What is the treatment for urethritis?

Treatment of Urethritis

The first-line treatment for urethritis is either azithromycin 1g orally in a single dose or doxycycline 100mg orally twice daily for 7 days. 1, 2

Diagnosis

Before initiating treatment, urethritis should be confirmed by at least 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 1
• Microscopic examination of first-void urine showing ≥10 WBC per high-power field 1

All patients with confirmed or suspected urethritis should be tested for both Neisseria gonorrhoeae and Chlamydia trachomatis to guide appropriate treatment 1, 2

Treatment Recommendations

First-Line Regimens

• Azithromycin 1g orally in a single dose 1, 2, 3
  • Advantages: Single-dose regimen improves compliance and allows for directly observed therapy 1, 4
  • Particularly effective against Mycoplasma genitalium 1, 5
• OR
• Doxycycline 100mg orally twice daily for 7 days 1, 2
  • Highly effective for chlamydial urethritis 1

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

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

Management Considerations

• Treatment should be initiated as soon as possible after diagnosis 1
• Medications should ideally be dispensed on-site in the clinic, with the first dose directly observed to maximize compliance 1
• Patients should abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a 7-day regimen, provided their symptoms have resolved 1
• All sexual partners within the preceding 60 days should be referred for evaluation and treatment 1, 2
• Patients should be instructed to return for evaluation if symptoms persist or recur after completion of therapy 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
• Such patients should be treated for both gonorrhea and chlamydia 1

Persistent or Recurrent Urethritis

• Objective signs of urethritis should be present before initiating additional antimicrobial therapy 6
• Consider testing for Trichomonas vaginalis using an intraurethral swab or first-void urine specimen 6
• Treatment options for persistent/recurrent urethritis:
  • Metronidazole 2g orally in a single dose OR tinidazole 2g orally in a single dose 6
  • PLUS azithromycin 1g orally in a single dose (if not used for initial episode) 6, 5

Common Pitfalls to Avoid

• Treating based on symptoms alone without confirming objective signs of urethritis 6
• Failing to test for both gonorrhea and chlamydia 1, 2
• Failing to address possible reinfection from untreated partners 6
• 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, 6

Clinical Efficacy

Clinical cure rates are comparable between azithromycin (81%) and doxycycline (77%) regimens, regardless of whether Chlamydia or Ureaplasma infection is present 4. Both treatments are generally well-tolerated with mild to moderate adverse effects 4.