What is the treatment for male urethritis?

Treatment of Male Urethritis

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

Diagnosis

Before initiating treatment, confirm urethritis with at least one of the following:

• Mucopurulent or purulent urethral discharge 1
• Positive leukocyte esterase test on first-void urine 1
• ≥10 WBC per high-power field on microscopic examination of first-void urine sediment 1

All patients with confirmed or suspected urethritis should be tested for:

• Neisseria gonorrhoeae 1
• Chlamydia trachomatis 1

Treatment Algorithm

First-line Treatment Options

• Azithromycin 1g orally in a single dose 1, 2
  • Advantages: Single-dose regimen improves compliance and allows for directly observed therapy 1
  • Particularly effective against Mycoplasma genitalium 1

OR

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

Alternative Regimens (if first-line options cannot be used)

• Erythromycin base 500mg orally four times a day for 7 days 1
• Erythromycin ethylsuccinate 800mg orally four times a day for 7 days 1
• Levofloxacin 500mg orally once daily for 7 days 1
• Ofloxacin 300mg orally twice a day for 7 days 1

Special Considerations

Empiric Treatment

• Empiric treatment without documentation of urethritis is recommended only for patients at high risk for infection who are unlikely to return for follow-up 1
• In such cases, treat for both gonorrhea and chlamydia 1

Partner Management

• All sex partners within the preceding 60 days should be referred for evaluation and treatment 1
• Partners should receive treatment effective against chlamydia regardless of whether a specific etiology is identified in the index patient 1
• Expedited partner treatment is an alternative approach 1

Post-Treatment Instructions

• Abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a 7-day regimen 1
• Sexual abstinence should continue until symptoms have resolved 1
• Sexual partners should be treated before resuming sexual activity 1

Management of Persistent or Recurrent Urethritis

If symptoms persist or recur after treatment:

1. Confirm objective signs of urethritis before initiating further antimicrobial therapy 1, 3
2. Rule out non-compliance with initial treatment or re-exposure to untreated partner 1, 3
3. If compliant with initial regimen and re-exposure 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

Common Pitfalls to Avoid

• Treating based on symptoms alone without confirming objective signs of urethritis 1, 3
• Failing to test for both gonorrhea and chlamydia 1
• Not addressing possible reinfection from untreated partners 1, 3
• Overlooking the possibility of tetracycline-resistant Ureaplasma urealyticum or Mycoplasma genitalium in persistent cases 1
• Ignoring the need for follow-up if symptoms persist 1

Follow-Up

• Patients should return for evaluation if symptoms persist or recur after treatment 1
• Persistence of pain, discomfort, and irritative voiding symptoms beyond 3 months should prompt evaluation for chronic prostatitis/chronic pelvic pain syndrome 1
• Test-of-cure is not recommended for asymptomatic patients who received recommended treatment 1
• Consider repeat testing 3-6 months after treatment due to high rate of reinfection 1