What is the recommended treatment for urethritis in men?

Treatment of Urethritis in Men

First-line treatment for urethritis in men is either azithromycin 1g orally as a single dose OR doxycycline 100mg orally twice daily for 7 days, with both regimens showing equivalent efficacy. 1, 2

Diagnostic Confirmation Before Treatment

Before initiating therapy, confirm urethritis with at least one of the following objective criteria: 1, 2

• Mucopurulent or purulent urethral discharge on examination
• Positive leukocyte esterase test on first-void urine
• ≥10 white blood cells per high-power field on microscopic examination of first-void urine sediment

All patients must be tested for both Neisseria gonorrhoeae and Chlamydia trachomatis before or at the time of treatment. 1, 2

First-Line Treatment Options

You have two equally effective choices: 1, 2

Option 1: Azithromycin

• Dose: 1g orally as a single dose 1, 2, 3
• Advantages: Single-dose therapy ensures compliance and allows directly observed therapy; particularly effective against Mycoplasma genitalium 1, 2
• FDA-approved indication: Urethritis and cervicitis due to Chlamydia trachomatis or Neisseria gonorrhoeae 3

Option 2: Doxycycline

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

Clinical cure rates are similar between both regimens (approximately 76-81%), though recent evidence suggests declining efficacy for both agents. 4

Key Etiologic Considerations

Chlamydia trachomatis is the most common identifiable cause of non-gonococcal urethritis, accounting for 15-55% of cases. 1 However, Mycoplasma genitalium is increasingly recognized as an important pathogen with particularly poor treatment response rates (30-40% microbiologic cure with standard regimens). 4

Empiric Treatment Without Diagnostic Confirmation

Empiric treatment without documented urethritis should only be given to high-risk patients unlikely to return for follow-up. 1, 2 In these cases, treat for both gonorrhea and chlamydia empirically. 2

Partner Management (Critical Component)

All sexual partners within the preceding 60 days must be referred for evaluation and treatment. 1, 2 Key points:

• Partners should receive treatment effective against chlamydia regardless of whether a specific pathogen is identified in the index patient 1, 2
• Both patient and all partners must abstain from sexual intercourse until 7 days after therapy is initiated AND symptoms have resolved 1, 2

Management of Persistent or Recurrent Urethritis

If symptoms persist or recur after initial treatment: 1, 2

1. Re-confirm objective signs of urethritis before giving additional antibiotics 1, 2
2. Rule out non-compliance with initial treatment 1, 2
3. Rule out re-exposure to untreated partner 1, 2

If urethritis is confirmed and compliance/re-exposure are ruled out, treat with: 1, 2

• Metronidazole 2g orally as a single dose OR tinidazole 2g orally as a single dose
• PLUS azithromycin 1g orally as a single dose (if not used for initial episode)

This regimen targets Trichomonas vaginalis and tetracycline-resistant Ureaplasma urealyticum. 5

Follow-Up Recommendations

• Patients should return for evaluation only if symptoms persist or recur after treatment completion 1, 2
• Test-of-cure is NOT recommended for asymptomatic patients who received recommended treatment 1, 2
• Consider repeat testing 3-6 months after treatment due to high reinfection rates (not to assess cure, but to detect reinfection) 1, 2

Common Pitfalls to Avoid

• Do not rely on semen analysis to diagnose urethritis—the absence of white blood cells in semen is irrelevant for urethritis diagnosis 5
• Do not treat syphilis with azithromycin at the recommended dose for urethritis—all patients with sexually transmitted urethritis should have serologic testing for syphilis at diagnosis 3
• Do not give additional antimicrobials for persistent symptoms without re-confirming objective urethritis—many men remain symptomatic without documented infection 1
• Do not forget HIV and syphilis testing—patients diagnosed with any new STD should receive testing for other STDs, including syphilis and HIV 1