Should a urologist be consulted for bilateral urethritis?

Urology Consultation for Bilateral Urethritis

Urology consultation is not indicated for uncomplicated bilateral urethritis, as this condition is managed medically with antimicrobial therapy by primary care providers or infectious disease specialists. 1

Primary Management Approach

Urethritis, whether unilateral or bilateral, is fundamentally a sexually transmitted infection that requires:

• Immediate empiric antimicrobial treatment with azithromycin 1 g orally as a single dose OR doxycycline 100 mg orally twice daily for 7 days 1
• Testing for both N. gonorrhoeae and C. trachomatis using nucleic acid amplification tests, which are more sensitive than traditional culture techniques 1
• Partner notification and treatment of all sexual contacts within the preceding 60 days 1, 2

When Urology Consultation IS Indicated

Urologic referral becomes necessary only when complications develop or alternative diagnoses require surgical expertise:

• Epididymitis or orchitis developing as a complication of urethritis, particularly if testicular torsion cannot be excluded 2
• Persistent or recurrent urethritis after appropriate antimicrobial therapy that fails to respond to second-line treatment 1, 3
• Suspected structural abnormalities requiring urologic examination, though this is rarely needed for straightforward urethritis 1
• Acute testicular pain requiring immediate evaluation to rule out testicular torsion, which is a surgical emergency 2

Clinical Reasoning

The evidence is clear that urethritis management falls within the scope of primary care and infectious disease practice. The CDC guidelines from 1998 and 2002 make no mention of routine urology consultation for urethritis management 1. The 2023 WSES guidelines on iatrogenic urinary tract injuries discuss urology consultation only in the context of surgical complications and traumatic injuries, not infectious urethritis 1.

Important caveat: The term "bilateral urethritis" is somewhat unusual terminology, as urethritis typically refers to inflammation of the single urethra rather than bilateral structures. If the question actually refers to bilateral epididymitis or bilateral upper tract involvement, urology consultation would be more strongly indicated 2.

Treatment Algorithm

1. Document urethritis with mucopurulent discharge, Gram stain showing ≥5 WBCs per oil immersion field, or positive leukocyte esterase test 1
2. Initiate empiric treatment immediately without waiting for test results if urethritis is confirmed 1
3. Test for gonorrhea and chlamydia to guide partner notification and ensure appropriate treatment 1
4. Instruct patients to abstain from sexual intercourse until therapy is completed and partners are treated 1, 2
5. Reserve urology referral for complications such as epididymitis, persistent symptoms after appropriate treatment, or when testicular torsion cannot be excluded 2, 3