What is the recommended treatment for urethritis?

Urethritis Treatment Guidelines

The recommended 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, confirm urethritis with at least one of the following:

• Mucopurulent or purulent urethral discharge 1
• Gram stain of urethral secretions showing ≥5 WBCs per oil immersion field 1
• Positive leukocyte esterase test on first-void urine 1
• Microscopic examination of first-void urine showing ≥10 WBCs per high-power field 1

All patients with urethritis should be tested for both Neisseria gonorrhoeae and Chlamydia trachomatis to guide appropriate treatment 2, 3

First-Line Treatment Options

Recommended Regimens:

• Azithromycin 1g orally in a single dose 1, 4

  • Single-dose regimens have the advantage of improved compliance and directly observed therapy 1
  • FDA-approved for urethritis and cervicitis due to Chlamydia trachomatis or Neisseria gonorrhoeae 4

• Doxycycline 100mg orally twice daily for 7 days 1

  • Equally effective as azithromycin for clinical cure of nongonococcal urethritis 5

Alternative Regimens:

• Erythromycin base 500mg orally four times a day for 7 days 1, 6
• Erythromycin ethylsuccinate 800mg orally four times a day for 7 days 1
• Ofloxacin 300mg orally twice a day for 7 days 1
• Levofloxacin 500mg orally once daily for 7 days 1

If only erythromycin can be used and a patient cannot tolerate high-dose erythromycin schedules:

• Erythromycin base 250mg orally four times a day for 14 days 1
• Erythromycin ethylsuccinate 400mg orally four times a day for 14 days 1

Partner Management

• All sexual partners within the preceding 60 days should be referred for evaluation and treatment 1, 2
• Partners should receive the same treatment regimen as the index patient 7
• Both patient and partners should abstain from sexual intercourse until 7 days after therapy is initiated and symptoms have resolved 1, 7

Follow-Up

• Patients should return for evaluation if symptoms persist or recur after completing therapy 1
• Symptoms alone, without documentation of signs or laboratory evidence of urethral inflammation, are not sufficient basis for re-treatment 1

Management of Persistent or Recurrent Urethritis

Before initiating further antimicrobial therapy, confirm objective signs of urethritis 7

Assessment:

• Rule out non-compliance with initial treatment regimen 1, 7
• Rule out re-exposure to an untreated sexual partner 1, 7
• If the above are ruled out, consider testing for Trichomonas vaginalis 1, 7

Recommended Treatment for Persistent/Recurrent Urethritis:

• Metronidazole 2g orally in a single dose 1, 7
• PLUS Azithromycin 1g orally in a single dose (if not used for initial episode) 7

Alternative Regimens for Persistent/Recurrent Urethritis:

• Metronidazole 2g orally in a single dose PLUS Erythromycin base 500mg orally four times a day for 7 days 1, 7
• Metronidazole 2g orally in a single dose PLUS Erythromycin ethylsuccinate 800mg orally four times a day for 7 days 1, 7

Special Considerations

HIV Infection

• HIV-infected patients with urethritis should receive the same treatment regimen as HIV-negative patients 1, 7, 2

Pregnancy

• Azithromycin 1g orally in a single dose is the recommended treatment for urethritis during pregnancy 8
• Erythromycin base 500mg orally four times a day for 7 days is an alternative 8, 6

Common Pitfalls to Avoid

• Treating based on symptoms alone without confirming objective signs of urethritis 7
• Failing to address possible reinfection from untreated partners 7
• Not testing for both gonorrhea and chlamydia 3, 9
• Re-treating without documentation of persistent urethritis 1
• Overlooking less common pathogens like Mycoplasma genitalium, Trichomonas vaginalis, and viral causes in persistent cases 3, 9