What are the initial steps for a male experiencing urethral burning and discharge, suspected of having a Sexually Transmitted Infection (STI)?

STI Screening Guidelines for Male Urethral Burning and Discharge

All males presenting with urethral burning and discharge should be tested for both Neisseria gonorrhoeae and Chlamydia trachomatis using nucleic acid amplification tests (NAATs) on first-void urine or urethral swab, and empiric treatment should be initiated immediately without waiting for results. 1

Immediate Diagnostic Steps

Confirm Urethritis

• Perform Gram stain of urethral discharge or intraurethral swab specimen to document ≥5 polymorphonuclear leukocytes per oil immersion field, which confirms urethritis 1
• Look for Gram-negative intracellular diplococci on the smear, which provides presumptive diagnosis of gonococcal infection 1
• If no visible discharge is present, examine first-void urine for leukocytes using culture and Gram stain of uncentrifuged urine 1

Obtain Specific Testing

• Collect specimens for NAAT testing for both N. gonorrhoeae and C. trachomatis - these are the preferred diagnostic methods and more sensitive than traditional culture 1, 2
• First-void urine or urethral swab are both acceptable specimens for NAAT 1
• Testing for both pathogens is strongly recommended because specific diagnosis improves partner notification, treatment compliance, and allows for mandatory reporting to state health departments 1

Additional Required Testing

• Obtain syphilis serology on all patients with suspected STI-related urethritis 1
• Offer HIV counseling and testing to all patients diagnosed with a new STI 1

Empiric Treatment Protocol

Critical principle: Treatment must be initiated immediately at the first visit, before test results are available. 1

First-Line Recommended Regimen

• Ceftriaxone 250 mg IM as a single dose 1, 3
  • PLUS
• Doxycycline 100 mg orally twice daily for 7 days 1, 3

This dual therapy covers both gonorrhea and chlamydia, which is essential because:

• If diagnostic tools are unavailable, patients must be treated for both infections 1
• Co-infection rates are substantial, making empiric dual coverage cost-effective 4
• Single-site infections are common but cannot be predicted clinically 5

Alternative Regimen

• Azithromycin 1 g orally as a single dose can replace doxycycline for chlamydia coverage 1, 6
• Single-dose regimens offer the advantage of improved compliance and directly observed treatment 1
• However, azithromycin is specifically indicated for urethritis due to C. trachomatis or N. gonorrhoeae per FDA labeling 6

Medication Dispensing Strategy

• Dispense medications on-site in the clinic whenever possible 1
• Directly observe the first dose to maximize compliance 1

Critical Management Requirements

Sexual Abstinence Instructions

• Patients must abstain from sexual intercourse for 7 days after initiating single-dose therapy or until completion of a 7-day regimen AND until symptoms have completely resolved 1, 3
• Abstinence must continue until all sex partners are adequately treated to minimize reinfection risk 1, 3

Partner Management

• All sex partners within the preceding 60 days must be referred for evaluation, testing, and empiric treatment 1
• Partners should receive treatment effective against both chlamydia and gonorrhea regardless of the index patient's specific diagnosis 1
• Expedited partner treatment (giving patients prescriptions for untested partners) is advocated by the CDC and approved in many states 2

Follow-Up Protocol

When to Re-evaluate

• Patients should return if symptoms persist or recur after completing therapy 1
• If no improvement occurs within 3 days, re-evaluate both the diagnosis and treatment regimen 1, 3
• Symptoms alone without objective signs of urethral inflammation are NOT sufficient basis for retreatment 1

Test-of-Cure Considerations

• Test-of-cure is NOT recommended for patients who received recommended therapy and whose symptoms resolved, unless therapeutic noncompliance or reinfection is suspected 1
• However, repeat testing at 3-6 months after treatment IS recommended for all men diagnosed with chlamydia or gonorrhea, regardless of whether partners were treated, due to high reinfection rates 1

Common Pitfalls to Avoid

Do Not Delay Treatment

• Never wait for culture or NAAT results before initiating therapy - the window for preventing transmission and complications is narrow 1
• Asymptomatic infections are extremely common, so absence of severe symptoms does not indicate less urgent need for treatment 1, 2

Do Not Miss Syphilis

• Antimicrobial agents used for urethritis may mask or delay symptoms of incubating syphilis 6
• Azithromycin at the recommended 1 g dose should NOT be relied upon to treat syphilis 6
• Always obtain baseline syphilis serology 1

Do Not Forget Age-Specific Considerations

• In sexually active men under 35 years, urethritis is almost always sexually transmitted (C. trachomatis or N. gonorrhoeae) 1, 3
• In men over 35 years with urinary symptoms, consider non-STI causes like Gram-negative enteric organisms, especially with history of urinary instrumentation 1, 3

Do Not Overlook Complications

• Be alert for epididymitis, which often accompanies sexually transmitted urethritis and may be asymptomatic 1, 3
• Consider chronic prostatitis/chronic pelvic pain syndrome in patients with persistent symptoms lasting >3 months 1