What is the treatment for urethritis without white blood cells (WBCs)?

Treatment of Urethritis Without White Blood Cells

If urethritis cannot be confirmed by objective laboratory evidence (absence of WBCs), empiric antimicrobial treatment should generally be withheld unless the patient is at high risk and unlikely to return for follow-up. 1, 2

Diagnostic Confirmation Required

The absence of WBCs challenges the diagnosis of urethritis itself, as standard diagnostic criteria require at least one of the following 1, 3:

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

Symptoms alone, without documentation of signs or laboratory evidence of urethral inflammation, are not sufficient basis for treatment. 2

When to Treat Without WBC Documentation

High-Risk Patients

The CDC recommends empiric treatment without documentation of urethritis only for patients who are 1:

• Unlikely to return for follow-up
• At high risk for sexually transmitted infections

These patients should receive treatment for both gonorrhea and chlamydia: 1

• Azithromycin 1g orally as a single dose 1, 4
• PLUS Ceftriaxone 250mg intramuscularly 3

Alternative First-Line Regimen

• Doxycycline 100mg orally twice daily for 7 days 1, 5
• PLUS Ceftriaxone 250mg intramuscularly 3

Clinical Approach Algorithm

1. Re-evaluate for objective signs: Look for urethral discharge on examination or repeat urinalysis for WBCs 2

2. If no objective signs are found:

   • Consider alternative diagnoses (prostatitis, cystitis, non-infectious causes) 3
   • Perform NAAT testing for Neisseria gonorrhoeae and Chlamydia trachomatis 1
   • Consider testing for Mycoplasma genitalium, Trichomonas vaginalis, and HSV if available 1, 5

3. If patient is high-risk and unlikely to follow up:

   • Treat empirically with dual therapy as above 1

4. If patient can return for follow-up:

   • Await test results before initiating treatment 1
   • Treat based on identified pathogens 1

Important Caveats

Do not treat based on symptoms alone if the patient can return for proper evaluation, as this contributes to antimicrobial resistance and may mask other conditions. 2

All sexual partners within the preceding 60 days must be evaluated and treated if treatment is initiated, regardless of whether urethritis is confirmed. 1

Patients should abstain from sexual intercourse until 7 days after therapy initiation and until symptoms resolve. 1

Partner Management

All partners should receive treatment effective against chlamydia regardless of whether a specific etiology is identified in the index patient. 1