapy 1
- Symptoms alone, without documentation of signs or laboratory evidence of urethral inflammation, are not sufficient basis for re-treatment 1
- Patients should abstain from sexual intercourse until 7 days after therapy is initiated, provided their symptoms have resolved and their sex partners have been adequately treated 1
- All sexual partners within the preceding 60 days should be referred for evaluation and treatment 1
- Persons diagnosed with a new STD should receive testing for other STDs, including syphilis and HIV 1
Management of Persistent or Recurrent Urethritis
- Objective signs of urethritis should be present before initiating additional antimicrobial therapy 1
- For persistent or recurrent urethritis, consider:
- Metronidazole 2g orally in a single dose OR Tinidazole 2g orally in a single dose
- PLUS Azithromycin 1g orally in a single dose (if not used for initial episode) 1
- Consider testing for Trichomonas vaginalis using an intraurethral swab or first-void urine specimen 1
- Some cases of recurrent urethritis after doxycycline treatment might be caused by tetracycline-resistant U. urealyticum 1
Special Considerations
- HIV-positive patients with urethritis should receive the same treatment regimen as HIV-negative patients 1
- Persistence of pain, discomfort, and irritative voiding symptoms beyond 3 months should alert the clinician to the possibility of chronic prostatitis/chronic pelvic pain syndrome 1
- In patients with urinary symptoms suggesting urethral stricture or obstruction, referral to a urologist may be necessary 1
Common Pitfalls to Avoid
- Do not rely on symptoms alone for re-treatment without documentation of signs or laboratory evidence of urethral inflammation 1
- Avoid blind urethral catheterization when urethral injury is suspected, as this may worsen the injury 5
- Do not confuse Neisseria meningitidis urethritis with gonococcal urethritis, as they appear identical by microscopy 6
- Remember that some cases of urethritis may be caused by multiple pathogens simultaneously - studies show that among men with C. trachomatis, up to 80% may be coinfected with N. gonorrhoeae 7