What is the treatment for a man with leukocytospermia (white blood cells in semen) or pyuria (pus in urine) presenting with whitish discharge in his urine?

Treatment for Whitish Discharge in Men's Urine

Treat empirically with ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 7 days to cover both gonorrhea and chlamydia, as whitish discharge indicates urethritis until proven otherwise. 1, 2

Understanding the Clinical Presentation

Whitish discharge in urine represents urethritis—inflammation of the urethra characterized by mucopurulent or purulent discharge. 1 The two primary bacterial pathogens are Neisseria gonorrhoeae and Chlamydia trachomatis, which account for the majority of cases in sexually active men. 1, 2

Critical point: Asymptomatic infections are extremely common—many patients have no symptoms yet remain infectious and at risk for complications like epididymitis and Reiter's syndrome. 1, 2

Diagnostic Confirmation Before Treatment (If Resources Available)

Document urethritis using any of these criteria:

• Gram stain of urethral secretions showing ≥5 WBCs per oil immersion field (preferred rapid test—highly sensitive and specific). 1
• Mucopurulent or purulent discharge on examination. 1
• Positive leukocyte esterase test on first-void urine OR ≥10 WBCs per high power field on microscopic examination. 1

If Gram stain shows intracellular Gram-negative diplococci: This confirms gonococcal infection—treat for both gonorrhea and chlamydia. 1

If no intracellular diplococci: This is nongonococcal urethritis (NGU)—C. trachomatis causes 15-55% of cases, with prevalence declining in older men. 1

First-Line Treatment Regimens

When Diagnostic Tools Are Unavailable (Most Common Scenario)

Treat empirically for both infections immediately:

• Ceftriaxone 250 mg IM single dose (for gonorrhea)
• PLUS Doxycycline 100 mg orally twice daily for 7 days (for chlamydia and NGU) 1, 2, 3

Alternative for chlamydia coverage: Azithromycin 1 g orally single dose can replace doxycycline (improves compliance with directly observed therapy). 1, 2

When Gonorrhea Is Ruled Out (Confirmed NGU)

Recommended regimens:

• Azithromycin 1 g orally single dose, OR
• Doxycycline 100 mg orally twice daily for 7 days 1

Alternative regimens if above cannot be used:

• Erythromycin base 500 mg orally four times daily for 7 days, OR
• Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days, OR
• Ofloxacin 300 mg orally twice daily for 7 days 1

For patients intolerant of high-dose erythromycin:

• Erythromycin base 250 mg orally four times daily for 14 days, OR
• Erythromycin ethylsuccinate 400 mg orally four times daily for 14 days 1

Critical Management Requirements

Sexual abstinence: Patients must avoid sexual intercourse for 7 days after therapy initiation AND until symptoms resolve AND partners are adequately treated. 2

Partner management: All sex partners within the preceding 60 days must be evaluated and treated—male partners are often asymptomatic carriers. 2, 3

Medication dispensing: Provide medication directly in the clinic to ensure compliance, especially with single-dose regimens. 1

Follow-Up and Treatment Failure

Re-evaluate if no improvement within 3 days of treatment initiation—failure requires reassessment of diagnosis. 2, 3

For persistent or recurrent urethritis:

• If poor compliance or re-exposure to untreated partner: Re-treat with initial regimen. 1
• If compliant with no re-exposure: Perform wet mount and culture for Trichomonas vaginalis; if negative, re-treat with alternative regimen extended to 14 days (e.g., erythromycin base 500 mg four times daily for 14 days). 1
• This extended alternative regimen ensures coverage of tetracycline-resistant Ureaplasma urealyticum. 1

Consider Mycoplasma genitalium testing if persistent urethritis with negative initial testing. 4

Additional Testing Recommendations

• Syphilis serology and HIV testing should be offered to all patients diagnosed with urethritis. 2, 3
• Nucleic acid amplification tests (NAAT) are more sensitive than traditional culture for C. trachomatis and are the preferred detection method. 1

Common Pitfalls to Avoid

Do not defer treatment in high-risk patients (e.g., adolescents with multiple partners) who are unlikely to return—treat empirically for both gonorrhea and chlamydia even without diagnostic confirmation. 1

Do not assume all whitish discharge is infectious—document urethritis with objective criteria before treating, unless patient is high-risk and unlikely to follow up. 1

Do not neglect partner treatment—untreated partners lead to reinfection and continued transmission. 2, 3