What is the treatment for a 23-year-old male with purulent (pus-like) discharge while urinating?

Management of Purulent Urethral Discharge in a 23-Year-Old Male

This patient requires immediate empiric dual therapy for both gonorrhea and chlamydia with ceftriaxone 250 mg IM plus either azithromycin 1 g orally or doxycycline 100 mg twice daily for 7 days, as purulent discharge in a young sexually active male is most commonly caused by N. gonorrhoeae and/or C. trachomatis. 1

Immediate Diagnostic Approach

Before initiating treatment, obtain the following:

• Gram stain of urethral discharge to look for >5 polymorphonuclear leukocytes per oil immersion field (confirms urethritis) and gram-negative intracellular diplococci (presumptive gonorrhea diagnosis) 1
• Nucleic acid amplification testing (NAAT) from urethral swab or first-void urine for both N. gonorrhoeae and C. trachomatis 1
• Urinalysis and urine culture to evaluate for concurrent urinary tract infection 1
• HIV and syphilis serology as all patients diagnosed with a new STD should receive testing for other STDs 1

First-Line Treatment Regimen

The CDC guidelines recommend treating for both infections empirically when diagnostic tools confirm urethritis, as coinfection is common and delays in treatment increase transmission risk: 1

For Gonorrhea:

• Ceftriaxone 250 mg intramuscularly as a single dose 1, 2

PLUS (for Chlamydia):

• Azithromycin 1 g orally as a single dose 1
• OR Doxycycline 100 mg orally twice daily for 7 days 1

The single-dose azithromycin regimen may improve compliance, though doxycycline for 7 days is equally effective. 1

Critical Management Points

• Instruct the patient to abstain from sexual intercourse for 7 days after initiating therapy to prevent transmission 1
• All sexual partners within the preceding 60 days must be evaluated and treated regardless of symptoms, as asymptomatic infections are common 1
• Patients should return for evaluation only if symptoms persist or recur after completion of therapy, as test-of-cure is not routinely recommended unless symptoms persist 1

Common Pitfalls to Avoid

• Do not delay treatment waiting for culture results in a patient with purulent discharge and confirmed urethritis on Gram stain, as empiric dual therapy is indicated 1
• Do not treat with fluoroquinolones (such as ciprofloxacin) for gonorrhea due to widespread resistance, despite their historical use 1, 3
• Do not assume a single pathogen - approximately 23-55% of nongonococcal urethritis cases are caused by C. trachomatis, and coinfection with gonorrhea is common in young sexually active males 1
• Do not discharge the patient as "cured" without addressing partner notification, as reinfection from untreated partners is a major cause of treatment failure 1

Management of Persistent or Recurrent Symptoms

If symptoms persist after appropriate treatment: 1

• First, assess compliance and partner treatment - if either was inadequate, re-treat with the initial regimen 1
• If compliance and partner treatment were adequate, obtain intraurethral swab or first-void urine for Trichomonas vaginalis culture, as this causes 2-5% of NGU cases 1
• Consider tetracycline-resistant Ureaplasma urealyticum (causes 20-40% of NGU) if symptoms persist after doxycycline 1

Recommended regimen for persistent urethritis after adequate initial treatment:

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

Special Considerations

HIV-positive patients should receive the same treatment regimen as HIV-negative patients, though gonococcal and chlamydial urethritis may facilitate HIV transmission. 1