What is the initial management for a patient presenting with penile discharge and shaft swelling?

Initial Management of Penile Discharge and Shaft Swelling

Immediately initiate empiric dual antibiotic therapy with ceftriaxone 1 g IM/IV plus doxycycline 100 mg orally twice daily for 10 days while simultaneously performing urgent diagnostic evaluation to rule out abscess formation requiring surgical drainage. 1

Immediate Diagnostic Evaluation

The diagnostic workup must be performed concurrently with treatment initiation, not as a prerequisite to therapy:

• Perform Gram stain of urethral discharge to identify polymorphonuclear leukocytes (≥2 WBCs per oil immersion field) and presumptively diagnose gonococcal infection by documenting gram-negative intracellular diplococci 2, 1
• Obtain nucleic acid amplification test (NAAT) on first-void urine or urethral swab for N. gonorrhoeae and C. trachomatis, as these have superior sensitivity compared to culture 2, 1
• Collect urethral swab culture before antibiotic administration to assess antimicrobial resistance profiles, particularly for gonorrhea 1
• Examine first-void urine with microscopy for ≥10 WBCs per high-power field or perform leukocyte esterase testing 2

Age-Stratified Empiric Antibiotic Regimens

The combination approach addresses both gonococcal and non-gonococcal pathogens simultaneously:

For Patients Under 35 Years (Sexually Transmitted Etiology Most Likely)

• Ceftriaxone 1 g IM or IV single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 3
• This regimen covers N. gonorrhoeae, C. trachomatis, and M. genitalium 2, 1
• The extended 10-day doxycycline course (rather than 7 days) is specifically recommended when shaft swelling suggests epididymitis 1, 3

For Patients 35 Years or Older (Enteric Organisms More Likely)

• Ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 1, 3
• These fluoroquinolones provide coverage for enteric gram-negative organisms (E. coli, Enterobacteriaceae) that cause epididymitis in older men 1, 3
• Critical caveat: Do not use fluoroquinolones if the infection was acquired in Asia or Pacific regions due to high quinolone-resistant gonorrhea rates 1

Alternative Regimen (If Ceftriaxone Unavailable or Contraindicated)

• Azithromycin 1 g orally single dose can substitute for doxycycline in patients with tetracycline allergy 2, 4
• However, azithromycin monotherapy without test-of-cure for M. genitalium risks selecting macrolide-resistant strains 5

Adjunctive Supportive Measures

These interventions reduce inflammation and accelerate symptom resolution:

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 1, 3
• Sexual abstinence for at least 7 days after treatment initiation and until symptoms completely resolve 2, 1
• Directly observed first dose when possible to ensure compliance, particularly with single-dose regimens 2

Urgent Surgical Consultation Criteria

Shaft swelling raises concern for complications requiring drainage:

• Immediate surgical evaluation if no clinical improvement within 3 days of antibiotic initiation 1, 3
• Emergency urologic consultation if blood at urethral meatus, gross hematuria, or inability to void (suggests urethral injury) 6
• Urgent imaging (ultrasound or MRI) if abscess formation suspected based on fluctuance, severe localized tenderness, or systemic toxicity 1

Mandatory Reassessment at 3 Days

This checkpoint prevents missed alternative diagnoses:

• If no improvement by 72 hours, broaden differential to include testicular tumor, testicular infarction, fungal infection, Streptococcus intermedius abscess, or tuberculosis 1, 3
• Rule out testicular torsion in all cases, especially in adolescents and young adults, as this is a surgical emergency requiring intervention within 6 hours to preserve testicular viability 3, 6
• Distinguish ischemic priapism (completely rigid corpora, painful, medical emergency) from non-ischemic priapism (tumescent but not rigid, painless, not urgent) if prolonged erection present 2, 6

Management of Sexual Partners

Partner treatment prevents reinfection and transmission:

• Refer all sexual partners from the preceding 60 days for evaluation and treatment with the same antibiotic regimen 2, 1
• Expedited partner therapy (providing prescriptions for partners without examination) is endorsed by CDC and legal in many states 7
• Both patient and partners must abstain from sexual intercourse until treatment completion and symptom resolution 2, 1

Common Pitfalls to Avoid

• Never delay empiric treatment while awaiting culture results, as this increases risk of complications and transmission 2, 1
• Do not use azithromycin monotherapy without test-of-cure for M. genitalium, as this selects for macrolide resistance 5
• Never treat with systemic therapy alone in patients with sickle cell disease or hematologic disorders if priapism present—intracavernous treatment must be provided concurrently 2
• Do not confuse epididymitis with testicular torsion—torsion presents with sudden onset, high-riding testis, absent cremasteric reflex, and requires emergency surgery 3, 6
• Avoid fluoroquinolones if gonorrhea suspected and patient has travel history to Asia/Pacific regions or men who have sex with men, due to resistance patterns 1

Special Populations

HIV-Positive or Immunocompromised Patients

• Use identical antibiotic regimens as immunocompetent patients 2, 3
• Maintain higher suspicion for atypical organisms including fungi (Candida, Cryptococcus) and mycobacteria (M. tuberculosis) 3
• Consider longer treatment duration if clinical response delayed 3

Patients with Penicillin/Cephalosporin Allergy

• Azithromycin 2 g orally single dose for gonorrhea (though resistance concerns exist) 2
• Doxycycline 100 mg twice daily for 10 days for chlamydia and non-gonococcal pathogens 2
• Gentamicin 240 mg IM single dose plus azithromycin 2 g orally is an alternative for severe cephalosporin allergy 1

Follow-Up Testing

• Test-of-cure is NOT routinely recommended less than 3 weeks after treatment due to false-positive NAAT results from dead organisms 8
• Repeat screening at 3 months for all patients treated for sexually transmitted infections, as reinfection rates are high 8
• If M. genitalium detected, perform test-of-cure no earlier than 3 weeks after treatment initiation; if positive, treat with moxifloxacin 400 mg daily for 7-14 days 5