What is the treatment for pustular discharge from the penis with no history of sexual contact?

Treatment of Pustular Discharge from Penis Without Sexual Contact History

Empiric treatment with ceftriaxone 250 mg IM plus doxycycline 100 mg orally twice daily for 10 days is recommended, as sexually transmitted infections remain the most likely cause regardless of reported sexual history. 1

Diagnostic Evaluation

Before initiating treatment, obtain the following:

• Gram stain of urethral discharge to identify polymorphonuclear leukocytes (≥5 per oil immersion field confirms urethritis) and to look for gram-negative intracellular diplococci suggesting gonorrhea 1
• Culture or nucleic acid amplification test (NAAT) of urethral swab or first-void urine for N. gonorrhoeae and C. trachomatis 1
• Syphilis serology and HIV testing should be performed in all cases 1

Empiric Treatment Approach

Treatment must be initiated before culture results are available to prevent complications including transmission and potential sequelae 1.

Recommended Regimen for Urethritis

• Ceftriaxone 250 mg IM single dose 1
• PLUS Doxycycline 100 mg orally twice daily for 10 days 1

This dual therapy covers both gonococcal and chlamydial infection, which are the most common causes of pustular urethral discharge 1.

Alternative Regimen

For patients with cephalosporin or tetracycline allergies:

• Ofloxacin 300 mg orally twice daily for 10 days 1
• OR Levofloxacin 500 mg orally once daily for 10 days 1

Single-Dose Alternative for Chlamydia Component

• Azithromycin 1 g orally as a single dose can replace doxycycline and offers improved compliance with directly observed therapy 1, 2

Non-STI Differential Diagnoses

While STIs are most likely, consider these alternatives when sexual history is truly absent:

• Candidal balanitis may present with discharge and responds to topical antifungal therapy (clotrimazole 1% or miconazole 2% cream), though this typically causes pruritus rather than pustular discharge 3
• Bacterial cellulitis presents with erythema, warmth, and swelling but requires broad-spectrum antibiotics rather than STI-directed therapy 4
• Perirectal abscess with fistulous extension is rare but can present with penile discharge; digital rectal examination is essential if this is suspected 5

Critical Management Points

Patients often underreport or deny sexual contact, making empiric STI treatment necessary even without acknowledged exposure 1. Asymptomatic infections in partners and non-penetrative sexual contact are frequently overlooked 1.

Instruct patients to abstain from sexual activity for 7 days after single-dose therapy or until completion of 7-day regimens and resolution of symptoms 1.

Partner notification and treatment is mandatory even if the patient denies sexual contact, as contacts within 60 days preceding symptom onset require evaluation 1.

Follow-Up Strategy

• Reassess within 3 days if symptoms do not improve; consider alternative diagnoses including abscess, tumor, or resistant organisms 1
• Test of cure is not routinely recommended unless symptoms persist, but repeat testing at 3 months is advised due to high reinfection rates 1
• Persistent discharge after appropriate treatment warrants culture for resistant organisms and consideration of Mycoplasma genitalium, which responds better to azithromycin than doxycycline 1

Common Pitfalls

Do not delay treatment waiting for culture results, as this increases transmission risk and potential complications 1. Do not rely solely on patient-reported sexual history to exclude STIs, as denial and recall bias are common 1. Do not use fluoroquinolones as first-line therapy for suspected gonorrhea due to widespread resistance, though they remain acceptable for enteric organism coverage in older patients 1.