What is the treatment for urethritis with symptoms but no leukocytospermia (presence of white blood cells in semen)?

Treatment of Urethritis with Symptoms but No Leukocytospermia

If you have urethritis symptoms but no white blood cells detected in semen, you should first confirm urethritis through proper urethral testing (not semen analysis), then treat empirically with azithromycin 1g orally as a single dose OR doxycycline 100mg orally twice daily for 7 days while awaiting test results for gonorrhea and chlamydia. 1, 2

Critical Diagnostic Clarification

The absence of white blood cells in semen (leukocytospermia) is not relevant for diagnosing urethritis. 1 Urethritis diagnosis requires documentation through:

• 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

Common pitfall: Semen analysis is used to evaluate fertility or prostatitis, not urethritis. The diagnostic criteria specifically require urethral secretions or first-void urine, not semen. 1

Treatment Algorithm

Step 1: Confirm Objective Evidence of Urethritis

Before initiating treatment, document urethritis using the criteria above. 1 Symptoms alone without objective evidence are insufficient for treatment, except in high-risk patients unlikely to return for follow-up (e.g., adolescents with multiple partners). 1

Step 2: Test for Specific Pathogens

All patients should be tested for both Neisseria gonorrhoeae and Chlamydia trachomatis using nucleic acid amplification tests (NAAT) on first-void urine or urethral swab. 1, 2 Testing is strongly recommended because:

• A specific diagnosis improves compliance and partner notification 1
• Both infections are reportable to health departments 1
• Treatment can be tailored based on results 1, 2

Step 3: Initiate Empiric Treatment

First-line recommended regimens (start immediately after confirming urethritis): 1, 2

• Azithromycin 1g orally as a single dose 1, 2, 3
  • Advantage: Single-dose ensures compliance and allows directly observed therapy 1
  • Particularly effective against Mycoplasma genitalium 2

OR

• Doxycycline 100mg orally twice daily for 7 days 1, 2
  • Highly effective for chlamydial urethritis 2
  • Requires patient compliance with multi-day regimen 1

Step 4: Alternative Regimens (if first-line options unavailable)

1

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

Management of Persistent or Recurrent Symptoms

If symptoms persist after initial treatment: 1, 4

1. Re-confirm objective signs of urethritis before retreating 1, 4
2. Rule out non-compliance or partner reinfection - if either present, repeat initial regimen 1, 4
3. Test for Trichomonas vaginalis using culture or NAAT on intraurethral swab or first-void urine 4
4. Consider tetracycline-resistant Ureaplasma urealyticum 4

Recommended treatment for persistent/recurrent urethritis: 1, 4

• Metronidazole 2g orally as a single dose OR Tinidazole 2g orally as a single dose 4
• PLUS Azithromycin 1g orally as a single dose (if not used initially) 4

Alternative regimen: 1

• Metronidazole 2g orally as a single dose PLUS Erythromycin base 500mg orally four times daily for 7 days

Partner Management

All sexual partners within the preceding 60 days must be evaluated and treated. 1, 2 Partners should receive treatment effective against chlamydia regardless of whether a specific pathogen is identified. 2, 5

Both patient and partners should abstain from sexual intercourse until 7 days after therapy is initiated and symptoms have resolved. 4

Critical Pitfalls to Avoid

• Do not treat based on symptoms alone without confirming objective signs of urethritis 1, 4
• Do not use semen analysis to diagnose urethritis - use urethral secretions or first-void urine 1
• Do not fail to treat partners - this is the most common cause of recurrence 1, 4
• Do not retreat without confirming persistent urethritis - symptoms alone are insufficient 1, 4

Follow-Up

Patients should return if symptoms persist or recur after treatment. 1 Test-of-cure is not recommended for asymptomatic patients who received recommended treatment. 2 Consider repeat testing 3-6 months after treatment due to high reinfection rates. 2