What is the treatment for recurrent urethritis?

Treatment of Recurrent Urethritis

For recurrent urethritis, the recommended treatment is metronidazole 2g orally in a single dose PLUS azithromycin 1g orally in a single dose (if not used for the initial episode) or erythromycin base 500mg orally four times a day for 7 days. 1

Initial Assessment

• Confirm objective signs of urethritis before initiating further antimicrobial therapy, including the presence of discharge or ≥5 polymorphonuclear leukocytes per high-power field 1
• Rule out non-compliance with initial treatment regimen or re-exposure to an untreated sexual partner, which would warrant repeating the initial regimen 1
• Symptoms alone, without documentation of signs or laboratory evidence of urethral inflammation, are not sufficient basis for re-treatment 2, 1

Diagnostic Testing

• Perform culture or NAAT testing for Trichomonas vaginalis using an intraurethral swab or first-void urine specimen 1
• Consider testing for tetracycline-resistant Ureaplasma urealyticum, which may cause recurrent urethritis after doxycycline treatment 1, 3
• Testing for Mycoplasma genitalium is important as it is found in up to 41% of men with persistent urethritis after doxycycline treatment 3

Treatment Recommendations

First-Line Treatment

• Metronidazole 2g orally in a single dose PLUS azithromycin 1g orally in a single dose (if not used for initial episode) 1
• Alternative regimen: Metronidazole 2g orally in a single dose PLUS erythromycin base 500mg orally four times a day for 7 days OR erythromycin ethylsuccinate 800mg orally four times a day for 7 days 2, 1

For Mycoplasma genitalium Infection

• Azithromycin 1.5g (500mg on day 1, followed by 250mg daily for 4 days) has shown better efficacy than single-dose therapy 3
• For azithromycin-resistant strains, moxifloxacin 400mg orally once daily for 7-14 days is recommended 4

For Persistent/Recurrent Urethritis After Azithromycin

• If azithromycin was prescribed as first therapy, switch to doxycycline 100mg twice daily for 7 days plus metronidazole, or consider moxifloxacin 400mg orally once daily for 7-14 days 4

Partner Management

• Refer all sexual partners within the preceding 60 days for evaluation and treatment 2, 1
• Partners should receive the same treatment regimen as the index patient 1
• Both patient and partners should abstain from sexual intercourse until 7 days after therapy is initiated, provided symptoms have resolved and partners have been adequately treated 1, 5

Follow-Up

• Patients should return for evaluation if symptoms persist or recur after completion of therapy 2, 1
• For Mycoplasma genitalium infections, test of cure samples should be collected no earlier than three weeks after start of treatment 4
• 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

Special Considerations

• HIV-infected patients with non-gonococcal urethritis should receive the same treatment regimen as HIV-negative patients 2, 1
• Urologic examinations usually do not reveal a specific etiology in cases of persistent urethritis 2, 1

Common Pitfalls to Avoid

• Treating based on symptoms alone without confirming objective signs of urethritis 1
• Failing to address possible reinfection from untreated partners 1
• Using fluoroquinolones as first-line therapy due to potential adverse effects and increasing resistance 2
• Prolonged or repeated courses of the same antibiotic without identifying the specific pathogen 6
• Using single-dose azithromycin for M. genitalium without test of cure, which may select for macrolide-resistant strains 4