From the Guidelines
To assess for urethritis, a thorough history and physical examination should be performed, followed by laboratory testing, including urinalysis, microscopic examination of urethral discharge, and nucleic acid amplification tests (NAATs) for Neisseria gonorrhoeae and Chlamydia trachomatis, as recommended by the Centers for Disease Control and Prevention 1. The assessment of urethritis should begin with a thorough history focusing on urinary symptoms, such as dysuria, frequency, and urgency, as well as urethral discharge, sexual history, and risk factors.
- A physical examination should include inspection of the external genitalia and urethral meatus for discharge, which can be expressed by gently milking the urethra.
- Laboratory testing is essential and includes urinalysis to check for pyuria (white blood cells in urine), microscopic examination of urethral discharge for white blood cells (>5 WBCs per high-power field suggests urethritis), and specific testing for causative pathogens.
- Nucleic acid amplification tests (NAATs) should be performed for Neisseria gonorrhoeae and Chlamydia trachomatis, the most common bacterial causes, as these tests are more sensitive than traditional culture techniques for C. trachomatis and are the preferred method for the detection of this organism 1.
- Additional testing for Mycoplasma genitalium, Trichomonas vaginalis, and herpes simplex virus may be warranted based on clinical presentation.
- First-void urine samples are preferred for testing as they contain the highest concentration of organisms and cells. The diagnosis of urethritis is confirmed by the presence of urethral inflammation (demonstrated by mucopurulent discharge or ≥5 WBCs per high-power field in urethral secretions) along with identification of a causative pathogen, as documented in the guidelines for the treatment of sexually transmitted diseases 1. This systematic approach allows for accurate diagnosis and appropriate treatment of urethritis, which is crucial for reducing morbidity, mortality, and improving quality of life.
From the Research
Assessment of Urethritis
To assess for urethritis, the following criteria can be used:
- Typical signs and symptoms, such as dysuria, mucopurulent urethral discharge, urethral discomfort, and erythema 2
- History of exposure to sexually transmitted infections (STIs) 2, 3
- Mucopurulent discharge 2
- Gram stain of urethral secretions showing at least two white blood cells per oil immersion field 2
- First-void urinalysis showing at least 10 white blood cells per high-power field 2, 3
- Positive leukocyte esterase result with first-void urine 2
Diagnostic Methods
Various diagnostic methods can be used to assess for urethritis, including:
- Culture 4, 5, 6
- Enzyme immunoassay 6
- Fluorescent antibody staining 6
- Hybridization 6
- Multiplex PCR, which is the fastest and most sensitive technique for the diagnosis of gonococcal and non-gonococcal urethritis 6
Clinical Evaluation
A clinical evaluation should include: