What is the recommended treatment for urethritis in men?

Treatment of Urethritis in Men

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

Diagnosis and Etiology

• Urethritis should be confirmed by at least one of the following: mucopurulent or purulent urethral discharge, positive leukocyte esterase test on first-void urine, or ≥10 WBC per high-power field on microscopic examination of first-void urine sediment 1
• All patients with suspected urethritis should be tested for both Neisseria gonorrhoeae and Chlamydia trachomatis 1, 2
• Chlamydia trachomatis is the most common cause of non-gonococcal urethritis (NGU), accounting for 15-55% of cases 2, 3
• Other causes include Mycoplasma genitalium (10-30%), Ureaplasma urealyticum, Trichomonas vaginalis, HSV, and adenovirus 2, 3
• Up to half of NGU cases have no identified pathogen 3, 4

Treatment Recommendations

First-Line Treatment Options:

• Azithromycin 1g orally in a single dose 1, 5
  • Particularly effective against Mycoplasma genitalium 1
  • Single-dose regimen improves compliance and allows for directly observed therapy 2

OR

• Doxycycline 100mg orally twice daily for 7 days 1, 2
  • Highly effective for chlamydial urethritis 1

Alternative Regimens:

• Erythromycin base 500mg orally four times a day for 7 days 2
• Erythromycin ethylsuccinate 800mg orally four times a day for 7 days 2
• Ofloxacin 300mg orally twice a day for 7 days 2
• Levofloxacin 500mg orally once daily for 7 days 2

Partner Management

• All sex partners within the preceding 60 days should be referred for evaluation and treatment 1, 2
• Partners should receive treatment effective against chlamydia regardless of whether a specific etiology is identified in the index patient 1
• Patients and partners should abstain from sexual intercourse until 7 days after therapy is initiated and symptoms have resolved 2

Management of Persistent or Recurrent Urethritis

• Confirm objective signs of urethritis before initiating further antimicrobial therapy 1
• Rule out non-compliance with initial treatment or re-exposure to untreated partner 1, 3
• Recommended treatment for persistent or recurrent urethritis:
  • 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, 3
• If azithromycin was prescribed initially, consider doxycycline 100mg twice daily for 7 days plus metronidazole, or moxifloxacin 400mg daily for 7-14 days 3

Follow-Up

• Patients should return for evaluation if symptoms persist or recur after treatment completion 2, 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
• Persistent symptoms without objective signs of urethritis do not warrant additional antimicrobial treatment 2

Special Considerations

• Empiric treatment without documentation of urethritis is recommended only for high-risk patients unlikely to return for follow-up 1, 2
• Patients diagnosed with a new STD should receive testing for other STDs, including syphilis and HIV 2
• Antimicrobial resistance, particularly of M. genitalium to macrolides, is an emerging concern 3