How to manage a 35-year-old male with urethral discharge and dysuria, who has been given a stat dose of azithromycin (Azithro) and cefixime (Cefixime), and also prescribed Tab Urispas (Flavoxate) and SYP Cital (probably a syrup, but unclear), with a urine culture showing a few pus cells?

Management of Urethral Discharge with Dysuria After Initial Treatment

The patient has already received appropriate empiric dual therapy for urethritis (azithromycin + cefixime), so the next step is to await culture results, ensure partner treatment, counsel on abstinence until cure, and plan follow-up only if symptoms persist beyond 7 days. 1, 2

Immediate Next Steps

1. No Additional Antibiotics Needed Now

• The stat dose of azithromycin 1g plus cefixime 400mg already provides adequate coverage for both gonococcal and non-gonococcal urethritis 3, 1
• This dual therapy covers Neisseria gonorrhoeae, Chlamydia trachomatis, Ureaplasma urealyticum, and most other common urethritis pathogens 2, 4
• Cefixime cures 97.4% of uncomplicated urogenital gonococcal infections, while azithromycin is highly effective for chlamydial and non-gonococcal urethritis 3

2. Discontinue Urispas (Flavoxate)

• Urispas is an antispasmodic with no role in treating infectious urethritis 5
• The "few pus cells" in urine confirm urethritis, not a simple bladder irritation requiring antispasmodics 5

3. Clarify and Likely Discontinue "SYP Cital"

• If this is a citrate-based alkalinizing syrup, it has no evidence-based role in urethritis management 5
• Symptomatic relief should come from treating the infection, not urinary alkalinizers 3

Essential Management Actions

Partner Management (Critical)

• All sexual partners within the preceding 60 days must be evaluated and treated with the same dual therapy regimen 3, 6
• Partners should receive azithromycin 1g single dose plus cefixime 400mg single dose empirically, even without examination 5
• Expedited partner therapy (giving the patient prescriptions for partners) is recommended to prevent reinfection 5

Sexual Abstinence Counseling

• Patient must abstain from sexual intercourse until 7 days after therapy initiation AND until both patient and all partners have completed treatment and are symptom-free 3, 1
• This prevents reinfection and transmission 2

Follow-Up Strategy

If Symptoms Resolve (Expected in 81% of Cases):

• No test of cure is needed 3
• Patients treated with recommended regimens do not require routine follow-up cultures 3

If Symptoms Persist Beyond 7 Days:

• Confirm persistent urethritis with microscopy showing >5 polymorphonuclear leukocytes per high-power field 4, 5
• Consider three possibilities:
  1. Reinfection from untreated partner (most common) - retreat patient and ensure partner treatment 3
  2. Non-compliance - verify the patient actually took the medications 4
  3. Resistant organism or alternative pathogen - proceed to culture with susceptibility testing 3

For Confirmed Persistent/Recurrent Urethritis:

• Test for Trichomonas vaginalis using intraurethral swab or first-void urine NAAT 3, 4
• Test for Mycoplasma genitalium if available, as 10-30% of NGU is due to this organism 4
• Treat with metronidazole 2g single dose PLUS moxifloxacin 400mg daily for 7-14 days if initial azithromycin was used 3, 4
• Alternative: metronidazole 2g single dose PLUS doxycycline 100mg twice daily for 7 days if azithromycin was the initial therapy 3, 4

Additional Testing Considerations

HIV and Syphilis Screening

• All patients with sexually transmitted urethritis should have serologic testing for syphilis and HIV 7
• Urethritis increases HIV concentration in semen and facilitates transmission 5
• This testing should be done at the initial visit or at follow-up 7

Gonorrhea Culture with Susceptibility Testing

• Only needed if symptoms persist after appropriate treatment, suggesting possible resistant N. gonorrhoeae 3
• Quinolone resistance is increasingly common (6.8% in 2004 GISP data), though cefixime remains highly effective 3

Common Pitfalls to Avoid

• Do not retreat based on symptoms alone without confirming persistent urethritis by microscopy 3, 6
• Do not assume treatment failure without first ruling out reinfection from untreated partners 3
• Do not use quinolones (ciprofloxacin/levofloxacin) empirically due to increasing resistance 3, 2
• Do not give azithromycin alone for gonorrhea - it requires 2g dose which causes significant GI distress, and 1g alone cures only 93% of cases 3
• Do not continue symptomatic medications (Urispas, alkalinizers) that have no role in treating the underlying infection 5

Expected Outcomes

• Clinical cure rates with azithromycin-cefixime dual therapy: approximately 81% for NGU and 97-99% for gonococcal urethritis 3, 8
• Most treatment failures represent reinfection rather than true antibiotic failure 3