What are the symptoms and treatment options for urethritis in women?

Symptoms of Urethritis in Women

Clinical Presentation

Women with urethritis typically present with dysuria, urinary frequency and urgency, urethral discomfort, and sometimes mucopurulent discharge, though symptoms may overlap significantly with cystitis and vaginitis. 1, 2

Primary Symptoms

• Dysuria is the most common presenting symptom in women with urethritis 1, 2
• Urinary frequency and urgency occur frequently and may be difficult to distinguish from bladder infection 1, 3
• Urethral discomfort or pain may be persistent or intermittent, sometimes extending to pelvic pain 3
• Mucopurulent discharge may be present but is less common in women than men 1
• Nocturia can occur as part of the symptom complex 3

Associated Findings

• Urethral erythema may be visible on examination 1
• Vaginal discharge should prompt consideration of concurrent vaginitis rather than isolated urethritis 2
• Women may experience urethral itching or tingling 4

Diagnostic Confirmation

Before treating, urethritis should be objectively documented using at least one of the following criteria 5, 1:

• Mucopurulent or purulent discharge on examination 5
• First-void urine showing ≥10 white blood cells per high-power field on microscopic examination 5, 1
• Positive leukocyte esterase test on first-void urine 5, 1
• Gram stain of urethral secretions showing ≥2 white blood cells per oil immersion field (though this is more commonly used in men) 1

Critical Diagnostic Pitfall

• Symptoms alone without objective evidence of urethral inflammation are not sufficient for diagnosis or treatment 5, 6
• The Centers for Disease Control and Prevention emphasizes that empiric treatment based solely on symptoms should be reserved only for high-risk patients unlikely to return for follow-up 5

Differential Diagnosis Considerations

Women presenting with dysuria require evaluation to distinguish between several conditions 2:

• Cystitis (bladder infection with E. coli or S. saprophyticus) is more common than urethritis in women with dysuria 2
• Chlamydia trachomatis urethritis should be tested for in sexually active women 5, 2
• Neisseria gonorrhoeae urethritis requires specific testing and treatment 5, 2
• Vaginitis can produce urinary symptoms and should be excluded by examining for vaginal discharge 2
• Trichomonas vaginalis can cause both urethritis and vaginitis 5

Treatment Approach

First-Line Treatment

Azithromycin 1 g orally as a single dose OR doxycycline 100 mg orally twice daily for 7 days are the recommended first-line treatments for nongonococcal urethritis in women. 5, 7

• Single-dose azithromycin has the advantage of directly observed therapy and improved compliance 5
• Doxycycline may be more effective for Mycoplasma genitalium infections, though azithromycin shows better response for this pathogen 5

Alternative Regimens (when first-line agents cannot be used)

• Erythromycin base 500 mg orally four times daily for 7 days 5, 8
• Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 5
• Levofloxacin 500 mg orally once daily for 7 days 5
• Ofloxacin 300 mg orally twice daily for 7 days 5

Special Population: Pregnancy

• Azithromycin 1 g orally as a single dose is the preferred treatment in pregnant women (including third trimester) as it is safe and effective 9, 7
• Erythromycin base 500 mg orally four times daily for 7 days is an alternative in pregnancy 9, 8
• Doxycycline and fluoroquinolones are contraindicated in pregnancy 9

Microbiological Testing

All women with confirmed or suspected urethritis should be tested for both gonorrhea and chlamydia before or at the time of treatment initiation. 5, 4

• Testing should use nucleic acid amplification tests (NAAT) as the primary diagnostic method for optimal sensitivity 4
• Culture or NAAT for Trichomonas vaginalis should be performed if symptoms persist after initial treatment 6
• Testing for tetracycline-resistant Ureaplasma urealyticum may be considered in recurrent cases 6, 10

Partner Management

• All sexual partners within the preceding 60 days must be evaluated and treated with the same regimen as the index patient 5, 6, 9
• Sexual abstinence is required for 7 days after treatment initiation and until symptoms resolve and partners are adequately treated 5, 9, 1
• Failure to treat partners is a common cause of treatment failure and reinfection 6, 10

Follow-Up and Persistent Symptoms

• Patients should return for evaluation only if symptoms persist or recur after completing therapy 5, 9
• Routine post-treatment testing is not recommended in asymptomatic patients 5
• For women whose symptoms do not resolve or recur within 2 weeks, urine culture and antimicrobial susceptibility testing should be performed 5

Management of Persistent Urethritis

If symptoms persist after initial treatment 6:

1. First, confirm objective signs of urethritis are still present (discharge or ≥5 WBCs per high-power field) 6
2. Rule out non-compliance or re-exposure to untreated partner before changing therapy 6
3. Test for Trichomonas vaginalis using NAAT or culture 6
4. Treat with metronidazole 2 g orally as a single dose PLUS azithromycin 1 g orally as a single dose (if azithromycin was not used initially) 6

Chronic Symptoms Beyond 3 Months

• Persistence of dysuria, discomfort, and irritative voiding symptoms beyond 3 months suggests urethral pain syndrome rather than infectious urethritis 6, 3
• This condition involves dysfunctional urethral epithelium leading to chronic inflammation and requires multimodal therapy including analgesia, alpha-blockers, and physical therapy 3

Common Clinical Pitfalls

• Never treat based on symptoms alone without confirming objective evidence of urethritis 5, 6
• Do not assume all dysuria in women is cystitis—sexually transmitted urethritis must be considered in sexually active women 2
• Always address partner treatment to prevent reinfection 6, 10
• Avoid empiric fluoroquinolone use in patients with recent fluoroquinolone exposure due to high resistance rates 10
• Do not perform test-of-cure earlier than 3 weeks after treatment as false-positive results are common during this period 1

Screening After Treatment

• All patients treated for sexually transmitted urethritis should have repeat screening in 3 months regardless of whether partners were treated, due to high reinfection rates 1
• Testing for other sexually transmitted infections including syphilis and HIV should be performed at the time of urethritis diagnosis 5