What is the diagnostic approach for urethritis in women?

Diagnostic Approach for Urethritis in Women

Critical Diagnostic Criteria

Urethritis in women should be diagnosed by documenting objective evidence of urethral inflammation using any of the following criteria: mucopurulent or purulent discharge, Gram stain of urethral secretions showing >5 WBCs per oil immersion field, positive leukocyte esterase test on first-void urine, or microscopic examination of first-void urine demonstrating >10 WBCs per high power field. 1

Step-by-Step Diagnostic Algorithm

1. Clinical Assessment

• Look for mucopurulent or purulent urethral discharge on examination, which alone confirms urethritis 1
• Document symptoms including dysuria, urethral discomfort, or abnormal discharge 2
• Obtain sexual history including partners within the preceding 60 days 1

2. Laboratory Confirmation (Choose One Method)

Gram Stain (Preferred Rapid Test):

• Obtain urethral secretions and perform Gram stain 1
• >5 WBCs per oil immersion field confirms urethritis 1
• Simultaneously identifies gonococcal infection if WBCs contain intracellular Gram-negative diplococci 1
• This is the most sensitive and specific rapid diagnostic test available 1

First-Void Urine Testing (When Gram Stain Unavailable):

• Positive leukocyte esterase test confirms urethritis 1
• OR microscopic examination showing >10 WBCs per high power field 1

3. Pathogen Identification (Mandatory)

All patients with confirmed urethritis must be tested for both:

• Neisseria gonorrhoeae 1
• Chlamydia trachomatis 1

Testing method:

• Nucleic acid amplification tests (NAATs) are preferred as they are more sensitive than culture for C. trachomatis 1
• NAATs can be performed on urethral swabs or first-void urine specimens 1

4. When Diagnostic Testing Is Not Available

If microscopy and Gram stain are unavailable, treat empirically for both gonorrhea and chlamydia in symptomatic patients 1

Important Clinical Pitfalls

Do NOT Treat Based on Symptoms Alone

• Defer treatment if none of the objective diagnostic criteria are present 1
• Test for N. gonorrhoeae and C. trachomatis and follow closely for results 1
• Symptoms without objective signs are not sufficient basis for treatment 1

Exception for High-Risk Patients

• Empiric treatment without documentation is acceptable only for high-risk patients unlikely to return for follow-up 1
• These patients should receive treatment covering both gonorrhea and chlamydia 1

Additional Considerations

When to Consider Alternative Pathogens

• Trichomonas vaginalis and HSV testing should be reserved for cases with suspected exposure or non-responsive urethritis 1
• Testing for Ureaplasma urealyticum and Mycoplasma genitalium is not routinely indicated as detection is difficult and would not alter initial therapy 1

Partner Management

• All sexual partners within the preceding 60 days require evaluation and treatment 1
• A specific pathogen diagnosis facilitates partner notification and improves treatment compliance 1